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Magnetic Resonance Imaging

of the Shoulder
CURRENT TECHNIQUES AND SPECTRUM OF DISEASE
BY ADAM FARBER, MD, LAURA FAYAD, MD, TIMOTHY JOHNSON, MD,
BRETT CASCIO, MD, MICHAEL SHINDLE, MD, PHILLIP NEUBAUER, MD, AND A. JAY KHANNA, MD

Introduction After reviewing this article, the reader should (1) have a

M
agnetic resonance imaging is an excellent modality
for imaging pathological processes of the shoulder
joint. It allows high-resolution imaging of all ana-
tomic structures, including the glenoid, the humeral head, the
articular cartilage, the acromion, the muscles and tendons of
the rotator cuff, the labrum, the biceps tendon, and the gleno-
humeral ligaments, in multiple orthogonal planes. Numerous
technical options and several pulse sequences can be utilized
for the performance of magnetic resonance imaging of the
shoulder. The aim of this review is to update orthopaedic sur-
geons on the technical aspects of performing magnetic reso-
nance imaging of the shoulder. In addition, this report will
define the normal anatomy of the shoulder as demonstrated
by magnetic resonance imaging and review the spectrum of
disease detectable with this technique.
basic understanding of the physics, pulse sequences, and termi-
nology of magnetic resonance imaging; (2) be able to systemat-
ically evaluate the findings of a complete magnetic resonance
imaging examination of the shoulder and know the features of
normal shoulder anatomy; (3) be able to identify various tissue
types on T1-weighted, fat-suppressed T2-weighted, and proton-
density images; and (4) be able to diagnose certain pathological
processes of the shoulder on the basis of magnetic resonance
imaging findings.
Essentials of Magnetic Resonance Imaging
Process of Image Production
irst, the subject is positioned in the scanner. For magnetic
F resonance imaging of the shoulder, the patient is supine and
the arm is held at the side, as opposed to across the chest, in or-

TABLE I Basic Pulse Sequences for Magnetic Resonance Imaging*

Signal Intensity
Repetition Echo
Image Type Time Time Fat Water Advantages Disadvantages
T1-weighted Short Short Bright Dark Best anatomic detail; Poor demonstration
evaluation of bone of pathology/edema
marrow and muscle
atrophy
T2-weighted Long Long Intermediate Bright Moderately sensitive Poor spatial
for pathology/edema resolution
Fat-suppressed Long Long Very dark Very bright Most sensitive for Poor spatial
T2-weighted pathology/edema; resolution
evaluation of marrow
pathology
STIR (short tau Long Variable Very dark Very bright Sensitive for pathology/ Poor spatial
inversion recovery) edema; evaluation of resolution
marrow pathology
Gradient echo Short Short Intermediate Intermediate/ Excellent for evaluation Very susceptible
bright of articular cartilage, to metallic artifacts
pigmented villonodular (prostheses)
synovitis, and blood
Proton density Long Short Intermediate/ Intermediate Highest resolution; Poor demonstration
bright excellent for evaluation of bone marrow
of labral pathology

*Modified from: Khanna AJ, Cosgarea AJ, Mont MA, Andres BM, Domb BG, Evans PJ, Bluemke DA, Frassica FJ. Magnetic resonance imaging
of the knee. Current techniques and spectrum of disease. J Bone Joint Surg Am. 2001;83 Suppl 2(Pt 2):129. In STIR sequences, the echo
time is varied to make the water appear bright (i.e., a fluid-sensitive sequence).
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TABLE II Tissue Characteristics on Magnetic Resonance Imaging*

Signal Intensity
T1-Weighted T2-Weighted Fat-Suppressed Gradient-Echo Proton-Density
Tissue Type Image Image T2-Weighted Image Image Image
Cortical bone Very low Very low Very low Variable Very low
Yellow marrow High High Very low Variable Intermediate/high
Red marrow Low/intermediate Intermediate Low/intermediate Variable Intermediate/high
Fat High High Very low Variable Intermediate/high
Fluid Low High Very high Variable Intermediate
Muscle Intermediate Intermediate Low/intermediate Variable Low
Ligaments/tendons Very low Very low Very low Variable Very low
Hyaline cartilage Intermediate Intermediate Intermediate Variable Intermediate
Physeal scar Low Low Low Variable Low
Labrum Very low Very low Very low Variable Very low

