MRI of the Shoulder - Atlantic Radiology Conference - Dalhousie ...

MRI of the Shoulder 

Alan Brydie FRCPC 

Department of Radiology 

Dalhousie University

Dislosures 

None

Objectives 

• Describe normal rotator cuff and 

labroligamentous anatomy of the shoulder 

• Discuss what the surgeon needs to know in 

rotator cuff injury 

• Describe imaging appearances across the 

range of labroligamentous shoulder injuries

• Rotator Cuff 

– Anatomy 

– Tears 

Outline 

– What surgeon wants to know 

• Labrum 

– Anatomy and variants 

– Anterior inferior quadrant injuries 

– Superior quadrant injuries 

– What the surgeon wants to know

Anterio 

r 

Rotator Cuff Anatomy 

Opsha et al. Eur J Radiol (2008);68:36-56 

• Supraspinatus 

– Supraspinatus Fossa 

– GT (Superior facet) 

– Two Bellies (A > P) 

• Infraspinatus 

– Infraspinatus fossa 

– GT (Middle facet) 

– Multipenate

Anterio 

r 



• Supraspinatus 

– Supraspinatus Fossa 

– GT (Superior facet) 

– Two Bellies (A > P) 

• Infraspinatus 

– Infraspinatus fossa 

– GT (Middle facet) 

– Multipenate

Anterio 

r 



• Subscapularis 

– Subscapular fossa 

– LT ( + GT : THL) 

– Multipenate 

• Teres Minor 

– Lat border Scapula 

– GT (Inf facet) 

– Multipenate

Anterio 

r 



• Subscapularis 

– Subscapular fossa 

– LT ( + GT : THL) 

– Multipenate 

• Teres Minor 

– Lat border Scapula 

– GT (Inf facet) 

– Multipenate

Sub 

Sub 

SS 

SS 

IS 

IS 

TMin 

Sub 

Sub 

SS 

SS 

IS 

TMin 

TMin TMin 

IS

IS 

Sub 

SS 

TMin 

TMin 

SS 

Sub

Rotator Cuff Tears 

• Tear vs. tendinopathy 

• Partial vs. Full thickness 

• Associated findings 

• What Surgeon wants to know

Tear vs Tendinopathy 

Tendinopathy 

• Hyperintense PD 

• Not fluid on T2 

• Often amorphous 

Tear 

• Hyperintense on PD 

• Fluid Signal on T2 

• Usually linear component 

T2 fat sat PD

Partial thickness rotator cuff tears 

• Types: 

– Articular 

– Bursal 

A tear which does NOT extend from 

Articular surface to Bursal Surface 

– Interstitial/intrasubstanc 

e 

• Grades 

– High (> 50% thickness) 

– Low (< 50% thickness)


Articular Bursal 

Intrasubstance 

(+ tendinopathy)


High Grade (Bursal) Low Grade (Bursal)

Full thickness cuff tear 

A tear which extends from the 

Articular surface through to Bursal surface 

• Describes only one component of the tear 

• Does not describe Anterior to Posterior extent


Thin, linear


Focal anterior suprasinatus

Full thickness cuff tears 

Large supraspinatus/infraspinatus

Important additional tear features 

• Size: 

– Anterior to Posterior 

– Medial to Lateral 

(tendon separation) 

• Delamination 

– Longitudinal 

intrasubstance tracking 

• Muscle Belly Atrophy


• Size: 







• Muscle Belly Atrophy


• Size: 







• Muscle Belly Atrophy 

fat 

fat 

fat 

ss

Additional Features – 

Bone Predisposing to Impingement 

Anything causing narrowing of subacromial 

space 

• Acromial morphology and slope 

• Subacromial spur or keel spur 

• AC joint osteophytes

Acromial morphology 

1: Flat 2: Gentle Curve 

3: Anterior Hook

Bony Impingement 

Laterally downsloping acromion Os acromiale

Bony Impingement 

Subacromial Spur Lateral keel AC osteophytes

What the surgeon wants to know 

• Tear vs. Tendinopathy vs. Normal 

• Full or partial thickness tear (+ grade) 

• Location (what tendons and where) 

• Describe extent (M‐L, A‐P, 

delamination) 

• Background tendinopathy 

• Muscle belly bulk 

• Predisposing bony morphology 

• Other abnormalities

Labroligamentous Injury 

• Anatomy 

• Normal variants 

• Anterior inferior pathologies 

• Superior pathologies 

• What the surgeon want to know

• Fibrocartilage 

• Circumferential 

Labroligamentous Anatomy 

Labrum 

• Deepens glenoid fossa 

• Clockface and “Quadrants” 

