SHOULDERINSTABILITYANDROTATORCUFFINJURIESJ.GARCIA第1頁INTRODUCTIONShoulderinjuriescomprise8-13%ofallathletesinjuriesResultfrom.repetitiveoverloadactivities:swimming,tennis...ordirecttrauma(collision):football,rugby…第2頁INCIDENCESPORTS%TYPEOFLESIONSBaseball11-17AC,imping.,RCtenditisWrestling17Glenohumsubluxordislocation,ACTennis56RCtendinitis,imping.Volley-ball44Bicepstendinitis,imping.Javelinthrowers29Bicepstendinitis,imping.etc…第3頁SHOULDERANATOMYBones:humeralheadandglenoidCartilageandlabrumCapsuleandligamentsMuscles

BELTRAN第4頁P(yáng)LASTICITYOFLABRUMArticularcartilage,andglenoidlabrum.LabrumwhichhavesomeplasticityseenondifferentpositionsExternalrotationofhumerusInternalrotation第5頁ANTERIORCAPSULEINSERTIONTypeIII,themoremedialinsertion,ispronetoanteriorglenohumeralinstabilityFromBELTRANImagingoforthopedicsportsinjuriesSPRINGER2023,p1293typesofinsertion第6頁SHOULDERBIOMECHANICSShoulderisthemostmobilejointinthehumanbodyFunctionrequirescoordinatedmotionof4joints.scapuloclavicular.acromioclavicular.glenohumeral.scapulothoracic

第7頁SHOULDERBIOMECHANICSMotion0-180%inelevationinternalandexternalrotation150%anteriorandposteriorrotation170%第8頁STABILIZINGMECHANISMSOFGLENOHUMERALJOINTPASSIVEMECHANISMS.Size,shape,tiltottheglenoidfossa.Negativeintracapsularpressure.Adhesion,cohesionofarticularsurfaces.Ligamentsandcapsule.Glenoidlabrum.Oseousbonerestraints:acromion,coracoidprocess第9頁STABILIZINGMECHANISMSOFGLENOHUMERALJOINTACTIVESTABILIZINGMECHANISMS.longheadofthebicepstendon.rotatorcuffmuscles.subscapularismuscleCoronalSagittalAxialArthroMR第10頁"VICIOUSCIRCLE"OFSHOULDERINJURIESPainoccursinwomenespeciallywhenthereisaphysiologicinstabilitythatmaybemultidirectionalSTONE1994INSTABILITYCOMPRESSIONIMPINGEMENTPAINMUSCULARIMBALANCEROTATORCUFFWEAKNESS第11頁LAXITYvsINSTABILITY

DefinitionsLAXITY:theabilitytopassivelytranslatehumeralheadtotheglenoidfossaINSTABILITY:aclinicalconditioninwhichsymptomsareproducedbytheunwantedtranslationoftheumeralhead,givingrisetopainordiminishedshoulderfunction第12頁SHOULDERINSTABILITYThislectureismainlydevotedtogleno-humeralinstabilityduetotimelimitations,butDONOTFORGETpleasescapular,clavicular,acromio-clavicular,sternoclavicularinjurieswhicharealsoseeninsportsactivities第13頁THEOVERHEADNTHROWING

MECHANISMCenterofrotationThecurvedharrowrepresentsthepathanddirectionofthegreatertuberosityasthearmexternallyrotatesBELTRAN2023第14頁IMAGINGTECHNIQUES