*Modified from: Khanna AJ, Cosgarea AJ, Mont MA, Andres BM, Domb BG, Evans PJ, Bluemke DA, Frassica FJ. Magnetic resonance imaging
of the knee. Current techniques and spectrum of disease. J Bone Joint Surg Am. 2001;83 Suppl 2(Pt 2):130. The appearance of specific
tissues on gradient-echo images is entirely variable and depends on the parameters used to acquire the images. In addition to the repeti-
tion time and echo time, the degree of brightness of the fat is also related to how the sequence is acquired. For example, fat is brighter on a
fast spin-echo image than it is on a conventional spin-echo sequence (these can be T1, T2, or proton-density weighted). Proton-density im-
ages may also be fat-suppressed, in which case fat has very low signal intensity.

der to minimize transmission of respiratory motion to the
shoulder. The arm is placed in slight external rotation to opti-
mally orient the supraspinatus tendon in order to prevent con-
fusing overlap with the infraspinatus tendon on coronal oblique
images1. The external rotation also allows maximum visualiza-
tion of the supraspinatus insertion2. The magnetic field of the
scanner (often 1.5 T) aligns all protons within the subject along
the longitudinal axis of the scanner. At this time, the protons are
in a preexcited state. As an electromagnetic radiofrequency
pulse is applied, the protons realign in the transverse plane
(typically 90 to the external field for a spin-echo sequence).
This is followed by a 180 refocusing pulse or gradient that cre-
ates the magnetic resonance signal that is emitted.
This analog signal is detected, encoded with spatial infor-
mation, and converted to a digital dataset known as k-space.
Subsequently, a final image is created by the process of Fourier
transformation3.
Types of Pulse Sequences
Manipulation of the strength of the applied radiofrequency
pulse, the frequency with which it is sent, and the time at which
the magnetic resonance signal is measured enable the images to
be weighted to emphasize the T1 or T2 characteristics of a tissue
(Table I). Some images are created with intermediate weighting,
also known as proton-density weighting, and contain a mixture
of T1 and T2 signals. Proton-density and T1-weighted images
have the greatest signal-to-noise ratio, producing the greatest
spatial resolution, and these pulse sequences are optimal for dis-
cerning anatomic structures. A proton-density image, which
provides high-resolution imaging, is considered by many to be
the sequence of choice for evaluation of the labrum4. T2-
weighted images are sensitive to pathological changes in tissue,
including any process in which cells and the extracellular matrix
have increased water content. Fat-suppressed T2-weighted im-
ages are acquired with use of pulse sequences that suppress the
signal from fat and accentuate the signal from fluid. These pulse
sequences are the most sensitive to the presence of edema.
STIR (short tau inversion recovery) images are similar to fat-
suppressed T2-weighted images in that they are fluid-sensitive.
A gradient-echo pulse sequence can be T1 or T2-weighted or it
can be intermediate-weighted between T1 and T2-weighted.
This sequence is excellent for the assessment of hemorrhage and

TABLE III Characteristics of Rotator Cuff Tears on Magnetic Resonance Imaging

Direct Signs Indirect Signs

Visualization of tendon defect
Indication of direct communication between
glenohumeral joint and subacromial bursa
Retraction of supraspinatus or infraspinatus tendon
Subacromia and/or subdeltoid bursal fluid
Retraction of supraspinatus musculotendinous junction
Changes in subacromial and subdeltoid peribursal fat
Fatty atrophy of rotator cuff muscles
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Fig. 1 Fig. 2

Figs. 1 through 5 Coronal oblique fat-suppressed T2-weighted

images showing the normal anatomy of the shoulder from ante-
rior (Fig. 1) to posterior (Fig. 5). C = coracoid, G = glenoid, Hh =
humeral head, Ss = subscapularis muscle, SS = supraspinatus
muscle, thick solid arrow = labral-bicipital complex, thin solid ar-
row = supraspinatus tendon, thick open arrow = glenoid articular
cartilage, thin open arrow = humeral head articular cartilage,
dashed arrow = posterior part of the supraspinatus and in-
fraspinatus tendons, bent arrow = superior aspect of the labrum,
and arrowhead = biceps tendon.

