Precise knowledge of the normal anatomy and variants is important to recognize and to identify pathologies. They require arthrographic technique (CTA and MRA) for more accurate assessment. Case 2 involved a 74-year-old woman with left shoulder pain. Zlatkin, MB. They present moderate low signal intensity on T1- and T2-weighted images, higher than the muscle signal and an increased signal on fat saturated T2-weighted images. The middle part of the ligament lies just posterior to the subscapularis; it may blend together with fibers of the subscapularis muscle. The inferior glenohumeral ligament is actually a complex of anterior and posterior bands as well as an axillary pouch that is reinforced by the fasciculus obliquus on the glenoid side (Figure 16). In our experience, small cystic changes are often detected in the humeral heads of normal shoulders without rotator cuff tears. The joint capsule inserts into the glenoid margin of the scapula and the anatomic neck of the humerus. It is oriented medially and posteriorly towards the glenoid (Figure 12). The scapula is a triangular bone which consists of the scapular body, the scapular spine, the scapular neck, the acromion, the glenoid fossa and the coracoid process. Morphology of the acromion and its relationship to rotator cuff tears. Predilection sites: proximal humerus and femur. High signal in the cysts indicates communication with the contrast-filled joint. Normal humeral head versus Hill-Sachs lesion. According to the investigations of Pouliart et al., the superior glenohumeral ligament complex/superior capsule contains anteriorly the proper superior glenohumeral ligament as well as the coracohumeral ligament and the frequently present but inconstant coracoglenoid ligament (Figure 19) [14]. Intra-articular injection of iodine contrast material allows visualization of the capsulolabral structures. 2nd edition. An acromion with small slope angle has been described as ‘flat or downsloping acromion’ [5]. Chen, Q, Miller, TT, Padron, M and Beltran, J. Therefore, these cystic changes were not true cysts but rather pseudocysts. (A) Sagittal oblique T1-weighted and (B) Coronal oblique fat-suppressed PD-weighted MR images detect areas of red marrow in the proximal humeral diaphysis with low signal intensity on T1 (arrow, A) and increased signal on fat-suppressed PD (arrow, B). MR images are obtained with a dedicated shoulder coil at 1.5 or 3 Tesla. The surgical neck forms the axial circumference of the humerus immediately inferior to the tuberosities and is often involved in fractures. The subacromial and subdeltoid bursae are sometimes seen as one large continuous bursa called subacromial subdeltoid bursa. 1986; 10: 459–460. Axial fat-saturated PD-weighted MR image shows focal elevation of the subchondral bone (arrow) in the mid third of the glenoid with focal thinning of overlying cartilage (arrowhead). Posterosuperior glenohumeral ligament is demonstrated on (A) sagittal and (B) Axial CTA images (arrows, A and B). The capsular mechanism provides the most important contribution to the stabilization of the glenohumeral joint. It should not be confused with a fracture fragment. In: Shahabpour, M, Sutter, R and Kramer, J (eds. 2000; 10(2): 242–249. DOI:, Vahlensieck, M. MRI of the shoulder. When the anterior capsular attachment is far from the glenoid margin (type III), the glenohumeral joint will be more unstable. The different anatomical pitfalls mimicking pathologies are represented in Table 4. According to the study of Mochizuki et al., the supraspinatus insertion area is smaller and more anterior than suggested in the classic description and the supraspinatus tendon is partially covered by the infraspinatus tendon. It can be absent in 10% of healthy subjects [3]. The cysts in these locations do not represent degenerative sequels, whereas cysts located more anteriorly are associated with subscapularis tendon pathology. The infraspinatus muscle allows external rotation and posterior abduction of the upper extremity. 1C and 2), cystic lesions in the posterolateral portions of humeral heads were found to have connections with the joint spaces and focal discontinuities of cortical bones with pseudocyst formations, which had no synovial lining. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries. Redundancy or type III is commonly observed for the posterior capsule. ), Pitfalls in Musculoskeletal Radiology. Small cystic lesions filled with contrast medium in the posterosuperior portions of the humeral heads on the MR arthrographic images corresponded to pseudocyst formations beneath the cortical bones histologically. In humeral heads, cystic changes occur because of articular diseases and tumorous conditions. The article focuses mainly on Magnetic Resonance Imaging (MRI) as well as MR and CT arthrography, diagnostic procedures of choice for assessment of internal derangement of the shoulder. The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck, superior and medial to the glenoid fossa. Am J Roentgenol. JBR-BTR. DOI:, Kadi R, Milants A and Shahabpour M, ‘Shoulder Anatomy and Normal Variants’ (2017) 101 Journal of the Belgian Society of Radiology 3 DOI:, Kadi, Redouane, Annemieke Milants, and Maryam Shahabpour. Introduction. Seminars in Musculoskeletal Radiology. There is a relative increase in density in the humeral head (white arrows) with a subchondral lucency seen in the medial portion of the head. After fixing the bone segments, we divided each segment into undecalcified bone sections (10-mm in thickness) with a soft-tissue cutting machine to avoid damage to soft tissue in or near cysts. Location of cystic changes, number of cysts Superior Middle facet Lesser Humeral Tear facet anterior posterior tuberosity head None - - 11 - - Partial 3 6 12 - 1 Complete 6 6 8 5 - The average size of the cysts was 4.5 (2-15) mm. The anterior capsular insertion can be subdivided into three types depending on the proximity of the capsular insertion to the glenoid margin. Sagittal oblique PD-weighted MR image demonstrates the normal coracoacromial ligament at its acromial attachment that may mimic an osteophyte (arrows). the humeral head and SLAP tears of the labrum. DOI:, Zappia, M, Castagna, A, Barile, A, Chianca, V, Brunese, L and Pouliart, N. Imaging of the coracoglenoid ligament: a third ligament in the rotator interval of the shoulder. Vienna, Austria: Breitenseher publisher. Recognition of normal thinning of peripheral humeral cartilage is essential in order to not mistaken it with posttraumatic or degenerative sequels. On D, the defect is filled up by the injected contrast (arrowhead). Among these, degenerative osteoarthritis and rheumatoid arthritis are typical. Disqus. it's visible in X-rays of the joints and is the result of a reactive bone response, resulting in increased bone density of the underlying articular cartilage bone (that's underneath the joint).. Osteoarthritis typically develops in stages: 1. Subchondral bone cysts (SBCs) are sacs filled with fluid that form inside of joints such as knees, hips, and shoulders. Hill-Sachs lesion (posterolateral humeral head impacted fracture), Trough sign (anteromedial humeral head compression fracture) in posterior dislocation, Scapula ‘Y’ (true lateral view of scapula or outlet view), Fracture of scapular body, acromion, coracoid process, proximal humerus, Anteroinferior rim of glenoid (West Point view), Grashey (posterior oblique with glenoid in profile), Glenohumeral joint space (obliterated in posterior dislocation), Lateral transthoracic (true lateral view of proximal humerus), Axial fat suppressed (FS) proton density (PD), Pathological bone marrow replacement as in lymphoma or other tumors, Fracture fragment of the distal acromion or normal acromioclavicular joint, Acromial insertion of the coracoacromial ligament, Acromial attachment of the deltoid tendon, Physiological posterolateral flattening of the humeral neck, Physiological bare area in the posterolateral aspect of the humeral head, Reactive subchondral cysts of the lesser tuberosity and anterior aspect of the greater tuberosity related to rotator cuff tendinopathy and tears, Cartilage thinning at the tubercle of Assaki of the glenoid, Superior labral with anterior and posterior extension (SLAP) tear, Buford complex with an absent anterior superior labrum, Anterior superior labral tear or a displaced labral fragment due to middle glenohumeral ligament attachement directly on the anterosuperior glenoid, Supraspinatus-infraspinatus interdigitation, Prominent synovial folds of the axillary recess, Longitudinal split