• Superior and anterosuperior 

– Poorest blood supply 

– Most lax 

– Variations 

Modarresi et al. AJR 2011;197:596-603

• Long Head Biceps 

Labroligamentous Anatomy 

– Supraglenoid Tubercle (SGT) 

– Superior labrum 11 ‐ 1 

• Ant/Ant‐Post/Post 

• SGHL 

– SGT and/or A/S labrum to LT 

– Stabilize biceps in groove 

• MGHL 

– SGT or A/S labrum or SGHL to LT 

– Variable –may be absent 

– Restricts inf translation humerus 

– Limits Ext Rot at 45 degree Abduction 

• IGHL (Ant and Post) 

– Inf labrum to inf anatomic neck humerus 

– AIGHL primary restraint Ant Dislocation 

– PIGHL limits post translation in 

Abduction and Ext Rotation (throwers) 

Glenohumeral ligaments and 

Biciptal labral complex 


Glenohumeral ligaments 

Superior GHL 

Middle GHL 

Anterior inferior GHL

Glenohumeral ligaments 

Superior Middl 

e 

Anterior Inferior Anterior Inferior Posterior Inferior

Labral Anatomy: Variations 

• Cross sectional morphology 

– Triangular, 

– round, crescent, notched, cleaved 

• Attachment 

– Firmly attached 

– Detached (location important) 

– Free central border “meniscoid” 

• Absent labrum 

– Location, relationship of labrum to MGHL

Labral Morphology Variants 

Triangular Round 

Flat Notched

Labral Attachment Variants 

• Initially 5 different types of labral morphology and 

attachment described …… 

• Simplified into 2 types: 

– Entirely secured to the glenoid peripherally and 

centrally 

– Attached to the glenoid peripherally, centrally 

mobile above the equator (meniscoid) 

• Meniscoid type described below equator up to 10% 

BUT almost never in the anterior/inferior quadrant

Meniscoid attachment

Labroligamentous Variants 

Sulcus or Recess 

• Location: 11 –1 o’clock (BLC) 

• Superior labrum not attached to 

glenoid (normal attachment to biceps) 

• Smooth margin 

• Parallels cortex of glenoid 

• Nearly always

Sublaral Sulcus or Recess

• Up to 19% of shoulders 

• Anterosuperior Labrum 

• Not attached to glenoid 

• Usually 


Foramen or Hole 

between 12 –3 o’clock … 

NEVER below 4 o’clock 

• “Labral slip” 

– 

reattaches to glenoid 

(versus Buford Complex) 

• Very often associated with 

sublabral recess BLC 

• ? High origin AIGHL (Stoller) 

Sublabral foramen 


Sublabral foramen


Absent Anterosuperior Labrum (Buford) 

• Up to 6% of shoulders 

• Absent anterosuperior Labrum 

• Thickened cord‐like MGHL 

Buford Complex 


Buford complex

Bottom line on the labrum 

• Many variations , anterosuperior and superior 

• No variations of attachment anteroinferior 

• BLC variants are never 

– Frayed 

– Not paralleling the glenoid 

– Asymmetric 

– Wider than 5mm (usually 2mm)

Labroligamentous Tears 

• Different patterns related to different trauma 

• Anterior Inferior quadrant 

• Bankart and variants 

• Anterior dislocation 

• Superior 

• SLAP “Superior Labrum Anterior to Posterior” 

• Overhead throwing or FOOSH

Anterior Inferior Quadrant Tears 

• Bankart and variants 

• IGHL tears 

• Anterior dislocation 

• Can coexist with SLAP tear 

• May have fracture 

• Macroinstability 

• Require surgical repair

Bankart 

• Anteroinferior avulsion of labroligamentous 

complex from glenoid/scapular neck 

• Disprupted Periosteum 

• Fragment comprises 

– Labrum, AIGHL (+/‐ 

MGHL), periosteum 

• Variable location and morphology

Bankart

Bony Bankart

• Avulsed labrum 

Bankart Variants 

• Different patterns of involvement (or lack of 

involvement) of periosteum and IGHL 

• Perthes 

• ALPSA (anterior labroligamentous periosteal sleeve avulsion) 

• GLAD (glenolabral articular disruption) 

• Double lesion/Triple lesion


• Attached to periosteum 

• Periosteum 

– Stripped 

– Intact 

• Minimal displacement 

Perthes Lesion

ALPSA Lesion 

(Anterior labroligamentous periosteal sleeve 

avulsion) 