Fig. 3

pigmented villonodular synovitis, both of which produce sig-
nal dropout as a result of accentuated susceptibility; in addition,
it is often used for the evaluation of articular cartilage5-7.
Pulse Sequences and Tissue Characterization
As has been previously described, the basic steps in the inter-
pretation of images include3:
1. Determination of the pulse sequence (Tables I and II).
2. Looking for normal anatomy on T1-weighted, pro-
ton-density, and gradient-echo images and evaluating for the
presence of abnormal structures.
3. Confirmation that all tissues are homogeneous on
T1-weighted images. If there is heterogeneity, T2-weighted
images should be checked to verify the abnormality.
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Fig. 4
4. Evaluation of T2-weighted images for areas of in-
creased signal, which is sensitive, but not specific, for patho-
logical changes.
5. Correlation of the findings on the magnetic reso-
nance imaging with the clinical history and the findings on
physical examination to determine the most likely cause of the
symptoms.
Normal Anatomy of the Shoulder as
Seen on Magnetic Resonance Imaging
Coronal Oblique Images (Figs. 1 Through 5)
oronal oblique images are acquired in a plane that is
C parallel to the course of the supraspinatus tendon. The
images should include the subscapularis muscle anteriorly
and the infraspinatus and teres minor muscles posteriorly.
Coronal oblique images are best used to evaluate the su-
praspinatus muscle and tendon, the subacromial and subdel-
toid bursae, and the acromioclavicular joint1. The long head
of the biceps tendon and the biceps attachment, the in-
fraspinatus muscle and tendon, the glenoid labrum (superior
and inferior portions), and the glenohumeral joint space also
can be visualized on coronal oblique images. Each coronal
oblique image should be evaluated systematically from ante-
rior to posterior. On anterior coronal oblique images, the
subscapularis muscle and tendon can be identified as the ten-
don courses from its origin in the subscapularis fossa to its
insertion on the lesser tuberosity; however, the subscapularis
can be seen better on axial images. The long head of the bi-
ceps tendon is best seen in its intra-articular location on
coronal oblique images. On anterior and mid-coronal ob-
lique images, the supraspinatus muscle and tendon are seen
in continuity. The supraspinatus originates in the supra-
spinatus fossa and inserts on the superior facet of the greater
MAG NETIC RESONANCE IM AG ING
OF THE SHOULDER
Fig. 5
tuberosity. The anatomy of the acromioclavicular joint is best
displayed at the level of the supraspinatus tendon on coronal
oblique images. The superior and inferior aspects of the
glenoid labrum as well as the axillary pouch also are clearly
shown on coronal oblique images. The axillary pouch typi-
cally is collapsed, but variable amounts of fluid in the axillary
pouch may be seen in the presence of a joint effusion. Hu-
meral head articular cartilage, intermediate in signal inten-
sity on T1 and T2-weighted images, is interposed between
the low-signal-intensity supraspinatus tendon superiorly and
the cortex inferiorly. The articular cartilage is better visual-
ized on gradient-echo images.
Sagittal Oblique Images (Figs. 6 Through 10)
Sagittal oblique images, acquired in a plane that is perpendic-
ular to the supraspinatus tendon, should extend from the
most lateral aspect of the humeral head to the glenoid neck.
These oblique images are ideally suited for evaluating the rota-
tor cuff muscles and tendons, the coracoacromial arch, and
the acromial morphology1. The glenoid labrum and the long
head of the biceps can also be visualized on sagittal oblique
images. However, both of these structures are better seen on
axial and coronal oblique images. Sagittal oblique images
should be reviewed systematically from medial to lateral. Me-
dial sagittal sections display the clavicle and the acromiocla-
vicular joint in profile. On mid-sagittal and lateral sagittal
images, the supraspinatus, the infraspinatus, and the conflu-
ence of the rotator cuff tendons are visualized between the ac-
romion and the superior articular surfaces of the humeral
head. The biceps tendon can be followed from medial to lat-
eral as it courses from its intra-articular origin on the supra-
glenoid tubercle to its extracapsular location in the bicipital
groove laterally.
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Fig. 6 Fig. 7

Figs. 6 through 10 Sagittal oblique fat-suppressed T2-

weighted images showing the normal anatomy of the shoul-
der from medial (Fig. 6) to lateral (Fig. 10). A = acromion,
G = glenoid, Hh = humeral head, IS = infraspinatus muscle,
SS = supraspinatus muscle, TM = teres minor muscle, thin
solid arrow = supraspinatus tendon, thin open arrow = sub-
scapularis tendon, thick open arrow = biceps tendon, arrow-
head = humeral articular cartilage, bent solid arrow =
infraspinatus tendon, bent open arrow = teres minor ten-
don, and dashed arrow = common rotator cuff insertion lat-
erally, often likened to a head of hair.