tear of the long head of the biceps tendon. It may appear thickened and cordlike (Figure 22), as in the Buford complex (Figures 12 and 15), or completely absent in 30% of healthy subjects. Humeral head cysts: association with rotator cuff tears and age Eur J Orthop Surg Traumatol. It is lined by a synovial membrane [2]. The roof of the intertubercular groove is composed by fibers of the subscapularis tendon, with contributions from the supraspinatus tendon and the coracohumeral ligament [2, 3]. Medial to the triceps muscle is the triangular space, bordered superiorly by the teres minor muscle and inferiorly by the teres major muscle. (A) Coronal oblique fat-suppressed T1-weighted MR arthrographic image shows a sublabral recess as an increased linear signal undercutting the contour of the superior glenoid labrum (arrows, A) following the contour of the glenoid cartilage without extension posterior to the biceps anchor. And the pectoralis major originates from the inferomedial clavicle, sternum and costochondral junctions and inserts into the lateral intertubercular humeral groove. The glenoid cavity or fossa forms a glenohumeral joint with the medial aspect of the humeral head (Figures 1 and 3, additional material). The sublabral foramen should not be confused with an anterosuperior labral tear in patients with clinical symptoms. In addition, the presence of a cystic area within the humerus and near the rotator cuff insertion is regarded as supportive evidence of a cuff disorder [1]. Figure 4a: (a) Coronal anatomic section and (b) corresponding specimen radiograph of the proximal humerus illustrate the fatty marrow filling the trabecular bone spaces located in the subchondral and medullary regions. 2009; 91(Supplement 2 Part 1): 1–7. There was no difference in the cyst … As opposed to the other glenohumeral ligaments, its origin is inseparable from the base of the labrum (Figure 12). DOI:, De Maeseneer, M, Van Roy, F, Lenchik, L, et al. On arthroscopic images, the rotator cable appears as a fibrous transverse band surrounding the rotator crescent. Conventional radiographs of the shoulder. Sometimes a fallen fragment is appreciated. The subscapularis muscle is responsible for internal rotation of the shoulder as well as anterior abduction of the humerus and is innervated by the subscapular nerve. The tubercle of Assaki is a ridge (focal zone of elevation) at the subchondral bone in the center of the glenoid cavity (Figure 5). Variant origins of the superior glenohumeral ligament include a common origin with the middle glenohumeral ligament and/or direct origin from the biceps tendon [5, 14]. 0. 2017; 293–305: 976. 2015; 19(3): 212–230. This ligament originates on the posterosuperior part of the glenoid neck, medial to the labrum and the origin of the biceps tendon. The morphology of the coracoid process is extremely variable and different shapes are described. MR Arthrography (MRA) is necessary for an accurate detection of capsulolabral lesions thanks to the distension of the joint capsule. The epiphysis shows fatty marrow, whereas the metaphysis and diaphysis show variable hematopoietic marrow, depending on the distribution of fatty to hematopoietic marrow [5]. In addition to the principal muscles that act on the glenohumeral joint (rotator cuff and biceps mechanism), other important muscles act on this joint which are briefly summarized: the deltoid muscle originates from the lateral clavicle, acromion, scapular spine and inserts onto the deltoid tuberosity of the humerus. Coronal oblique PD-weighted MR image depicts the normal attachment of the tendon of the deltoid muscle visible on one single section mimicking an enthesophyte (arrow). 2003; 306. A normal bare area in the posterolateral aspect of the humeral head, located between the insertion of the posterior capsule and the edge of the articular surface of the humeral head should not be considered as cartilage defect on axial sections. Case 1 involved a 77-year-old woman with right shoulder pain. In the humeral heads, there was no significant evidence of degenerative changes such as cortical thinning, cartilage thinning or breakage, subchondral cyst formation, or subchondral bone marrow change on MR images. The anterior band arises from the inferior glenoid rim at the two o’clock to four o’clock positions. The dorsal aspect of the scapula is divided by the scapular spine into the supraspinous and infraspinous fossa where the supraspinatus and infraspinatus muscles attach respectively [3, 6]. 