479
RADIOLOGIC
Normal MR Imaging Anatomy
of the Rotator Cuff Tendons,
Glenoid Fossa, Labrum,
and Ligaments of the Shoulder
Michel De Maeseneer, MD, PhDa,*, Peter Van Roy,
Maryam Shahabpour, MDa
- Bony structures of the glenohumeral joint
- Soft tissues of the glenohumeral joint
- Coracoacromial arch
- Rotator cuff and bursae
The shoulder is commonly imaged using MR im-
aging, with or without intraarticular contrast me-
dium. Some anatomic structures, such as the
rotator cuff tendons and bony components, can
be assessed without arthrographic technique,
whereas the glenohumeral ligaments and labrum
require arthrographic technique for more accurate
assessment. In either case, an understanding of
the normal anatomy of the shoulder with regard
to bony and soft tissue structures is essential for
MR imaging interpretation. In this article we discuss
normal anatomy and variations of the glenohum-
eral joint (bone and soft tissues), rotator cuff ten-
dons, and coracoacromial arch.
Bony structures of the glenohumeral joint
The shape of the glenoid fossa may vary consider-
ably. Some glenoid fossae are pear shaped with
a narrower superior portion compared with the
This article was previously published in Magnetic Resonance Imaging Clinics of North America 2004;12:1–10.
a
Division of Radiologic Sciences, Wake Forest University Hospital, Medical Center Boulevard, Winston-
Salem, NC 27157, USA
b
Department of Experimental Anatomy, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
* Corresponding author.
E-mail address: mdemaes2@wfubmc.edu (M. De Maeseneer).
0033-8389/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
radiologic.theclinics.com
CLINICS
OF NORTH AMERICA
Radiol Clin N Am 44 (2006) 479–487
PhD
b
,
- Neurovascular structures
- Acknowledgements
- References
inferior portion. A small bony indentation may be
present along the anterior border of the glenoid
fossa. As a result, the anterosuperior portion of
the labrum may remain unattached to the glenoid
fossa, creating a sublabral hole [1].
The concavity of the bony glenoid fossa also may
vary. Some may be shallow, others more concave.
Some 18% to 25% of individuals may present with
a blunted posterior margin, also designated as pos-
terior glenoid rim deficiency, predisposing to poste-
rior subluxation. The shape of the cartilage and
labrum, however, may compensate for the bony
deficiency. Usually the glenoid cavity reveals a 5- to
7-degree retroversion relative to the mediolateral
axis of the scapula. When retroversion becomes
more important, this may also predispose to poste-
rior luxation, although scientific evidence remains
controversial [2].
Dysplasia of the scapular neck is a rare condition
usually showing a shallow glenoid fossa with an
doi:10.1016/j.rcl.2006.04.002
480 Maeseneer et al

anterior bony notch. Usually the cartilage is mark-

edly hypertrophied in such patients [2].
The biceps groove offers a stable sulcus for the bi-
ceps tendon. The groove may be continuous with
a supratubercular extension, the ridge of Meyers.
The presence of the ridge of Meyers predisposes to
the formation of traction spurs at the edges of the
biceps groove, as shown by specimen studies [3].

Soft tissues of the glenohumeral joint

The biceps tendon attaches to the supraglenoid tu-
bercle, but fibers also insert on the superior labrum
and the base of the coracoid process (Figs. 1 and 2)
[4]. In its intraarticular position the biceps tendon
may be surrounded by a synovial layer of cells. It
may attach to the capsule by means of a mesen-
tery-like fold (Fig. 3) [5]. Rarely, the intraarticular
part of the tendon may be missing and the origin
may be in the intertubercular sulcus. Up to three ac-
cessory heads of the biceps muscle may originate
from the lesser tuberosity or from the anterior as-
pect of the capsule [6]. The short head of the biceps
muscle originates from the coracoid process. It may
be broadened by a lateral extension that runs over
the coracoacromial ligament.
The glenoid labrum is made of fibrous tissue and
enlarges the glenoid cavity (Fig. 4). The labrum
contains only sparse chondrocytes. Normally the la-
brum is larger at its superior aspect than at its infe-
rior aspect, and is also larger at its posterior aspect
than at its anterior aspect. Variations between indi-
viduals in the width and thickness of the labrum
vary from 2 to 14 mm. Significant variations in
Fig. 2. Attachment of biceps to superior labrum is
shown on transverse fat-saturated MR arthrogram
(short arrows).
the morphology of the labrum are also present
[4,7,8]. On transverse sections the labrum may be
triangular, rounded, crescent shaped, or blunted
(Fig. 5). Between the cartilage and the labrum a sub-
labral recess may be evident. This is especially so at
the level of the superior labrum (Fig. 6). In contra-
distinction to what many radiologists tend to think,
such a recess may also be found along other por-
tions of the labrum. Some authors have attempted
to identify characteristic distributions that would
allow differentiation of these recesses from trau-
matic dehiscence. Unfortunately, differentiation
from traumatic dehiscence may be difficult on all
imaging modalities, even arthroscopy [4,8].