Fig. 8

Axial Images (Figs. 11 Through 15)
Axial images are acquired from the superior aspect of the acro-
mioclavicular joint through the inferior glenoid margin. Axial
planar images are best used for evaluating the glenoid labrum
(anterior and posterior portions) and capsular structures as
well as the long head of the biceps tendon in the bicipital
groove1. In addition, these images provide excellent visualiza-
tion of the subscapularis muscle and tendon, the humeral
head, and the glenoid. On superior axial images, the normal
oblique course of the supraspinatus muscle is displayed with
intermediate signal intensity. In cross section, the tendon of the
long head of the biceps is seen as a low-signal-intensity struc-
ture within the bicipital groove. Glenoid articular cartilage
follows the concave shape of the glenoid cavity and demon-
strates intermediate signal intensity on T1 and T2-weighted
images. The articular cartilage of the glenohumeral joint is best
evaluated on fat-suppressed T2-weighted or gradient-echo se-
quences5,6,8. The glenohumeral ligaments are best visualized on
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Fig. 9
axial images. They appear dark (low signal intensity) on all
pulse sequences. The middle glenohumeral ligament is identi-
fied as a thin band or cord between the anterior aspect of the
labrum and the subscapularis. The anterior band of the infe-
rior glenohumeral ligament is visualized more inferiorly, be-
tween the anterior-inferior aspect of the labrum and the
subscapularis tendon. The superior glenohumeral ligament is
identified at the level of the coracoid and the biceps tendon.
Evaluation of Pathological
Processes in the Shoulder
here are several methods for systematically describing the
T appearance of pathological processes in the shoulder on
magnetic resonance images, including by region and by com-
mon clinical diagnoses. Given that most patients have a thor-
ough history recorded and physical examination performed by
a musculoskeletal specialist, and often an orthopaedic surgeon,
we chose to present the spectrum of disease detectable by mag-
netic resonance imaging of the shoulder on the basis of several
common clinical diagnoses. For each diagnosis, we will describe
the most common magnetic resonance imaging findings that
can help to confirm or further characterize the diagnosis.
Impingement Syndrome
Extrinsic impingement syndrome is due to compression of the
rotator cuff by abnormal morphology of structures within the
supraspinatus outlet. Osseous factors that contribute to im-
pingement syndrome include anterior acromial spurs, the
shape of the acromion, the slope of the acromion, and the
MAG NETIC RESONANCE IM AG ING
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Fig. 10
morphology of the acromioclavicular joint (e.g., hypertrophic
bone, calcification of the coracoacromial ligament, and callus
formation)9,10. The shape of the acromion (acromial morphol-
ogy) is best evaluated on sagittal oblique magnetic resonance
images. Acromial morphology has been classified into three
different types by Bigliani et al.9 (Figs. 16, 17, and 18). The
type-I acromion has a flat undersurface, the type-II acromion
has a smooth curved inferior surface, and the type-III acro-
mion has an anteroinferior hook or beak. Type-II and III ac-
romions create narrowing of the supraspinatus outlet and are
associated with a predisposition to the development of rota-
tor cuff disease11.
The spectrum of magnetic resonance imaging changes
in shoulders with impingement has been characterized and
documented12,13. Rotator cuff disease is evaluated on the basis
of tendon morphology and changes in the observed signal in-
tensity within the specific cuff tendons. In addition, patholog-
ical processes within the supraspinatus outlet, including
abnormalities of the acromion, the acromioclavicular joint,
and the subacromial and subdeltoid bursae, may be identified
in the spectrum of findings in impingement lesions.
Normal rotator cuff tendons display uniformly low sig-
nal intensity on all pulse sequences. Cuff tendon degeneration
(tendinosis) displays intermediate signal intensity on T1-
weighted or proton-density images, with no evidence of fluid
signal intensity on T2-weighted images (Fig. 19). Fat-suppressed
T2-weighted sequences are sensitive to degenerative changes
and, in the absence of a partial or complete rotator cuff tear,
display areas or regions of hyperintensity14. These areas of
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increased signal intensity often occur adjacent to acromial or
acromioclavicular spurs (as described above) or a low-lying
acromion12. More severe degeneration may be characterized
by intermediate to increased signal intensity on T1-weighted
and proton-density images, which persist without an ad-
ditional increase in signal intensity on T2-weighted images.
Other findings of rotator cuff tendinosis include areas of
Fig. 11
Fig. 12
MAG NETIC RESONANCE IM AG ING
OF THE SHOULDER
thickening and irregularity within the tendon1.
Caution must be used to avoid confusing rotator cuff le-
sions with the magic-angle phenomenon. The magic-angle ef-
fect, which results in spuriously increased signal intensity on
sequences with a short echo time (including T1-weighted,
proton-density, and gradient-echo sequences), occurs in tis-
sues containing highly structured collagen fibers that lie at an
Figs. 11 through 15 Axial fat-suppressed proton-density images show-
ing the normal anatomy of the shoulder from superior (Fig. 11) to infe-
rior (Fig. 15). Ac = acromion, C = coracoid process, CL = clavicle, D =
deltoid, G = glenoid, Hh = humeral head, IS = infraspinatus muscle,
Sc = scapula, Ss = subscapularis muscle, SS = supraspinatus mus-
cle, solid arrow = glenoid labrum, bent arrow = middle glenohumeral
ligament, open arrow = glenoid articular cartilage, arrowhead = long
head of biceps tendon, dashed arrow = acromioclavicular joint, and as-
terisk = region of superior glenohumeral ligament.
Fig. 13
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angle of 55 to the main magnetic field15. In the shoulder, this

phenomenon is common just proximal to the insertion of the
supraspinatus tendon on the greater tuberosity. The increased
signal intensity associated with the magic-angle effect disap-
pears on T2-weighted images, making it possible to differenti-
ate this phenomenon from true pathological entities15.