• Attached to periosteum 

• Periosteum 

– Stripped 

– Intact 

• Labroligamentous 

fragment rotated and 

folded inferomedially

GLAD lesion 

(Glenoid labrum articular disruption) 

• Superficial AI labral tear 

• AI glenoid articular 

cartilage defect 

• Different mechanism 

– Forced adduction when ext 

rotated 

• Not assocd with instability

IGHL Injuries 

• Humeral avulsion anterior band 

(HAGL) 

• HAGL with bone involvement 

(BHAGL) 

• Glenoid avulsion with normal 

labrum (GAGL) 

• HAGL and GAGL (AIGHL) 

• Mid axillary pouch tears 

• Posterior band (PHAGL) 

Normal IGHL’s 

Anterior Inferior 

Posterior Inferior

HAGL 

• Humeral avulsion anterior 

band (HAGL) 

• Much less frequent than 

Bankart in Anterior 

Instability 

• May coexist with Bankart 

• Look for contrast extending 

down humeral metaphysis 

– Loss of U or hammock 

configuration at insertion 

IGHL Injuries

SLAP Tears 

• Superior labrum anterior to posterior 

• Overhead throwing or FOOSH 

• Ten types 

• 4 initially (Synder 1990), 6 more added since 

• All involve superior labrum with varying 

extension around labrum and/or into other 

structures 

• Should know types I –IV, look up the others 

• All > SLAP 1 are unstable ‐ 

surgery

• 10 –2 o’clock 

• Fraying inner margin of 

superior labrum 

• Peripheral attachment 

labrum and biceps to the 

glenoid remains intact 

SLAP I

• 10 –2 o’clock 

SLAP II 

• Labrum and biceps stripped from 

glenoid, biceps tendon not torn 

• “the superior labrum and 

attached biceps tendon were 

stripped off the underlying 

glenoid” ‐ Snyder 

• 3 subtypes: Ant, Post, Both 

• Most common type of SLAP (40‐ 

50%) 

• Infequently solitary (28%)

SLAP II versus Sublabral Recess 

• SLAP II (vs biciptal labral 

recess) 

– Irregular 

– Not paralleling glenoid 

– Wider than 5mm (most if 

wider than 2mm) 

– Asymmetric width 

– Post to BLC – 

– Paralabral cyst ‐ 

usually tear 

tear 

SLAP II: Irregular (fragmented) 

Not paralleling glenoid



recess) 

– Irregular 







usually tear 

tear 

SLAP II: Paralabral cyst



recess) 

– Irregular 







usually tear 

tear 

SLAP II: Paralabral cyst



recess) 

– Irregular 







usually tear 

tear 

Normal Recess or Sulcus

• 10 to 2 o’clock 

• Bucket handle tear of 

superior labrum 

– Off glenoid 

– Off biceps 

• Biceps attached to 

glenoid and intact 

SLAP III

• Similar to SLAP III BUT 

• Tear extends into the 

biceps tendon 

(usually longitudinal split) 

SLAP IV

• Out of order, but: 

SLAP VI 

• Flap tear of superior labrum 

• i.e. III or IV with tear through one side of the 

buckethandle 

• Tough to differentiate from III or IV 

• Approx 1% of SLAP tears

Others: SLAP I –IV plus extension 

• V into bankart variant 

• VII into MGHL 

• VIII into posterior labrum 

• IX (near) global labral tear 

• X into rotator interval 

– SGHL/CHL/SS/SC 

SLAP V








SLAP VII








SLAP VIII








SLAP IX








SLAP X


• V into bankart 


variant 


• IX (near) global labral 



tear 

SLAP X

Labrum: what surgeon wants to know 

• Description is more important than classification or 

acronym 

• Location and extension of tear (labrum, biceps and GHL’s) 

– clock face and/or quadrants 

• Morphology 

– complete/split/fragmented/frayed/detached/displaced 

• Location of displaced components 

• Associated abnormalities – 

common 

– Specifically say if biceps is involved 

– RC, RI, Bone, articular cartilage, paralabral 

cysts

Objectives 

• Describe normal rotator cuff and 

labroligamentous anatomy of the shoulder 

• Discuss what the surgeon needs to know in 

rotator cuff injury 

• Describe imaging appearances across the 

range of labroligamentous shoulder injuries

Take home points 

• Know anatomy and variants 

– Esp. Labrum anterior superior 

quadrant 

• Be descriptive when reporting 

• Surgeon wants to know 

– What is the pathology 

– Can it be fixed 

– What needs done to fix it 

– What else is injured

Thank you

MRI of the Shoulder - Atlantic Radiology Conference - Dalhousie ...

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