Fig. 1. Line drawing shows attachment of biceps ten-

don to supraglenoid tubercle (1, arrow), to superior Fig. 3. Fat-saturated MR arthrogram. Arrow points to
labrum (2,3, arrows), and fibers coursing toward cor- biceps tendon. Note mesentery-like fold attaching to
acoid (4, arrow). the biceps tendon (arrowheads).

Fig. 4. Anatomic dissection after removal of head of
humerus. Photograph of glenoid fossa. Note labrum
(l), glenoid cavity (G), and biceps tendon (b). Superior
glenohumeral ligament is shown (asterisk), middle
glenohumeral ligament (black short arrows). Also
note inferior glenohumeral ligament (small arrows).
Opening (º) is seen between superior glenohumeral
ligament and subscapularis muscle. Ss, subscapularis
tendon.
At the level of the superior labrum three types of
attachments are recognized (Fig. 7). In a type 1 at-
tachment there is no cleft between the labrum and
cartilage. In contradistinction in a type 2 attach-
ment, a small recess may be present between
labrum and cartilage. In a type 3 attachment a large
Fig. 5. Line drawing of different shapes of glenoid la-
brum on transverse section. Note triangular shape (1),
blunted shape (2–5), recess under labrum (6), pseu-
dosplitting of labrum caused by adjacent ligament
(7), and heterogenous signal or calcification in la-
brum (8).
Normal MR Imaging Anatomy of the Rotator Cuff 481
Fig. 6. Photograph of model showing typical superior
sublabral recess (arrows).
recess is evident (Fig. 8). As mentioned previously
such large superior sublabral recesses may be diffi-
cult to differentiate from traumatic lesions, desig-
nated superior labrum anterior to posterior
(SLAP) lesions [4].
The sublabral hole or foramen is different from
the sublabral recess. It is present in 11% of
Fig. 7. Line drawing shows labrum (l), biceps (b), and
cartilage (c). Note type 1 superior labrum (no recess
present), type 2 (small recess), type 3 (large sublabral
recess).
482 Maeseneer et al

Fig. 9. Transverse gradient echo MR image. Note thick

Fig. 8. Type 2 recess is seen on coronal MR arthrogram cordlike middle glenohumeral ligament (arrowhead).
(small arrow).

