Jebmh.com Original Research Article MAGNETIC RESONANCE IMAGING EVALUATION OF ROTATOR CUFF IMPINGEMENT Chandrakanth K. S1, Harshavardhan Nagolu2, Meera Krishnakumar3 1Senior Registrar, Department of Radiology, Apollo Hospitals, Greams Road, Chennai, India. 2Registrar, Department of Radiology, Apollo Hospitals, Greams Road, Chennai, India. 3Senior Consultant, Department of Radiology, Apollo Hospitals, Greams Road, Chennai, India. ABSTRACT BACKGROUND Shoulder pain is a common clinical problem. Impingement syndrome of the shoulder is believed to be the most common cause of shoulder pain. The term ‘impingement syndrome’ was first used by Neer to describe a condition of shoulder pain associated with chronic bursitis and partial thickness tear of Rotator Cuff (RC). The incidence of Rotator Cuff (RC) tear is estimated to be about 20.7% in the general population. This study is intended to analyse various extrinsic and intrinsic causes of shoulder impingement. MATERIALS AND METHODS 110 consecutive patients referred for MRI with clinical suspicion of shoulder impingement were prospectively studied. All the patients were evaluated for Rotator Cuff (RC) degeneration and various extrinsic factors that lead to degeneration like acromial shape, down-sloping acromion, Acromioclavicular (AC) joint degeneration and acromial enthesophyte. Intrinsic factors like degeneration and its correlation with age of the patients were evaluated. RESULTS Of the total 110 patients, 19 (17.3%) patients had FT RC tear and 31 (28.2%) had PT (both bursal and articular surface) tears. There was no statistically significant correlation (p=0.76) between acromion types and RC tear. Down-sloping acromion and enthesophytes had statistically significant association with RC tear (p=0.008 and 0.008, respectively). Statistically significant (0.008) correlation between the severity of AC joint degeneration and RC tears was noted. AC joint degeneration and RC pathologies also showed a correlation with the age of the patients with p values of <0.001 and 0.001, respectively. CONCLUSION No statistically significant correlation between RC pathologies with hooked acromion was found, that makes the role played by hooked acromion in FT RC tear questionable. AC joint degeneration association with RC tear is due to the association of both RC tear and AC joint degeneration with age of the patient. Down-sloping acromion, AC joint degeneration and enthesophytes proved to be independent variables significantly associated with RC tear. KEYWORDS Shoulder Impingement, MRI Shoulder, Rotator Cuff Impingement, Rotator Cuff Tear. HOW TO CITE THIS ARTICLE: Chandrakanth KS, Nagolu H, Krishnakumar M. Magnetic resonance imaging evaluation of rotator cuff impingement. J. Evid. Based Med. Healthc. 2017; 4(51), 3116-3122. DOI: 10.18410/jebmh/2017/619 BACKGROUND acromion, acromioclavicular joint degeneration and acromial Shoulder pain is a common clinical problem. Impingement enthesophytes. All these factors either alone or in syndrome of the shoulder is believed to be the most common combination tend to reduce the subacromial space and cause of shoulder pain.1 The term ‘impingement syndrome’ entrap the rotator cuff tendon and subacromial bursa, was first used by Neer2 to describe a condition of shoulder especially in the abducted elevated posture of the arm, pain associated with chronic bursitis and partial thickness leading to impingement and subsequently tear of rotator cuff tear of Rotator Cuff (RC). The incidence of Rotator Cuff (RC) tendon. Initial studies by Neer et al and Bigliani et al were tear is estimated to be about 20.7%3 in the general the basis of the popular theories of ‘external impingement’ population. as the cause of RC tear. While, the cause - and - effect Four important extrinsic factors have been implicated in relationship between external factors like acromial the external impingement of shoulder rotator cuff morphology and Subacromial Impingement (SAI) was degeneration and tear like acromial shape, down-sloping studied by Neer, Bigliani et al4 correlated the type of Financial or Other, Competing Interest: None. acromion with the incidence of full thickness RC tear and Submission 11-05-2017, Peer Review 18-05-2017, identified three types of acromial morphology; Type 1 - Flat, Acceptance 31-05-2017, Published 24-06-2017. Corresponding Author: Type 2 - Curved, Type 3 - Hooked. A high (70%) prevalence Dr. Harshavardhan Nagolu, of Full Thickness (FT) RC tears was noted to be associated No. 19-41-S5-1192, Jayanagar, Tirupati -517501. with type 3 acromion. A fourth type of acromion shape (type E-mail: [email protected] 5 DOI: 10.18410/jebmh/2017/619 4) has also been recently described. Acromion angle is also considered to be important factor in SAI leading to 6 degeneration of RC and subsequent tear. A low lying J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 51/June 26, 2017 Page 3116 Jebmh.com Original Research Article acromial position relative to the distal clavicle may decrease conducting machine (Intera, Philips). Dedicated phased the space between the acromion and