 To become familiar with the normal

anatomy
 To be able to identify normal variants
 To appreciate the range of pitfalls that may
simulate pathology
 KISS principle

 Keep
 It
 Simple
 Straightforward
 Introduction
 Bones
 Rotator Cuff
 Intra articular structures

• MR approach
• Glenohumeral ligaments
 Take home messages
 Conclusion
 Discrepancy in size
• Small glenoid fossa
• Large humeral head
 Great mobility
 Vulnerable to dislocation
 Stability
• Passive mechanisms
• Active mechanisms
 Coracoacromial arch
 Rotatorcuff
 Glenohumeral ligaments
 Glenoid labrum
 Associated with lesions of capsule,
labrum, rotator cuff, coracoacromial arch,
bone
 In case of an isolated finding:
 THINK OF A NORMAL VARIANT
Impression in the posterior
contour of the humeral
head

Beneath the level of the

coracoid

Collum anatomicum=
normal

C
 Hill
Sachs defect AT THE LEVEL OF
CORACOID
S. Beltran
 Impingement and critical zone

Bianchi and Martinoli;Ultrasound of the

musculoskeletal system 2007
Non fused apofysis at the acromion
normal in a 15 year old boy

Acromial apofysis is closed>25 years

 T2SPIR

3 times risk RC tear!!

T2 T2SPIR
SPI
R
 Failure of fusion of accessory ossification
center
 Diagnosis after age 25
 Frequency ranges 1.3-15%
 Bilateral in 33-62%
 Higher frequency males and blacks
 Associated with RC tear and
impingement
 DD fracture, pseudarthrosis
Park JG Radiology 1994;193:255-257
Bigliani
 Type I flat
 Type II curved
 Type III hooked
 Type IV convex inferiorly

Controversial
 Type III associated with high incidence of
RC pathology
Pope. Imaging in the musculoskeletal system. 2008.
Ch 6. p 119
42 year woman
Persistent shoulder pain
No trauma
Refuses intra articular contrast

Coronal PD fat sat image

Normal
Be careful to diagnose an abnormal acromion on
Bigliani Type II curved acromion MR
Bigliani Type II
 Normal variants in anatomy
• Extremely rare (accessory muscles limited to
case reports)
• Volume (M/F)
• Fatty infiltration/atrophy (age)

Semin Musculoskelet Radiol 2010; 14(2): 106-121

RadioGraphics 2008; 28:481–499
 magic angle phenomenon
 55 degrees!

Increase in signal intensity when

collagen fibers are oriented at 55
degrees relative to the static main
magnetic field (B0) on short –TE MR
images
 anisotropy

www.essr.org; Bianchi and Martinoli

Normal sag oblique T1W Normal variation?
 72year old woman
 Posttraumatic instability
 Complete Cuff tear
 Joint
distension
 MR arthrography
 External rotation
 Local anaesthesia
 20-22 G needle
 Anterior approach
• Not directly in the joint space
 Non-ionic contrast
 Diluted gadolinium (total 18 cc)
 Start imaging no later than 30
minutes after injection
Jacobson Radiographics 2003
 Shoulder coil
 T1 SE fat suppression
• Coronal oblique
• Sagittal oblique
• Axial
• ABER
 DUAL coronal oblique
 T1 SE sagittal oblique
 Thickenings of the joint capsule
 Function depends on
• Collagenous integrity
• Site of attachment
• Position of the arm
 Extend from glenoid to
proximal portion of the humerus

Salvador Beltran
Stoller DW. Magnetic resonance imaging in orthopaedics and sports medicine.Vol.2, Wolters Kluwer,
Philadelphia
 ligaments are variable in number
 ligaments are variable in size
  Z-shape
 Superior GHL
• Present in 90-97%
 Middle GHL
• Present in 73-92%
 Inferior GHL
• Present almost 100%

Stoller DW. Magnetic resonance imaging in orthopaedics and sports medicine.Vol.2, Wolters Kluwer, Philadelphia, pp 608-620
 Origin:
• Anterior labrum
• Biceps tendon
• In common with middle GHL
 reflectionpulley system,
with coracohumeral ligament
(biceps tendon stability)
 Axial images
 Origin:
• Anterior portion of labrum
(most common)
• Glenoid
 variablein size
 important stabilizer
• (esp in case of IGHL injury)
 Axial and sagittal images
 Origin:
• Labrum
• glenoid
 Anterior, posterior band
 axillary recess
• Anterior Band – arises 2-4 o’clock
• Posterior Band – arises 7-9 o’clock

 Main stabilizer of an abducted

glenohumeral joint
 Coronal and sagittal images

Salvador Beltran
Stoller DW. Magnetic resonance imaging in orthopaedics and sports medicine.Vol.2, Wolters Kluwer, Philadelphia
 Sagittal
oblique images
 Anterosuperior quadrant
• From equator: anterior indentation of glenoid
rim as visualized on sagittal images
• To: biceps labral complex in a 12 o’clock
position

 Above the m. subscapularis

 12

ssc

9 3

6
 Congenital absence of anterosuperior
labrum
 Associated with cord-like MGHL
 6.5% of population

Salvador Beltran
Stoller DW. Magnetic
resonance imaging in
orthopaedics and sports
medicine.Vol.2, Wolters
Kluwer, Philadelphia
 Absence of anterior superior labrum
 Cord-like MGHL

De Maeseneer M, et al. Radiographics 2000; 20: S67-S81

 Sublabral foramen or hole
 Partially detached anterior superior
labrum
 Associated with cord-like MGHL in 75%
of cases

Williams MM Arthroscopy 1994;10:241-247

  14% of normal population

Stoller. Magnetic resonance imaging in orthopaedics and

sport medicine 2007
 Recess or Sulcus between the superior
labrum and the glenoid
 Directs medially

 DD
• Labral tear
• Directs laterally
Pope Imaging of the
musculoskeletal system 2008
Radiographics Beltran 1997
Radiographics Maeseneer 2003
 Type I
 Insertionfurther from the
glenoid margin (type III),
more unstable
 On MR appearance of Type II

capsular insertion varies with

endo- or exorotation
Type III

Pope. Imaging in the musculoskeletal system. 2008. Ch 6.p 121

1. Acromion variants can have clinical impact
Os acromiale (>25 years)
2. Rotator cuff variations extremely rare
US: anisotropy
MR : magic angle phenomenon
3. Intra articular variants are predominantly
located in the anterosuperior quadrant
 Knowledge of normal anatomy is
necessary

 Think of a normal variation especially in

an isolated finding

 Normal variations can have clinical

impact
www.boerhaavenet.nl
MSK Ultrasound course
Basic course: 16 and 17 may 2011
Advanced Course: 18 and 19 may 2011 MUSEUM OF NATURAL HISTORY
LEIDEN, The Netherlands