individuals but may coexist with a superior subla- The subscapularis bursa is located between the scap-
bral recess [5]. A sublabral hole is typically found ula and subscapularis muscle. It communicates with
at the 2 o’clock position and is often seen when the joint through openings between the glenohum-
the glenoid cavity is pear shaped, becoming smaller eral ligaments and also through the sublabral fora-
above the equator. Measuring the width of the gle- men. A capsular reinforcement, designated as the
noid cavity below and above the equator may be an rotator cable, may be found on the posterosuperior
additional clue to the diagnosis of a sublabral hole. aspect of the capsule, presenting as a vertically ori-
In about 2% of individuals the anterosuperior la- ented fold [10].
brum is entirely absent. In some of these individ- The glenohumeral ligaments reinforce the ante-
uals the middle glenohumeral ligament may show rior and inferior portions of the capsule (Figs. 10
a cordlike thickening. This situation is often desig- and 11). Their appearance may vary from well-devel-
nated the Buford complex, and is seen in 1.5% of oped ligaments to bundles of collagen fibers in the
persons [4]. capsule with an orientation different from other
On the anterior aspect of the scapula the attach-
ment of the capsule was differentiated in three types
by Zlatkin et al [9]. In type 1 the capsule attaches
adjacent to the glenoid labrum. In type 2 the cap-
sule attaches at the level of the neck of the scapula,
and in type 3 the insertion is situated at the transi-
tion area between neck and body of the scapula.
The precise level of attachment may occasionally
be misinterpreted related to a large overhanging
subcoracoid or digitiform joint recess [9]. In the ax-
illary region the capsule may be partially fused with
the tendon of the triceps muscle that inserts on the
infraglenoid tubercle. At the level of the humerus
the capsule inserts on the anatomical neck. On
the posterior side a small bare area is present be-
tween the cartilage and the insertion of the capsule
on the humerus. The capsule of the glenohumeral
joint has three enlargements: the subcoracoid, axil-
lary, and intertubercular recesses [7]. Openings are
present in the capsule through which the joint cav-
ity is in direct continuity with these expansions. A Fig. 10. Note inferior glenohumeral ligament (arrow)
constant recess surrounds the long tendon of the on transverse MR arthrogram. Biceps tendon sur-
biceps muscle in the intertubercular groove (Fig. 9). rounded by peribicipital recess also is seen (B).