RADIOGRAPHYAP,axialviewsCT,ARTHRO-CTMRI,ARTHRO-MR第15頁RADIOGRAPHYAntero-inferiordislocationonAPandNeerviews.AxialviewisbetterthanNeertoappreciatecorrectlythehumeralheadpositionAxialview第16頁ARTHRO-CTArthro-CTforstagingoflesionsafterbilateralgleno-humeraldislocation:humeralheadbonedefectsandglenoidlesions第17頁ARTHRO-MRArthro-MRtechnique:iodinecontrastanddilutedGd.RadiographyafterfluoscopicguidanceandMR(3planes,T1wFSandT2w)第18頁ANTERIORINSTABILITYMorefrequent90%Recurrences>50%Inyoungpatients,aftertrauma第19頁ABNORMALITIESINANTERIORINSTABILITYAvulsionofgelnoidlabrum75%IGHligamentlesion,HILL-SACHS50%SLAPlesions25%CapsulelaxityRotatorcuffteras(olderpatients)20%第20頁ANTERO-INFERIORDISLOCATIONFirstepisodeThirdrecurrence第21頁BONELESIONSAFTERANTERO-INFERIORDISLOCATIONDislocationAfterreduction,Hill–Sachslesion第22頁ASSOCIATIONOFLESIONSBankartlesiontype4Hill–Sachslesion(samepatient)第23頁BANKARTLESIONSArthro-MR:BankarttypeIII4typesofBankartto1:small,3severe,4fracture第24頁ASSOCIATIONOFLESIONSAvulsion,fractureandloosebodyFromBELTRAN,Radiographics1994,666第25頁P(yáng)OSTERIORINSTABILITYLesscommon<5%Unidirectionalisuncommon.Commonlybidirectional(postandinf)ormultidirectional

Inepilepsy,ethanol,elcetricityshock(3Erule)Alsoduringrepetitiveappliedathleticforces:swimming,throwing,punching,andinsportscollisionsuchasfootball第26頁P(yáng)OSTERIORINSTABILITYClinicaldiagnosismuchmoredifficultthaninanteriorinstabilityImagingtechniquesareimportantEspeciallythefirstradiographicevaluationisESSENTIAL第27頁P(yáng)OSTERIORINSTABILITYPosteriordislocationwithfractureofanterioraspectofthehumeralhead(inverseofHill.Sachsinjury)第28頁P(yáng)OSTERIORINSTABILITYPosteriordislocationwith"poteriorBankart"

FromTIRMAN,MRIclinicsNAm1997,883第29頁MICROINSTABILITYOFSHOULDERMicroinstabilityconcernsthe1/3supjointinsportmenandsportwomen,especiallyforriskofSLAPlesionsArthro-MRissuperiortonativeMRforagoodstagingoflesions,includingviewsinABERposition第30頁MRinABERPOSITIONForanteriorshoulderinstabilityForcapsuleandlabruminjuriesForHILL–SACHSinjuriesWINTZELL1998第31頁MULTIDIRECTIONALINSTABILITYInstabilitymorethaninonedirectionAntero-inferior,postero-inferior,or3directions

Oftenatraumatic(withouttrauma),orviolentinjury,orrepeatedmicrotrauma第32頁ISOLATEDLABRUMTEARSTearswithoutinstabilityButsourceofdysfunctionIntheathleticpopulationInjurysimilartogleno-humeraldislocationSensationofinstability第33頁LABRUMTEARSSLAPlesiontype2c,onarthro-MRSLAP=SsuperiorLlabrumAanteriorPposteriorARTHRO-MRISTHETECHNIQUEOFCHOICE第34頁ROTATORCUFFINJURIESAgeisimportantinshoulderpathologyAccordingtoHoffmeyer<30y.laxityandinstability>30y.tendinopathies,tears>40y.tears,perforation>50y.gleno-humeralosteoarthritis(OA)Med.Hyg1998,56:2218第35頁IMPINGEMENTSYNDROME95%ofrotatorcuff(RC)lesions,Neer1972Mechanicalinjuryfromcompressionofthesubacromialstructures:Suprasupinatus(SSP)tendon,greatertuberosityofhumerus,subacromialbursa

第36頁SECONDARYIMPINGEMENTInyoungpatientsandathletesinvolvedinthrowingsports,shoulderimpingementcanoccurwithinstability第37頁IMAGINGTECHNIQUES

RADIOGRAPHYSONOGRAPHYMRIANDARTHRO-MR第38頁RADIOGRAPHYAP,neutralrotationInternalrotationExternalrotationNeerviewAtleastAPneutralandNeerviews,sometimesint.etext.rotation!第39頁SONOGRAPHYTechnique.broadband-transducers5-12MHz.differenttypesofprobe,includingtype"hockey-stick-shaped"MultidirectionalapproachDynamicandcomparativestudy(bothsides)Onlyperpendicularstructures,becauseobliquitycreatesartefactsOperatordependant第40頁SONOGRAPHYESSENTIALREQUIREMENTS:

.personnalexperience.rigourousexamination.verygoodknowledgeofanatomyPositionofprobeforanteriorapproachofsholuder第41頁SONOGRAPHYFINDINGSDegenerativesuprasupinatustendonandtearPosttraumaticSSPtear第42頁SIGNSOFRCTEARSDIRECTSIGNSOFCOMPLETETEAR1.Flatarea,scaleoftheborder2.Anechoiczonethroughthetendon3.Massivethinessofthetendon4.TendoninvisibleINDIRECTSIGNS1.Erosionsofthegreatertuberosity2.Subacromialbursitis,jointfluid3.Deltoidherniation4.MuscleatrophyPEETRONS2023第43頁SONOGRAPHYEFFICIENCYINPARTIALRCTEARSSensitivity93%Specificity94%

HOLSBEECKMvRadiology1995,197:443BUTONLYBYEXPERIENCEDOPERATOR!第44頁MAGNETICRESONANCEMRoffersamultiplanarapproachandagoodtissuedifferenciation(thebest)Examinationin3planes:coronal,sagittal,axialMultiplesequences:PDforanatomyT2wFSforsignalFE3DforcartilageArthro-MRforincompletetears,labrumtears

第45頁MAGNETICRESONANCECoronalAxialSagittal第46頁ANATOMICVARIATIONSTHATMAYPREDISPOSETOIMPINGEMENTAcromialshapeAcromiallateraltiltDiminishedarcheightCoracoidlenghtMusclehypertrophyOsacromialeDisplacedgreatertuberosityAcromialshapeflat,curved,hocked第47頁ACROMIALSHAPEANDRCTEARSHockedacromiononAPandNEERviewsAtrhro-MRT1FS:completetearofSSPtendon第48頁ROTATORCUFFTEARSFunctionalinfirmityElevationofRupperlimbimpossibleArthro-MR:completetearofSSPtendonwitretraction第49頁ROTATORCUFFTEARSDimensionsoffullthicknesstearsclassifiedonbasisofgreatestdimensionsSmall<1cmMedium1-3cmIMPLICATIONFORTTLarge3-5cmMassive>5cmDeOrio,CofieldJBJSam1984,66(4):563第50頁P(yáng)ARTIALRCTEARSInferiorSSPtearmorecommonthansuperiortearNottreatedmayleadtochronicpainandinvalidityMaypropagatetofullthicknesstearGradingofpartialtears1.less3mm2.3-6mm3.more6mm第51頁P(yáng)ARTIALRCTEARSArthro-MR:inferiorpartialofthesuprasupinatustendon;noperforation,nopassageofcontrastmediuminsubacromialbursa第52頁MULTIPLERCTEARSSometimesinfrasupinatusandsubscapularistearsareassociatedwithasuprasupinatustearAcompletegoodstagingiscompulsoryforchoosingthebesttt,especiallybeforeeventualsurgery(whichtypeofsurgicalrepair…)Forasuchevaluation,MRandsometimesarthroMR,arethetechniquesofchoice第53頁MULTIPLERCTEARSSuprasupinatuscompletetear,retractionoftendon,muscleatrophywithinfrasupinatuspartialtearandmuscleatrophy.AlsoOAinAC第54頁EXTENTOFRCTEARSTHOMAZEAUClinOrthopRelatRes1997,344:275第55頁MUSCLEATROPHYMuscleatrophyfollowsarotatorcufftearnottreatedMuscleatrophyverywellappreciatedbyMRDependsonthelenghtofevolutionStage1.fewfattytrails2.moremusclethanfat3.muscle=fat4.morefatthanmuscleAfter6monthsofevolutionstage>2,after1yearstage4GoutalierDClinOrthop1994,304:78第56頁MUSCLEATROPHYAnormalSSPmuscleoccupythewholesupraspinatusareaWhenatrophythevolumedecreased第57頁ACROMIOCLAVICULARJOINTINJURIES

VeryofteninlookingforaneventualRCtear,anacromioclavicularjointinjuryisdiscovered,suchasosteoarthritiswithbonyspurs,andevenwithaninflammatorycomponent(bon