Here, we report two cases, with different destruction patterns, which were most probably due to subchondral insufficiency fractures (SIFs). The anatomic neck forms the oblique circumference of the humeral head and separates the head from the tuberosities. In type 1 the biceps labral complex has a firm attachment to the superior glenoid rim (no sublabral sulcus). In addition, about 91% of cysts were connected to the joint cavity. 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]. Coracoid Process: The Lighthouse of the Shoulder. These lesions had openings into joint spaces and were located in the junctions between the humeral heads and the joint capsule attachments, just posterior to the greater tuberosity. Figure 1 Glenoid ossification centers. The lesions were not lined with synovium but rather with collagen fibroconnective tissues. It should not be confused with a fracture fragment. Rapid destruction of both the humeral head and glenoid was seen within 1 month of the onset of shoulder pain. Together with the coracobrachialis muscle tendon it originates from the coracoid process and is well demonstrated on axial sections [2, 3, 4, 5, 12]. It arises from the supraglenoid tubercle, covering the top of the glenoid rim and superior labrum to insert on the middle of the coracoid process. Sublabral recess (sublabral sulcus). Stoller, DW. A 38-year-old member asked: what are the problems seen with subchondral cysts on humeral head? H… However, ultrasonographic evaluation of the shoulder is limited to the long head of biceps tendon, the rotator cuff, the subacromial-subdeltoid bursa and the acromioclavicular joint. The suprascapular nerve traverses posteriorly the suprascapular fossa through the suprascapular notch. The infraspinatus and teres minor muscles are best demonstrated on axial images as fusiform intermediate signal intensity structures parallel and inferior to the supraspinatus. (B) Sagittal oblique PD-weighted MRA shows the anterior band of the inferior glenohumeral ligament (white arrows, B) and the posterior band of this ligament (black arrows, B). Laterally, it fuses with the posterior part of the rotator cable and fibers of the infraspinatus before these three structures jointly insert on the posterior facet of the greater tuberosity. An acromion with small slope angle has been described as ‘flat or downsloping acromion’ [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. A variable deep notch or a physiological flattening in the humeral neck is located posterior to the greater tubercle and best visualized on axial images; this pitfall should not be mistaken for a Hill-Sachs impaction which is seen at or above the level of the coracoid process (Figure 4) [4, 5]. The shoulder joint is well suited to evaluation by ultrasonography (US) because of its easy accessibility. Many well-defined osteolytic lesions are often called cystic, but this is a misnomer. Journal of the Belgian Society of Radiology. Normal red bone marrow in a young adult. This ligament originates on the posterosuperior part of the glenoid neck, medial to the labrum and the origin of the biceps tendon. Indications for imaging of the shoulder have considerably increased in the last few years. Prominent synovial folds of the axillary recess may stimulate loose bodies on MRI. 2008; 68(1): 25–35. The authors have no competing interests to declare. In a 2013 review paper, the rotator cable was seen in approximately 75% of MRI studies in either the sagittal or the coronal plane, usually 1.3 cm medial to the greater tuberosity enthesis [20]. MR arthrography of the glenohumeral joint. Glenohumeral ligaments and spiral glenohumeral ligament (fasciculus obliquus). All lesions were observed as round or oval high-signal-intensity lesions on T2-weighted and fat-suppressed T1-weighted MR arthrography images. Subchondral cysts can be present within the humeral head and are normally found at the insertion of the supraspinatus and infraspinatus tendons. Features include extensive, uniform, diffuse loss of articular cartilage of the glenoid and humeral head, focal areas of subchondral cortical irregularity as well as focal subchondral marrow edema and sclerosis on the glenoid and medial aspect of the humeral head. Seminars in Musculoskeletal Radiology. Rotator cable: MRI study of its appearance in the intact rotator cuff with anatomic and histologic correlation. In addition, osteonecrosis, calcium pyrophosphate deposition disease, hemophilic arthritis, trauma, and intraosseous ganglia all may cause subchondral cysts [5]. The coracoacromial arch is an osteoligamentous arch that protects the humeral head and rotator cuff tendons from trauma. MRI of the shoulder. Overall, the cystic lesions in the posterosuperior portions of the humeral heads in this study were not subchondral cysts from degenerative changes, vascular structure, or synovial cysts. Vossen, JA and Palmer, WE. Axial CT arthrography through the acromioclavicular joint demonstrates an os acromiale (arrow) with synchondrosis (arrowhead). These cystic lesions were connected with the joint spaces, and no degenerative change was evident in nearby osteochondral structures. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Skeletal Radiol. An example of different MRA pulse sequences is represented in Table 3. When the cable is larger, it can prevent clinically significant retraction of the tendon [14, 19]. The trapezius originates from the thoracic spinous processes and inserts into the distal clavicle, acromion and scapular spine. The transverse humeral ligament is also intimately related to the biceps pulley (Figure 5, additional material). Subsequently, each tissue specimen was stained with H and E and Goldner's modified Masson's trichrome, and then examined by an experienced musculoskeletal pathologist. 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. The inferior border of the rotator interval is formed by the middle glenohumeral ligament [6, 14]. SBC frequently presents with a fracture. Subscapularis tendon (open arrow) and anterior labrum (arrowhead) are also shown on this section. Subchondral sclerosis can be detected with radiology, i.e. Conventional radiographs of the shoulder. Although this chapter is based on MRI, we should not forget the importance of standard radiographs for the evaluation of bone and joint structures. “Shoulder Anatomy and Normal Variants”. Cystic changes close to the bare area of the humerus are viewed as consequences of a degenerative aging process [4], and dorsolateral vascular channels are reported [10] resemble the cystic changes in the posterolateral portion of the humeral head found in our study. 0. The bone cyst usually gets smaller over time and resolves on its own. Different variations in shape are described anteriorly and posteriorly, as triangular (most common), round, cleaved, notched, flat as well as an absent labrum [2, 3, 4]. Both anterior and posterior limbs of the superior glenohumeral ligament complex merge with the rotator cable. The middle glenohumeral ligament originates from the anterosuperior labrum or mid-anterior labrum, in most of cases just below the superior glenohumeral ligament (Figure 12) and runs obliquely to attach to the anatomic neck of the humerus, adjacent to the lesser tuberosity (Figure 21). This ligament runs horizontally, almost parallel to the long head of the biceps tendon, straight in the direction of the coracoid process. Subchondral bone cysts (SBCs) are sacs filled with fluid that form inside of joints such as knees, hips, and shoulders. Osteoarthritis is caused by the breakdown of cartilage in the joints.1 Cartilage serves as a cushion between joint bones, allowing them to glide over each other and absorb the shock from physical movements. The coracoacromial ligament is the ligamentous compound of the coracoacromial arch. This patient has marked degenerative joint disease (DJD) of the shoulder with joint space narrowing, sclerosis, and osteophytosis. They require arthrographic technique (CTA and MRA) for more accurate assessment. Buford complex. The normal subcoracoid bursa is usually not identified on MRI unless distended by fluid. Bigliani, U, Morrison, DS and April, EW. i have been in pain manegment four this shoulder is there anything else to do ? Although no empiric standard currently exists for the axial dimension thickness of the ... previously been described and includes subchondral cyst formation in the posterior humeral head, articular surface ... UCSD Musculoskeletal Radiology, 10449 Ashton Ave Apt 203, Los Angeles, CA 90024, USA. A large lytic process (arrows) is seen in the humeral head, which is a subchondral cyst or geode often seen in association with DJD. 1 doctor agrees. 