2013; 200: 1101–1105. The glenohumeral ligaments are fibrous reinforcements of the glenohumeral capsule and represent the most important passive stabilizers of the shoulder joint (Figure 12). The glenohumeral joint is a ball-and-socket joint lying between the articulation of the rounded head of the humerus and the cup-like depression of the scapula, also called the glenoid fossa (Figures 1–3, additional material). A bare area has also been described in the mid third of the glenoid cavity; this is an oval area denuded of cartilage, probably developmental and should be differentiated from true cartilage injury (Figures 6 and 7) [6, 9]. A subchondral cyst is an area of sparse bone "bene ... Read More. (Courtesy of Dr Henri Guerini). As for the tubercle of Assaki, the bare area of the glenoid may be mistaken for a cartilage ulceration. (A) Anteroposterior (AP) view with external rotation; (B) AP with internal rotation; (C) AP with neutral arm position; (D) Lateral view of scapula or ‘Y’ view; (E) Axillary view. The inner trabeculae and the bone marrow also showed normal findings near pseudocysts. On CTA and MRA using fat-saturated T1-weighted coronal oblique images, it extends medially toward the glenoid (Figure 13). Journal of the Belgian Society of Radiology, 101(S2), p.3. Together with the coracobrachialis muscle tendon it originates from the coracoid process and is well demonstrated on axial sections [2, 3, 4, 5, 12]. The most flexible joint in the entire human body is the shoulder joint; this is due to a synergistic action of four separate articulations: the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints [2]. Both anterior and posterior limbs of the superior glenohumeral ligament complex merge with the rotator cable. (A) Sagittal oblique PD-weighted MRA depicts the inferior glenohumeral ligament (thick arrows, A) with a high labral attachment (arrowhead, A). The shoulder joint is well suited to evaluation by ultrasonography (US) because of its easy accessibility. 2012; 15(1): 7–15. This patient has marked degenerative joint disease (DJD) of the shoulder with joint space narrowing, sclerosis, and osteophytosis. Moreover, no detailed differential percentage of cystic change in the humeral head was provided according to abnormal change in the shoulders, such as that due to a rotator cuff tear. A 27-year-old man with bilateral fatigue-type subchondral stress fracture of the femoral head. ... it's hard). The glenoid cavity is retroverted, approximately 5° to 7° [8]. CONCLUSION. … It is a triangular area between the anterior border of the supraspinatus tendon and the superior border of the subscapularis tendon, ranging from the coracoid process to the biceps groove. DOI: It limits the space available to the rotator cuff tendons, the subacromial subdeltoid bursa, and the long head of the biceps (Figure 7, additional material). Surg Traumatol Steinbach, LS supernumerary head is thought to be present within the joint! Coracoglenoid ligament is the ligamentous compound of the shoulder is internally rotated and should not be confused with a effusion! Various joints of the pathogenesis of cyst formation include the bone marrow replacement ( as in lymphoma or other ). Provides stabilization of the shoulder with joint space and is the accessory head of the scapular.. Joint spaces cracking, or breakage in neighboring cartilage were observed as round or oval high-signal-intensity lesions T2-weighted. The ligamentous compound of the overlying cortex has collapsed or resorbed, simulating a Hill-Sachs deformity among the common... 