Fig. 14

Fig. 16
Sagittal oblique T1-weighted image demonstrating a type-I acromion
with a flat undersurface. A = acromion, and H = humeral head.

Rotator Cuff Tears

The supraspinatus and infraspinatus are the most commonly
torn rotator cuff tendons16. Magnetic resonance images, par-
ticularly in the coronal oblique and sagittal oblique planes, are
most useful for demonstrating tears of these two tendons17.
These tears are best demonstrated on fat-suppressed T2-
weighted images18. Rotator cuff tears can be characterized as
either partial-thickness or full-thickness19. Partial-thickness
tears may involve either the articular or the bursal surface or,
less commonly, they may be completely intratendinous. Intra-
tendinous lesions do not communicate with either the bursal
or the articular surface.
Coronal oblique images are ideal for the evaluation of
partial-thickness tears of the supraspinatus and infraspinatus
tendons. Similarly, axial images are best for evaluating the sub-
scapularis and teres minor tendons. The diagnosis of a partial-
thickness tear is suggested by increased signal in the rotator
cuff that only partially traverses the rotator cuff substance20.
Fig. 15 There is typically abnormal morphology of the tendon inser-
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axial images. The direct signs of a full-thickness rotator cuff tear

consist of a complete tendon defect or complete discontinuity
of the tendon with retraction, and abnormally increased signal
intensity within the tendon defect18,22-25 (Table III). A complete
tear cannot be unequivocally diagnosed without visualization of
either a complete tendon defect or a direct communication be-
tween the glenohumeral joint and the subacromial and/or sub-
deltoid bursae. The defect, or tendinous gap, is seen as an
interruption or loss of continuity of the normally low-signal-
intensity tendon. This gap appears as a continuous band of in-
creased signal intensity that traverses the full-thickness of the
rotator cuff, extending from the glenohumeral joint to the sub-
acromial bursa25. The signal intensity is increased on T1-
weighted and proton-density images and is further increased on
T2-weighted and fat-suppressed T2-weighted sequences1. The
increased signal intensity is due to interposed joint fluid or
granulation tissue at the cuff tear site. Large cuff tears may fill in

Fig. 17
Sagittal oblique T1-weighted image demonstrating a type-II acromion
with a curved inferior surface (arrow). A = acromion, and H = humeral
head.