Fig. 11. Transverse CT arthrogram shows common or-
igin of biceps (arrowheads) and superior glenohum-
eral ligament (arrow).
capsular fibers. In this situation the capsular folds
are only evident with certain arm positions. The su-
perior glenohumeral ligament originates from the
superior part of the glenoid cavity, anteriorly to the
origin of the biceps tendon. Its origin may be shared
with the biceps tendon or middle glenohumeral lig-
ament. On transverse images the ligament courses
parallel to the lateral aspect of the coracoid process.
The superior glenohumeral ligament is a fairly con-
stant structure, present in most persons [4].
The middle glenohumeral ligament attaches on
the anterosuperior labrum or the neck of the scap-
ula. It then courses in an inferolateral direction, in-
serting on the humerus medial to the lesser
tuberosity. It is the most variable ligament in size
and presence. It may be absent in 8% to 30% of
shoulders. It may have a cordlike appearance or
may correspond to a capsular fold. Openings above
and below the middle glenohumeral ligaments
have been reported in 36% to 46% of shoulders.
One single opening superior to the middle gleno-
humeral ligament is reported in 6% to 18% of indi-
viduals. When the middle glenohumeral ligament
is absent a large communication may be found be-
tween the joint and subscapular bursa [11–13].
The inferior glenohumeral ligament has an ante-
rior and a posterior band and an intermediate por-
tion, the axillary recess. All structures together are
sometimes referred to as the ‘‘inferior glenohumeral
ligament complex.’’ The anterior band originates on
the anterior labrum at the 2 to 4 o’clock position.
The anterior band is thicker than the posterior band
in 75% of individuals. The posterior band origi-
nates on the posterior labrum at the 7 to 9 o’clock
position. The anterior band attaches inferiorly to
the humeral head. It plays an important role in
the stability of the shoulder [14].
The coracohumeral ligament originates from the
lateral aspect of the base of the corocoid process. It
Normal MR Imaging Anatomy of the Rotator Cuff 483
inserts on the tuberosities of the humerus on both
sides of the intertubercular groove. In 20% of indi-
viduals fibers from the pectoralis minor tendon
may insert on to the coracohumeral ligament. The
coracohumeral ligament is therefore a rudimentary
insertion of the pectoralis minor muscle [15].
Coracoacromial arch
The supraspinatus outlet corresponds to an osteoli-
gamentous ring formed by the spina scapula, the
acromion, the coracoacromial ligament, and the co-
rocoid process.
The dimensions and orientation of the acromio-
clavicular joint surfaces varies significantly among
individuals. A fibrous plica or cartilaginous menis-
cus may be present in the joint space, also altering
joint configuration. The shape of the acromion
may show considerable interindividual variation.
The undersurface of the acromion, as seen on obli-
que sagittal MR images, has been classified into dif-
ferent types. It may show a flattened, concave,
convex, or hooked appearance (Fig. 12). Although
it has been suggested that the convex and hooked
types may predispose to rotator cuff tears, there also
appears to be high interobserver variation in the
classification of acromial types. In the oblique sag-
ittal plane, anterior downsloping of the acromion
may be assessed, and has also been listed as a cause
of impingement. At the anterior aspect of the acro-
mion spur formation may occur in the coracoacro-
mial ligament as a result of humeroacromial
conflict [2,16].
In the oblique-coronal plane, lateral downslop-
ing of the acromion may be evaluated. The slope
and the length of the acromial process in this plane
may result in limited subacromial space, although
Fig. 12. Line drawing showing different aspects of the
undersurface of the acromion in the oblique sagittal
plane. Hooked acromion with marked downsloping
limiting subacromial space (A), convex undersurface
(B), concave undersurface with wide subacromial
space (C).
484 Maeseneer et al
again the relationship with impingement remains
unclear. The scapular spine root angle, the slope
of the acromion in the sagittal plane, and the acro-
mial offset all are factors determining the supero-
posterior bony coverage of the humeral head.
Most of these variations have been studied with
conflicting results, and precise values that allow dif-
ferentiation of the normal from the abnormal are
still lacking [2]. Dynamic MR studies may be per-
formed with the arm in different positions, prefera-
bly those that provoke the pain caused by
impingement. The clinical relevance of the results
of such studies remains to be proven [17].
The os acromiale is an accessory ossicle between
the distal aspects of clavicle and acromial process
(Fig. 13). It is reported to be present in 1% to
15% of persons. It often results in clinical symp-
toms of impingement, although in some cases it
may be asymptomatic. The presence of secondary
MR findings, such as rotator cuff tendinopathy
and bone marrow edema, suggest the clinical rele-
vance of the os acromiale [18,19].
The coracoclavicular ligament is comprised of the
laterally situated trapezoid ligament and the medial
and posterior conoid ligament. The coracohumeral
interval lies between the humeral head and cora-
coid process. In normal individuals this space aver-
ages 6.7 to 8.7 mm. Several morphologic variations
may predispose to anterior impingement [20].
These coracoid changes include coracoid slope in
the sagittal and transverse planes, length of the cor-
acoid process, and coracoid offset. These factors de-
termine the available space between the anterior
aspect of the humeral head and the coracoid
process.
Fig. 13. Transverse CT image shows os acromiale
(star).
Rotator cuff and bursae
The rotator cuff is comprised of the subscapularis,
biceps, supraspinatus, infraspinatus, and teres mi-
nor muscles (Fig. 14). The subscapularis muscle
may be divided into nine bellies (Fig. 15). The most
inferior belly may insert separately on the humerus
distally form the main insertion on the minor tro-
chanter [6]. Occasionally a belly may insert on the
coracoid process. The supraspinatus tendon con-
tains a single large tendon and inserts on the greater
tubercle and superolateral aspect of the humerus
(Figs. 16 and 17). The most cranial portion of the
tendon appears more rounded and is also twice as
long as the remainder of the tendon. It constitutes
the posterior margin of the rotator cuff interval
[6]. A fusion between the infraspinatus and teres
minor tendons is so common that the latter is
sometimes considered the inferior belly of the infra-
spinatus. Hence, the presence of a separate teres mi-
nor tendon should be considered a variation
(Fig. 18) [6].
Bursae about the shoulder joint are divided into
communicating and noncommunicating types.
The communicating bursae include the subcora-
coid bursa, the subscapular bursa and the peribici-
pital recess. Noncommunicating bursae include
a bursa superior to the acromioclavicular joint,
a bursa near the inferior tip of the scapula, and
Fig. 14. Oblique sagittal T1 weighted MR image at
level of coracoid process. Supraspinatus (S), infraspi-
natus (I), and subscapular muscle (SC) are seen, as
well as attachment of triceps tendon (t) to inferior
glenoid.
 Normal MR Imaging Anatomy of the Rotator Cuff 485