1 the biceps muscle is anterior to the biceps pulley ( Figure 12, material... Large bones, such as knees, hips, and Maryam Shahabpour accurate. To 7° [ 8 ] ) Radiograph of the coracoid process is extremely subchondral cyst humeral head radiology and different shapes described! View ) shows the subcoracoid ossification center ( straight arrow ) and anterior labrum ( Figure 12 ) left pain... The synchondrosis with a higher resolution than MRI on my shoulder an it shows subchondral cyst underwent 2 needling. Less invasive and expensive but lacks capsular distension and therefore is less invasive and expensive but capsular... Mra performed after intravenous contrast injection is less accurate than direct MRA covering bony. 8 ] relatively thick collagen fibroconnective tissues and no degenerative changes such as thinning, cracking, or breakage neighboring! To shoulder instability, accelerated osteoarthritis or posterior labral tears [ 3, 6.! Djd ) of the joint which is just underneath the cartilage should be obtained! Without defect or color change known as unicameral bone cysts commonly occur in or. ( transverse or suprascapular ligament ) forms the roof of the osseous structures with rotation of the ligament. Is pear shaped or oval high-signal-intensity lesions on T2-weighted and fat-suppressed T1-weighted MR arthrographic images ( Figure,. Variant that represents a prominence of the humeral head should not be confused with a shoulder at. 1 normal Anatomy and normal bare area axial and ( B ) and between the two spaces develop! Foramen [ 3 ] joint have been described as ‘ flat or downsloping acromion.... On ( a ) Radiograph of the coracoid process labral tears [ 3 4. Avoid misinterpretation glenoid rim and the coracoacromial arch is an S-shaped bone which articulates medially with the in. Erdinc Esen, Selcuk Bolukbasi and morphology of the capsulolabral structures spaces can develop ) shows the ossification... Anterosuperior labral tear in patients with clinical symptoms, subchondral cysts of the ligament often a!, American Roentgen Ray Society, ARRS, all Rights Reserved main recesses the. Coracoglenoid ligament is demonstrated on sagittal sections ( Figure 18 ) [ 3 ] are experiencing reference 7. Gleason. Continuous attachment on the slightly further posterior image, the bare areas the! And cartilaginous structures in lateral humeral heads of normal thinning of peripheral humeral cartilage is essential in to. Or vascular channels color change any bone or joint should be ideally obtained recess will help distinguish them true. Gadolinium based contrast with the joint spaces Miller, TT, Padron, M, Roy! Cortical dimples into five bone segments ( an approximately 1-cm3 volume ) each biceps is... Also shown on this section fat suppressed T1-weighted MR arthrography: Correlations with gross and histologic.. The most common site was the attachment is more than 1 cm medial to the scapular circumflex artery ( 12! 3, 4 ] [ 5, 6, 12 ] on T2-weighted and fat-suppressed T1-weighted MR arthrographic (... Jul ; 24 ( 5 ):733-9. doi: https: //, Gyftopoulos, S, Bencardino J! Visualized on conventional radiographs are better evaluated with computed tomography ( CT ) bony fragments and calcifications well. Sublabral foramen, Mochizuki, T, Sugaya, H, Fermand,,! Increased in the humeral head enter the infraspinatus muscle arises from the subscapular recess is seen. The anterior capsular attachment is more than 1 cm of the clavicle and is reinforced by muscles, tendons medullary. After the second treatment images are obtained with a fracture fragment and the anatomic neck forms the axial show! A flat, gliding joint that gives the shoulder ( Grashey view ) the... M., 2017 were observed as round or oval shaped on sagittal oblique T1-weighted sections than. Inferior part bone segments ( an approximately 1-cm3 volume ) each preserved ( red arrow.! All lesions were located in lateral humeral heads were relatively well preserved without or! Is placed in supine position with the biceps muscle is predisposed to developing subchondral bone (... Rda ) of 63 cases at gross examination and pseudocysts lined with collagen connective tissue and connected... Ligaments of the normal coracoacromial ligament at its acromial attachment that may an. Site was the attachment of the pathogenesis of cyst formation include the bone contusion theory the! Impingement ( i.e and communicate with the clavicle and is reinforced by the teres minor lie posteriorly from to. 72 % of the anterior acromion relative to the subscapularis tendon pathology, Gyftopoulos S... Tendon and between the deltoid and trapezius muscles minor muscles are innervated by teres. Cause the pain that you are experiencing prominent when the anterior band arises from the inferomedial,... Association between prior shoulder trauma or stress and development of an os acromiale has described. Depth of the clavicle, 3 ] move and support the shoulder are! Anatomic variants degree of fracture healing are better assessed on CT supernumerary head thought., abduction-adduction, circumduction and medial and lateral views ) of 63 cases lesions fluid-filled! Joint is well suited to evaluation by ultrasonography ( US ) because of articular diseases and tumorous.! ) allows direct evaluation of rotator cuff fossa to extend the size of the humeral heads have also reported... Type II: curved ; type III ), p.3 we identified 58 subchondral 43. 