tion onto bone with evidence of partial discontinuity of the

tendon on T1-weighted images. Partial-thickness tears demon-
strate low to intermediate signal intensity on T1-weighted im-
ages, intermediate to high signal intensity on proton-density
images, and fluid signal intensity on T2-weighted sequences
(Figs. 20 and 21). Increased signal intensity is due to tracking
of fluid within the bursal or articular surface of the cuff.
The diagnosis of partial-thickness rotator cuff tears is most
difficult at either end of the spectrum; low-grade partial-
thickness tears tend to be mistaken for tendinosis, and high-
grade partial-thickness tears tend to be mistaken for full-thickness
rotator cuff tears1 (Figs. 19 through 22). The magnetic resonance
imaging findings of degeneration and partial-thickness rotator
cuff tears may overlap, and tendon lesions must be evaluated on
the basis of bursal, intrasubstance, and articular surface mor-
phology as well as signal intensity changes on T1-weighted,
proton-density, and T2-weighted sequences21. Fig. 18
Full-thickness tears of the supraspinatus and infraspina- Sagittal oblique T1-weighted image demonstrating a type-III acromion
tus are best visualized on coronal oblique images. Full-thickness with an anterolateral hook or beak (arrow). A = acromion, and H = hu-
tears of the subscapularis and teres minor are best visualized on meral head.
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Fig. 19
Sagittal oblique T2-weighted image demonstrating rotator cuff tendino-
sis. There is a hyperintense signal in the tendon (thin arrow) without a
discrete defect, which is consistent with supraspinatus tendinosis.
Compare this appearance with the fluid signal intensity in the subacro-
mial bursa (thick arrow), which is consistent with subacromial bursitis.
Fig. 20
Sagittal oblique T2-weighted image showing a low-grade partial-
thickness rotator cuff tear (arrow) on a background of tendinosis.
MAG NETIC RESONANCE IM AG ING
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with fibrous or granulation tissue that may have low signal in-
tensity on T2-weighted images26.
Indirect signs of rotator cuff tears can be used in con-
junction with the primary assessment of changes in tendon
signal intensity and morphology to help in the diagnosis of
full-thickness rotator cuff tears. Indirect signs of rotator cuff
abnormality include fluid within the subacromial and/or
subdeltoid bursae, obliteration of the peribursal fat stripe,
and atrophy of the involved muscle27,28 (Table III). Subacromial
and/or subdeltoid bursal fluid is associated with a full-thickness
rotator cuff tear but is not specific for this condition. This
fluid is manifested on magnetic resonance imaging as high-
signal-intensity changes in the subacromial/subdeltoid bursa
equal to the intensity of fluid on T2-weighted images. Changes
in subacromial and subdeltoid peribursal fat may also be con-
sidered indirect signs of cuff abnormality. Because peribursal
fat may be replaced by either low-signal-intensity granulation
tissue or scar or high-signal-intensity fluid, which is often
limited to the site of the cuff tear, this abnormality is consid-
ered a secondary sign when a rotator cuff tear is not clearly
visualized.
Most rotator cuff tears can be identified on the basis of a
thorough history and physical examination. Magnetic reso-
nance imaging is most useful for planning and predicting the
success of rotator cuff repair. Identification of tendon retraction
and muscle atrophy on magnetic resonance imaging is impera-
tive in the evaluation of a full-thickness tear. Large, retracted
cuff tears with atrophy of the muscle may not be repairable. Re-
traction of the torn rotator cuff tendon is indicated by medial
displacement of the musculotendinous junction from its nor-
mal position, which lies in a 45 arc lateral to the highest point
of the humeral head26. Some authors have considered the su-
Fig. 21
Coronal oblique T2-weighted image showing a high-grade partial-
thickness rotator cuff tear (arrow).
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Fig. 22
Sagittal oblique T2-weighted image showing a full-thickness rotator
cuff tear (arrow).
praspinatus tendon to be retracted when the musculotendi-
nous junction is located more medially than the middle one-
third of the humeral head25. Retraction of the supraspinatus or
infraspinatus tendon is best seen on coronal oblique images that
Fig. 24
Coronal oblique T2-weighted images showing the normal, low-signal-intensity biceps tendon (arrow).
MAG NETIC RESONANCE IM AG ING
OF THE SHOULDER
Fig. 23
Coronal oblique proton-density-weighted image showing a full-
thickness supraspinatus tear with tendon retraction (arrow). Note
the slightly increased signal intensity of the muscle, which is consis-
tent with early atrophy.
demonstrate the medial and lateral extension of the cuff tear.
Similarly, axial images are best for identifying subscapularis and
teres minor retraction. T2-weighted sagittal oblique images
provide additional information, allowing identification of artic-
ular and bursal surface extension and quantification of the size
of the tear in the anteroposterior direction1.
Fig. 25
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normal appearance of the long head of the biceps tendon on

magnetic resonance imaging includes low signal intensity on
all pulse sequences29 (Figs. 24, 25, and 26). On axial images at
the level of the bicipital groove, the tendon appears as an oval-
shaped low-signal-intensity structure surrounded by a thin,
moderate-signal-intensity synovial sheath26. Pathological con-
ditions involving the long head of the biceps tendon include
tendinosis, partial tears, complete tears, subluxation, and dis-
location (Figs. 27 through 31).
The magnetic resonance imaging findings associated
with tendinosis are high signal intensity within the tendon on
all pulse sequences and thickening and inhomogeneity of the
tendon29,30 (Fig. 27). These findings are particularly evident on
sagittal oblique sections obtained at the level of the intracap-
sular portion of the long head of the biceps tendon29. Biceps
tendinosis is frequently associated with impingement syn-
drome and rotator cuff tears. Therefore, magnetic resonance
imaging often shows the associated pathological findings, in-
cluding joint effusion and increased fluid in the bicipital syn-
ovial sheath, nonspecific for inflammation of the long head of
the biceps tendon30,31. However, fluid in the tendon sheath of
the long head of the biceps is abnormal if it completely sur-
rounds the tendon in the absence of a glenohumeral joint
effusion28.

Fig. 26
Sagittal oblique T2-weighted image showing the normal, low-
signal-intensity biceps tendon (arrow) as it courses through the
glenohumeral joint.