Fig. 15. Oblique coronal MR arthrogram. The differ-

ent tendons arising from the subscapularis muscle
belly are seen (arrows).

another between scapula and ribs. Still others are

located at the insertion sites of the latissimus dorsi,
teres major, and pectoralis major muscles [21].
The subacromial and subdeltoid bursae are usu-
ally fused to form to subacromiodeltoid bursa
(Fig. 19). This primary bursa has a typical synovial
layer.
Neurovascular structures
Neurovascular structures about the shoulder in-
clude the brachial plexus and axillary artery and
Fig. 17. Coronal T1-weighted MR image. Note inser-
tion of infraspinatus tendon and teres minor tendon
on posterior aspect of humerus (curved arrow).
vein. Twenty-nine variations of the brachial plexus
and its emerging nerves have been described. Many
of these variations predispose to thoracic outlet syn-
drome [22]. Accessory scalenus muscles are fre-
quent (28% of the population) and may lead to

Fig. 16. Note single supraspinatus tendon (S). Supe-

rior sublabral recess is also seen (short arrow) as well
as suprascapular notch (curved arrow). Note that Fig. 18. Sagittal oblique T1-weighted MR image. Note
suprascapular notch is covered by ligament. insertion of supraspinatus tendon (asterisks).
486 Maeseneer et al

Fig. 19. Coronal anatomic slice. Joint space is seen
(short white arrow). Also note subacromiosubdeltoid
bursa (asterisks). Communication between joint space
and bursa is present as a result of ruptured supraspi-
natus tendon (Courtesy of D. Resnick, MD, San Diego,
CA.)
Fig. 20. Transverse anatomic slice. Note anterior and
posterior labrum (stars). Spinoglenoid fossa contain-
ing nerves for infraspinatus muscle is shown (white
short arrow). (Courtesy of D. Resnick, MD, San Diego,
CA.)

neurovascular compression when hypertrophied, in athletes. Instead, the axillary nerve may pierce
such as in respiratory disease and certain sports. Be- the subscapularis muscle, leading to entrapment.
cause of the tremendous anatomic variability, most Other accessory muscles may be present in the ax-
surgeons are reluctant to operate in this region out illa and exert compression on diverse neurovascular
of concern for inadvertently injuring neurovascular structures.
structures, with catastrophic consequences.
Langer’s muscular arch of the axilla consists of
a tendinous or muscular connection between the Acknowledgements
latissimus dorsi and pectoralis major muscles. The
arch may exert compression on neurovascular struc- The authors thank Eric Barbaix, MD, Lecturer, De-
tures in the axilla [23]. partment of Anatomy, Rijks Universiteit Gent, Bel-
The suprascapular nerve passes through the scap- gium, for his knowledge of classic anatomic
ular notch and contains motor branches for the textbooks and anatomic variations. This work was
supraspinatus and infraspinatus muscles (Fig. 20).
The scapular notch is covered by the transverse
scapular ligament. In some individuals the notch
may be covered by a fibrous or bony bridge, result-
ing in nerve compression [24]. Also, an accessory
ligament (50%) may be present anteroinferiorly
to the transverse scapular ligament, with the supra-
scapular nerve passing inferior to it. Hence signifi-
cant friction is exerted on the nerve in case of
sudden shoulder movements [25]. Of the supra-
scapular nerve, two motor branches are directed
to the supraspinatus fossa innervating the supraspi-
natus muscle, and two other motor branches are di-
rected to the infraspinatus fossa innervating the
infraspinatus muscle. Depending on the location
of compression, a particular type of compressive
neuropathy may result (Fig. 21). Labral cysts are
one such cause of nerve branch compression, and
may be easily diagnosed with MR imaging [26].
The quadrilateral space is located between the
humerus, triceps, teres minor, and teres major ten-
dons (see Fig. 18) [27]. The axillary nerve and pos- Fig. 21. Spinoglenoid notch often contains marked
terior humeral circumflex artery pass through this vascular structures (black circle) not to be confused
space and compression may occur here, especially with labral cysts.

financially supported by Prijs Professor Dr. A. Baert,
Katholieke Universiteit Leuven.
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