the humerus and may array coil (SENSE coil) was used for improvement in the predispose certain individuals to shoulder impingement.7 signal to noise ratio. All the images were reviewed on Philips Spurs on anterior and inferior aspect of acromion arise at work station by two radiologists with at least five years’ the acromial attachment of coracoacromial ligament and experience. Each patient was evaluated for the following maybe strongly associated with the incidence of RC tear.8 parameters- 1. RC morphology; 2. Acromion shape; 3. Subacromial spurs were considered to be more correlative Lateral acromion angle; 4. Acromioclavicular joint marker of SAI changes and RC disease.9 Although, these degeneration; 5. Enthesophyte at the lateral margin of studies have been widely cited in the literature,5 the recent acromion process. investigations questioned their reliability and reproducibility. RC morphology was classified into 4 types using the With the introduction of USG and MRI of the shoulder, following criteria- 1. Normal- Normal uniform signals in all the radiological evaluation of shoulder disorders has the pulse sequences with smooth margins and normal undergone marked change. While ultrasound is mainly used thickness; 2. Degeneration/tendinosis - Increased signals in as a screening tool in the evaluation of RC pathologies, MRI the tendon on T2W images, which are not approaching fluid has established itself as the definitive modality in evaluating signals and which became normal or showed only mild the RC as well as bony and other soft tissue structures increase in signals on T1W images; 3. Partial thickness tear- around the shoulder. MRI findings have shown over the Partial disruption of the RC tendon involving either bursal or years that the incidence of RC tears increases linearly with articular surfaces and not involving both surfaces age of the patient.10 In the light of MRI findings, few authors simultaneously and showing increased signals on T2W/fat have come up with ‘intrinsic’ theories as the cause of RC suppressed T2W images, which approach fluid signals; 4. pathologies, which implicate intrinsic factors like age related Full thickness tear- If there is abnormal fluid signals on T2W RC degeneration, muscle weakness and overuse as the images in the RC tendon approaching both articular and primary factors leading to RC tear. Studies by McCallister et bursal surfaces. al11 showed good results of RC repair performed without Shape of acromion process was evaluated using sagittal acromioplasty and Budoff et al12 noted that debridement of T1W images with the plane passing just lateral to the AC Partial Thickness (PT) tears of the RC without acromioplasty joint.15 Anterior end of acromion process visible in the is clinically beneficial as well. The recent operative sagittal plane was divided into three parts using three points techniques to treat RC tears also employ tendon along the inferior cortex.15 If all three points are along the debridement alone and RC repair without acromioplasty,11 straight line, it was considered as type I (flat). If there was further questioning the exact role of extrinsic factors in a curvature in the middle part, it was considered type II impingement. (curved). If the acromion process showed a curve in the In view of contradictory theories, it becomes imperative distal third, it was considered type III (hooked). If the to re-emphasise the role played by various factors inferior surface of the acromion is convex to the humeral supposedly causing extrinsic impingement as they might still head, it was considered type IV. have important bearing on the management of RC The lateral acromion angle in the coronal plane was pathology. The accuracy of MRI in diagnosing RC pathology measured by drawing a line through the midsubstance of and other shoulder pathologies has been studied clavicle and another line through the midsubstance of the extensively.13-14 Hence, in this prospective study, the acromion process.16 The angle between the two lines is hypothesis that extrinsic factors are predominantly classified as neutral or non-down-sloping when the angle responsible for RC tear was tested. The aim of the study is was 0 to 10 degrees, down-sloping when the angle was evaluation of rotator cuff pathology on MRI and to study its more than 10 degrees. association with various factors of extrinsic impingement like Acromioclavicular joint degeneration was graded on a 1- acromial shape, down-sloping acromion, acromioclavicular 3 scale (mild, moderate and severe) according to the joint degeneration, acromial enthesophytes and intrinsic following criteria.17 Grade 1 (mild)- Joint space narrowing factors like age and degeneration of tendons. and/or irregularity of the joint margins and/or presence of high signal in T2W images in the joint. Grade 2 (moderate)- MATERIALS AND METHODS Grade 1 plus the presence of subchondral cysts and/or bone The study was conducted in a tertiary care setup. sclerosis and/or small osteophytes (<2 mm) around the Consecutive 110 patients over a period of 1 year 5 months joint.