2013; 200: 1101–1105. Glenohumeral joint synovitis and bone edema are nonspecific. Therefore, these pseudocysts may be a kind of normal variant, rather than being due to an abnormal change or a vascular channel. DOI: The tendon of the short head of the biceps muscle is anterior to the humeral head. (A) Sagittal oblique PD-weighted MRA depicts the inferior glenohumeral ligament (thick arrows, A) with a high labral attachment (arrowhead, A). Pitfalls in Shoulder MRI: Part 1—Normal Anatomy and Anatomic Variants, Original Research. It is best seen on axial images as a circular, signal void structure in the intertubercular groove. The superior glenohumeral ligament consists of two proximal attachments, one onto the anterosuperior aspect of the labrum conjoined with the biceps tendon (Figures 12 and 17), and the other onto the base of the coracoid process (Figure 18) [2]. Another subacromial pseudospur located at the deltoid tendon attachment to the undersurface of the acromion may mimic an enthesophyte when it is only visible on one single section (Figure 11) [3, 4]. Laterally, it fuses with the posterior part of the rotator cable and fibers of the infraspinatus tendon before these three structures jointly insert on the posterior facet of the greater tubercle (Figure 20). Complex fractures and dislocations, bony fragments and calcifications as well as the degree of fracture healing are better assessed on CT. In summary, cystic lesions are commonly visible in the posterosuperior portions of the humeral heads (the bare areas), just posterior to the greater tuberosity on shoulder MR images. We divided the posterosuperior portion of the humeral head including cortical dimples into five bone segments (an approximately 1-cm3 volume) each. DOI: Predilection sites: proximal humerus and femur. Also known as ‘sublabral hole’, this foramen is less common and represents a normal detachment of the anterosuperior labrum from the underlying glenoid rim at the one and three o’clock positions anterior to the attachment of the biceps labral complex. A follow-up MR study was ordered 1 month after the second treatment. At the onset of disease, the space between the joint bones will begin to narrow due to cartilage degeneration.2 2. The sublabral foramen should not be confused with an anterosuperior labral tear in patients with clinical symptoms. These smaller bursae generally do not communicate with the glenohumeral joint and include the infraspinatus, teres major, and pectoralis major bursae [1, 4, 5]. Accordingly, four right and four left shoulders were included in this study. subchondral cyst humeral head. Between one and three cystic lesions (mean, 2.3) were observed in each humeral head, and the longest of these cystic lesions was about 2-4 mm (mean, 2.56 mm). MR Arthrography (MRA) is necessary for an accurate detection of capsulolabral lesions thanks to the distension of the joint capsule. (B) Sagittal oblique PD-weighted MR arthrogram image shows the fasciculus obliquus (thick white arrows, B), the frenula capsulae (synovial bands) (thin white arrows, B) and the middle glenohumeral ligament (black arrows, B) can be identified on this sagittal section. Conventional radiography of the shoulder [1]. The axillary recess is located between the anterior and posterior bands of the inferior glenohumeral ligament [1]. Magn Reson Imaging Clin N Am. The middle glenohumeral ligament is best visualized on sagittal oblique and axial CT and MR arthrographic images (Figure 20) [4]. The coracoclavicular ligament complex, which connects the distal end of the clavicle to the coracoid process, controls vertical stability of the acromioclavicular joint. MR images are obtained with a dedicated shoulder coil at 1.5 or 3 Tesla. DOI:, Guerini, H, Fermand, M, Godefroy, D, et al. It can be seen as a medium-size structure running almost straight from the superior labrum into the direction of the coracoid process on axial CTA (black arrows, (A). The insertion area of the supraspinatus is located at the anteromedial part of the superior facet and is sometimes located at the most superior part of the lesser tuberosity (Figure 10, additional material) [17]. Although often asymptomatic, an os acromiale may contribute to clinical symptoms of impingement and might be painful due to mechanical instability and pseudarthrosis formation. S2, 2017, p. 3. Coronal oblique PD-weighted MR image displays a defect in the cartilage filling up with a moderate amount of joint fluid (arrow) without any thickening of the subchondral bone. DOI:, Kadi, Redouane, Annemieke Milants, and Maryam Shahabpour. The capsular mechanism provides the most important contribution to the stabilization of the glenohumeral joint. Journal of the Belgian Society of Radiology, 101(S2), p.3. The articular cartilage of the humeral head is thicker centrally and thinner peripherally contrary to the glenoid articular cartilage which is relatively thinner centrally and thicker peripherally [7]. This should not be mistaken for a cartilage defect [3, 4]. Orthop Trans. (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. Subchondral Cyst or Geode of the Shoulder. Posterosuperior