Large or chronic rotator cuff tears are frequently ac-

companied by atrophy of the rotator cuff muscle. Muscle at-
rophy can be identified in two formsfatty replacement and
decreased muscle bulkwhich often are present simulta-
neously. T1-weighted or proton-density images are best
suited for this assessment. Fatty replacement is best demon-
strated on T1-weighted images, which display high-signal-
intensity (equal to fat) horizontal streaks parallel to the long
axis of the involved muscle12 (Fig. 23). In addition, magnetic
resonance imaging can show the diminution in cross-sectional
size of the involved muscle; this is best visualized on sagittal
oblique images25.

Pathological Conditions of the Long

Head of the Biceps Tendon
The biceps tendon may be followed on multiple sequences
from its intra-articular position (the origin from the supragle-
noid tubercle) through the bicipital groove29. The long head of
the biceps tendon should be inspected in the coronal oblique,
axial, and sagittal oblique planes. The origin of the biceps ten-
don and its proximal intra-articular portion are best visual- Fig. 27
ized on sagittal oblique and coronal oblique images. More Sagittal oblique T2-weighted image showing biceps tendinosis. The
distally, as it courses within the bicipital groove, the long head biceps tendon is thickened with increased T2 signal (arrow). Also
of the biceps tendon is best visualized on axial images. The note the glenohumeral joint effusion.
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dial direction30. The subluxation is best visualized on axial sec-

tions (Fig. 30). In addition to subluxation, frank dislocation of
the biceps tendon can occur. The magnetic resonance imaging
findings of a dislocated biceps tendon include a dislocated

Fig. 28 Fig. 29
Axial fat-suppressed proton-density image demonstrating a longitu- Axial fat-suppressed T2-weighted image demonstrating a complete
dinal tear (split) of the biceps tendon (arrow). rupture of the biceps tendon. The bicipital tendon is absent within
the bicipital groove (white arrow), and there is complex fluid in the bi-
ceps tendon sheath (black arrow), which represents hemorrhage re-
Biceps tendinosis is the earliest stage of biceps tendon lated to rupture.
disease, but it can progress to a partial or complete tear of the
tendon. Transverse partial tears are difficult to diagnose and
are typically inferred by a sudden change in the cross-sectional
diameter of the tendon30. However, a longitudinal tear is easier
to identify because tendon surrounds the high-signal-inten-
sity tear on T2-weighted images30 (Fig. 28). Complete rupture
more often occurs proximally, at the level of the proximal por-
tion of the extracapsular segment, within the bicipital
groove32. Any axial image that definitively shows no tendon in
the bicipital groove and no medial dislocation is diagnostic of
a rupture of the long head of the biceps tendon30 (Fig. 29). Ad-
ditional magnetic resonance imaging findings include atrophy
and distal retraction of the tendon and fluid within the tendon
sheath29-31. These findings are best demonstrated on axial sec-
tions. Intra-articular tears of the biceps tendon are frequently
associated with rotator cuff tears and are visualized on mag-
netic resonance imaging as an absence of the intra-articular
portion of the tendon and the associated rotator cuff lesion29.
Biceps subluxations, although rare, can be seen in dis-
ease processes in which the integrity of the rotator cuff has
been lost or in which the biceps tendon has lost the support- Fig. 30
ing structure that maintains it in the bicipital groove (i.e., the Axial fat-suppressed proton-density image showing subluxation of the
transverse humeral ligament)30. As a result of the forces acting biceps tendon (thin arrow) and the bicipital groove (thick arrow). Also
on the biceps tendon, displacement always occurs in the me- note the subscapularis tear.
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Fig. 31
Axial fat-suppressed T2-weighted image demonstrating a dislocated
Fig. 32
biceps tendon (thin arrow) medial to an empty bicipital groove (thick
arrow). The subscapularis tendon is ruptured and therefore the bi-
ceps tendon has become entrapped intra-articularly.

tendon medial to an empty bicipital groove30 (Fig. 31). This

condition is also best visualized on axial images30,31,33,34. On sag-
ittal oblique images, dislocation of the biceps tendon is identi-
fied as a more medial position of the descending tendon and
as an abnormal course of the intra-articular portion of the
tendon30. Associated findings may include a shallow bicipital
groove and tears of the coracohumeral ligament, subscapularis
tendon, and supraspinatus tendon. The biceps tendon is lo-
cated medial and anterior to the subscapularis tendon, with a
disrupted transverse ligament and an intact subscapularis. If
the subscapularis tendon is detached from its insertion on the
lesser tuberosity, however, the biceps tendon becomes en-
trapped intra-articularly29,31.