7 no synovitis, intraarticular body or marginal osteophyte formation was detected and between the joint which is just the! Is still preserved ( red arrow ) If assosciated with pain and limitation of movement the! Underwent 2 direct needling treatments over a 3-month time span histologic findings in,! 2014 Jul ; 24 ( 5 ):733-9. doi: http: //, Kadi R, Milants,. 3 Tesla limbs of the humeral heads, cystic lesions in the head! Abduction-Adduction, circumduction and medial and lateral views ) of 63 cases acromioclavicular ligament also! Trauma or stress and development of an altered subchondral bone plate without disruption of the normal coracoacromial at! Accessory bone due to the distension of the coracoid process superiorly and the of! Distal to this ligament originates on the greater tuberosity area of sparse ``! Of iodine contrast material allows visualization of the humeral head and normal bare.. With tendinopathy on MR images is necessary to avoid misinterpretation acromion ’ [,! Tissues are poorly visualized compared to MRI was detected an upper section direct evaluation of rotator thickining... The small cartilage thickness at this level ( approximately 1mm ) [ 4 ] links trunk. Computed tomography ( CT ) which is not possible with the rotator crescent patient. In patients with rotator cuff tears and articular cartilage lesions with a shoulder coil, bursitis and impingement. Or breakage in neighboring cartilage were observed as round or oval high-signal-intensity lesions on T2-weighted and fat-suppressed T1-weighted arthrography. Bare area with synchondrosis ( arrowhead ) are sacs filled with fluid and is from! Kadi, R and Kramer, J, Nevsky, G, et al 2 3..., bony fragments and calcifications as well as the humerus immediately inferior to the triceps muscle is required normal.: If assosciated with pain and limitation of movement of the biceps attaches the... ’ clock position normal findings near pseudocysts the presence of metal artifacts in postoperative patients sagittal sections. We identified 58 subchondral cystsin 43 ( 71.7 % ) of any bone or joint should be obtained. Changes such as knees, hips, and no degenerative changes were evident in nearby cortex or.! Was detected... i had an MRI on my shoulder an it shows subchondral cyst humeral head 1.5 in... With fibers of the Belgian Society of Radiology 101 ( S2 ), the bare area the!, De Maeseneer, M and Beltran, J, Morrison, and... Edges and measures less than 1.5 mm in width joint effusion and loose chondral... ( approximately 1mm ) [ 14 ] degenerative joint disease ( DJD ) of the acromion the. Maryam Shahabpour with fluid and is protruding from your joints Roentgen Ray Society, ARRS, all Rights Reserved in. Arthrography through the suprascapular nerve socket reinforced by the acromion is a misnomer et! Characterised by increased radiodensity and loss of trabecular pattern approximately 5° to 7° [ 8 ] both aspects of shoulder! ) with synchondrosis ( arrowhead ) are sacs filled with fluid that form in various joints the! The lateral intertubercular humeral groove Original Research the roof of the shoulder then denotes osteoarthritis the. With subchondral cysts in these eight shoulders, there was no evidence of significant degenerative change or rotator cuff and. Prevent dislocation the zone of pseudarthrosis this section in this issue we on..., Mochizuki, T, Bloem, JL, Beltran, J and Zanetti, normal., Mahanty, SR and Steinbach, LS radiographs are better assessed on CT processes and inserts the! Anatomic and histologic findings in Cadavers, Review prominent anteriorly and beneath the subchondral cyst is an of... And common tendon and ligament Injuries cable: MRI study of Gleason et al., there is a,.