Imaging of Disorders Dr Quentin Reeves FRANZCR Auckland City Hospital / SRG Radiology Auckland Introduction

• What are we trying to achieve? • Accurate diagnosis and reassurance • Effective therapy • Physiotherapy • Judicious injection therapy • Selective surgery Role of Imaging

• Assist optimal patient outcomes • Define type and extent of pathology • Must know normal from abnormal • Surgical/Management planning • Arthroscopic surgery

• ACC GUIDELINES FOR SHOULDER IMAGING Shoulder Disorders

• Rotator cuff disease • Instability • Adhesive capsulitis • Trauma • Arthritis • Infection • Avascular necrosis • Pagets disease/Metabolic bone disease • Neoplasm Normal Anatomy

• Rotator cuff tendons • Coracoacromial arch • AC Joint • Subacromial/ Subdeltoid Bursa • Biceps Tendon Normal Anatomy Etiology of Rotator Cuff Disease • Controversial • Impingement • Ischemia/degeneration • Overuse • Occupational • Athletic • Trauma • Chronic inflammatory change Important Concept • < 5% of tears occur in normal tendons Mostly middle age or older Rotator Cuff Disease

• • Partial thickness tears • Bursal surface • Articular surface • Intrasubstance • Full thickness tears • Small < 1cm • Moderate 1-3 cm • Large 3-5 cm • Massive > 5cm • Rotator interval tears Pattern of Rotator Cuff Tears

• Most originate in anterior supraspinatus and extend anteriorly and/or posteriorly • Isolated biceps /subscapularis/infraspinatus tendon pathology is uncommon • Dislocation in older patients has higher association with tears Plain Xrays

• Essential • Supraspinatus outlet /subacromial space • AC joint • Calcification • Bone lesions/fractures/loose bodies • Variants • Glenoid shape/ fractures •

Acromion Shapes/ Spurs Greater Tuberosity Erosions OA/CPPD Glenoid Hypoplasia Os Acromiale AC Joint: Osteolysis AC Joint

• Important cause of shoulder pain. • Often not considered especially in chronic pain cases Fractures Fractures Instability Hill Sachs Charcot/Neuropathic Joint

• Charcot Joint • Etiology (Multiple) • Diabetes -30% incidence if peripheral neuropathy • Syrinx • Spinal cord injury • Multiple Sclerosis Synovial Metastases Ultrasound

• Cost effective • Excellent resolution • Operator/Equipment dependent • Accurate/Rivals MRI • Dynamic/Clinical examination/Intervention • Side to side comparison • Limited visualisation of some Bone/Joint pathology • Must be combined with Xray Supraspinatus Tendon Biceps tendon Subacromial Bursal Thickening Impingement Tear Classification

• Tendinosis • Partial Thickness • - Articular / Bursal / Intrasubstance • Full Thickness • -Small <1cm • -Moderate 1-3 cm • -Large 3-5cm • -Massive > 5cm Rotator Cuff US Accuracy

• Wide range of results • Reflects • Rapid improvement in technology • Developing expertise • Full thickness / Partial thickness • Sensitivity 80% / 71% • Specificity 100% / 100% • (Roberts et al Am J Orthop 2001; 30:159-62) Bursal Side Fraying Partial Thickness Tear Partial Thickness Tear Complex Full Thickness Tear

Subscapularis Tendon US Muscle Atrophy Mimics

• Greater tuberosity fractures • Distal clavicular osteolysis • Adhesive capsulitis • Calcific tendinitis • Osteoarthritis/ other arthropathy • Denervation muscle weakness - suprascapular nerve - axillary nerve - acute brachial neuritis/other Calcific Tendinitis Adhesive Capsulitis

• Common • Synovial inflammatory condition • Trauma, OA , rheumatoid arthritis, idiopathic • Clinical findings may be non specific • Inflammation of • joint capsule • capsular ligaments of rotator interval • periarticular bursae • biceps/subscapularis tendons Adhesive Capsulitis MRI

• Imaging gold standard • Accuracy has improved greatly • Improved surface coils/software/3T • Most complete examination / Multiplanar • Soft tissue /Bone marrow/Articular surfaces • Muscle atrophy/Denervation • Role of Gadolinium arthrography • Limitations: • Calcium, Metal, Pacemakers, Non Dynamic MRI Normal Anatomy

Coracoacromial Arch AC Joint MRI Bursal Inflammation Partial Thickness Tear MRI Full Thickness Laminated Tear