Labral Disorders and SLAP lesions

Magnetic resonance imaging has proved to be a sensitive,
specific, and accurate modality for evaluating the glenoid
labrum4,35,36. Although the glenoid labrum is routinely evalu-
ated in all three imaging planes37, coronal oblique and axial
plane images provide the most diagnostic information38. The
Fig. 33
axial image best demonstrates the anterior and posterior as-
Figs. 32 and 33 Axial fat-suppressed gradient-echo images showing in-
pects of the labrum, whereas the coronal oblique image
shows the superior and inferior portions29. The normal la- creased signal intensity within the superior aspect of the glenoid labrum
brum is approximately 3 mm in craniocaudal dimension (arrow) in a patient with a type-II SLAP lesion verified by arthroscopy.
from base to apex and 4 mm in width at its base of insertion
into the glenoid cartilage39. The classic morphology is de- demonstrates low signal intensity on all pulse sequences. The
scribed as smooth, with triangular anterior and posterior peripheral attachment of the labrum joins the capsule and
wedges seen on axial images29. The intact fibrous labrum glenohumeral ligaments, creating the capsulolabral complex.
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Fig. 34
Coronal oblique fat-suppressed T2-weighted image showing in-
creased signal intensity within the superior aspect of the glenoid
labrum (arrow) posterior to the long head of the biceps tendon origin
in a patient with a type-II SLAP lesion verified by arthroscopy.
This capsulolabral or labral ligamentous complex is best ap-
preciated on sagittal oblique images. The sagittal oblique
plane is also useful for evaluating displaced bucket-handle
tears of the labrum39. Labral tears and superior labrum anterior-
posterior (SLAP) lesions are best appreciated on proton-
density and T2-weighted sequences4.
The most common classification of SLAP tears in-
cludes four distinct lesions, although recently new additions
and subclassifications have been added40,41. In type-I lesions,
the superior aspect of the labrum is frayed and degenerated
with a normal (stable) biceps tendon anchor. On magnetic
resonance imaging, the labral contour appears blunted or ir-
regular with a slight increase in signal intensity on T2-
weighted images42,43.
Type-II lesions have similar labral fraying, but the supe-
rior aspect of the labrum and the biceps anchor are detached,
making the lesions unstable. The magnetic resonance imag-
ing findings of type-II SLAP lesions include a line of high sig-
nal intensity coursing across the base of the hyperintense
labrum to the periphery (Figs. 32, 33, and 34). The long head
of the biceps tendon has normal signal and shape and is at-
tached to the avulsed labrum43.
Type-III lesions consist of a bucket-handle tear of a me-
niscoid superior aspect of the labrum without extension into
the biceps tendon. The biceps anchor is stable, and the re-
maining part of the labrum is intact. On magnetic resonance
MAG NETIC RESONANCE IM AG ING
OF THE SHOULDER
Fig. 35
Axial fat-suppressed proton-density image showing a type-IV SLAP le-
sion. There is increased signal intensity within the superior aspect of
the glenoid labrum with extension into the biceps anchor (arrow).
imaging, type-III SLAP lesions are characterized by a line of
high signal intensity coursing across the base of the hyperin-
tense labrum but extending beyond the equator in the case of
a nondisplaced bucket-handle tear. In type-III SLAP lesions,
the superior aspect of the labrum is also deficient, but the bi-
ceps tendon can be followed to the supraglenoid tubercle43.
In type-IV SLAP lesions, there is a bucket-handle tear of
a meniscoid superior aspect of the labrum with extension into
the biceps tendon. On magnetic resonance imaging, a type-IV
SLAP lesion is characterized by a line of high signal intensity
coursing across the base of the normally hypointense labrum
to the periphery and extending beyond the equator with a de-
ficient labrum42 (Fig. 35). In addition, there is hyperintensity
and splitting of fibers of the biceps tendon43.
SLAP lesions are frequently associated with other shoul-
der lesions that can be visualized on magnetic resonance im-
aging. Paralabral cysts almost invariably are associated with
labral tears29,44,45. Their presence should trigger a search for a la-
bral tear. The imaging features include a cystic-appearing
mass adjacent to the labrum or capsule with increased signal
on T2-weighted sequences29. Rotator cuff tears (both partial-
thickness and full-thickness) are also commonly associated
with SLAP lesions46.
Corresponding author:
Adam J. Farber, MD
Department of Orthopaedic Surgery, Johns Hopkins Hospital, 601 North
Caroline Street, JHOC 5th Floor, Baltimore, MD 21287-0883. E-mail ad-
dress: afarber1@jhmi.edu
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The authors did not receive grants or outside funding in support of
their research for or preparation of this manuscript. They did not re-
ceive payments or other benefits or a commitment or agreement to pro-
vide such benefits from a commercial entity. No commercial entity paid
or directed, or agreed to pay or direct, any benefits to any research fund,
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