MRI Full Thickness Tear Cuff Tear Muscle Atrophy Adhesive Capsulitis

• Pain and severely restricted motion (Frozen shoulder) • Thickening and contraction of joint capsule and synovium • Aetiology-Cytokine mediated and fibrosis • Idiopathic • Secondary: trauma, sugery, diabetes, other shoulder disorders, inflammatory disease Inflammed Subcoracoid Space Gadolinium Enhancement MRI Labro-Capsular Complex

• Glenoid labrum and shoulder instability common cause of shoulder symptoms • Shoulder inherently unstable • Labrum/glenohumeral ligaments major stabilisers • Labral tears without instability can cause shoulder symptoms MRI Anterior Labral Tear Glenoid Chondral Lesions SLAP Lesions

• Superior labral tears at and posterior to biceps insertion into labrum • Pain, clicking, instability sensation • MR arthrography preferred • Classification: Type I-IV • Normal variations - Sublabral recess • - Ant/Sup labrum • Paralabral cysts MRI SLAP Lesion Suprascapular Nerve Entrapment: Clinical Diagnosis

• Can be difficult • Non specific shoulder pain/weakness • May mimic rotator cuff /instability/AC jt pain • Visible muscle atrophy Paralabral Cyst Spinoglenoid Notch Synovitis Acute Brachial Neuritis

• Self limiting, uncommon • Sudden onset non traumatic shoulder pain associated with progressive weakness of shoulder musculature • Clinical mimics • Etiology uncertain Viral Immunisation infection Acute Brachial Neuritis IMAGE GUIDED SHOULDER INJECTIONS/ASPIRATION

Dr Quentin Reeves FRANZCR Introduction

• Enables precise guidance of needles for injection and aspiration in real time with less discomfort • Is cost effective and minimally invasive. • Allows use of fine needles with minimal risk • Image proof of the placement of injection or site of aspiration. Important if outcome less than expected Essential Requirements

• Operator experience • Knowledge of anatomy • Sterile technique • High quality equipment • Knowledge of treatment alternatives • Followup of results Injection Agents • Steroid • Dry Needling/Autologous Blood/PRP • Prolotherapy e.g. Dextrose • Polidoconol –vascular sclerosant

• Skeletal Radiology(2010)39:425-434

• Ventral scraping Achilles

• Ultrasound guidance superior results and less painful Corticosteroids: Action

• Action not fully understood • Reduces prostoglandin production by up to 50% • Decreases interleukin-1 secretion by synovial membranes • Reduces immune cell migration,reduced vasodilatation and vessel permeability- this increases concentration of hyaluronic acid and increases viscosity of synovial fluid

• In general decreases inflammation and swelling which reduces pain and increases joint mobility • 3-5 days to take full effect Corticosteroids • Well tolerated and offer good short to medium term relief • Especially in acute post traumatic bursal inflammation can be very effective in breaking cycle of symptoms • Less effective longer term if significant tendon damage/tear/OA. • Very useful in enabling rehabilitation especially in adhesive capsulitis Steroid Injection Tips

• Choice: DepoMedrol,Kenacort,Celestone Chronodose • 20-40mg Kenacort / 5.7mg Celestone • Local anaesthetic as indicator of success • Rest 2-5 days • Repetition frequency

• Steroid flare • 1-10% • 8-24 post injection • Reaction to preservative/corticosteroid • Ice/Anti inflammatory agents/Analgesics Potential Complications • Rare • Relative contraindications • Warfarin • Diabetes-need to monitor glucose levels • Epilepsy-may be seizure provoking • HIV treatment Ritovir-Cushings/Addisons • Antibiotics –Fluoroquinones can cause tendinosis • Antismoking therapy –Zyban(Bupropion) seizures • Fat atrophy- lateral epicondyle most common • Depigmentation • Tendon rupture-Role of steroid controversial • Infection-rare Subacromial Bursa Injection Glenohumeral Joint Injection Fluoroscopic Injection Calcific Tendonitis Aspiration Calcific Tendonitis Calcific Aspirate Pre/Post Calcium Needling 7/12 Interval Paralabral Cyst Paralabral Cyst Aspiration Ganglion Aspiration PRP/Autologous Blood

• Platelets contain granulesthat store growth factors • Interleukin 1 • Tumour necrosis factor • Transforming growth factor • Others

• Alpha granules released when platelets aggregate at a site of injury or inflammation • Activation of platelets and release of growth factors key to tissue repair.