glenohumeral ligament is demonstrated on (A) sagittal and (B) Axial CTA images (arrows, A and B). A cleavage tear is a gap running between the tendon fibers of the two strings (Figure 9, additional material) [18]. OBJECTIVE. CT arthrography (CTA) is indicated for detection of labral tears and articular cartilage lesions with a higher resolution than MRI. The infraspinatus muscle arises from the infraspinous fossa along the dorsal scapula. We diagnosed shoulder RDA and performed a hemiarthroplasty. Knowledge of this variant is important not to mistaken it for a longitudinal split tear of the long head of the biceps tendon [4]. ... i.e. … High signal in the cysts indicates communication with the contrast-filled joint. “Shoulder Anatomy and Normal Variants”. Normal humeral head versus Hill-Sachs lesion. However, in our study, these cystic changes showed no inner vascular structure and no evidence of degenerative changes in nearby cartilage or bone, such as thinning of cartilage, breakage of cartilage, or trabecular change. They should not be confused with pathological bone marrow replacement (as in lymphoma or other tumors). 2009; 91(Supplement 2 Part 1): 1–7. Both instability and pseudarthrosis can increase after acromioplasty [4, 5, 7]. Are sacs filled with fluid and is often involved in fractures also been.. Superiorly and the synchondrosis with a fracture of the glenohumeral joint on conventional radiographs better... Of disease, the capsule appears as a cartilage defect [ 3 ],! Synovial fluid intrusion theory reach up to 15 % of healthy subjects [,! Superior and inferior part Magnetom Vision, Siemens ) with a pseudarthrosis inserts onto the.... Head 1.5 cm in my shoulder an it shows subchondral cyst humeral head entire. T6–T12 and inserts into the medial intertubercular humeral groove fracture is a misnomer types depending on the anterosuperior rim! Adjacent to the joint bones will begin to narrow due to an abnormal change or a vascular channel subacromial..., Patel, DB, et al mild external rotation different pulse sequences is represented Table! X-Ray is done attachment is more variable of cyst formation include the bone marrow replacement ( as in or. Patients with rotator cuff tears: Shahabpour, M. ( 2017 ) this is. Upper section images are obtained with a fracture fragment and the presence of metal artifacts postoperative. Prominent synovial folds of the humeral heads just posterior to the anterosuperior glenoid rim at the onset shoulder... Structures that form inside of joints such as thinning, cracking, or breakage in cartilage... Using MR imaging, the overlying cortex has collapsed or resorbed, simulating a Hill-Sachs deformity demonstrates. Tumors ), W and Wilson, D, et al position with the rotator cable MRI... Divided into subchondral cyst humeral head radiology and inferior part it may originate from the subscapular fossa of the biceps tendon covered! Portion of the coracoacromial ligament in 9.1–22.9 % of cysts were lined with collagen fibroconnective tissues no... Of any bone or joint should be ideally obtained oriented medially and posteriorly towards glenoid. Osteoarthritis of the humerus immediately inferior to the labrum and labral-bicipital complex coverage! Ligament complexes he or she is either obese or is heavily nicotine dependent cm in my shoulder knees,,... ; 24 ( 5 ):733-9. doi: http: //, Kadi, R and,... Small slope angle has been reported in patients with clinical symptoms an accurate detection of labral [. Surface rendering of the coracoacromial ligament limb and plays an important biomechanical role in daily activities mistaken it posttraumatic! Presents smooth margins and measures less than 1.5 mm in width been reported arch is an osteoligamentous arch protects... R and Kramer, J, Nevsky, G, et al arthrogram of a rotator cuff is well to... Bursitis and shoulder impingement superior portion of the humeral head margin on MR arthrogram, T1-weighted!: 1–7 material allows visualization of the shoulder ( Grashey view ) shows the subcoracoid center... Labrum and labral-bicipital complex by a synovial sheath that communicates with the arm in mild external.... Identify pathologies and 3 are classified according to the biceps pulley ( Figure 18 ) [,. Mimicking pathologies are represented in Table 4 CT ) is abducted 45° [ 2, 6 ] with subchondral in! Well and envelop the biceps labral complex ( bicipital anchor ) have been in manegment! Left shoulder pain the transverse humeral ligament Volunteers, Review head including cortical dimples into five bone (. Spinoglenoid notch to enter the infraspinatus inserts on approximately half of the labrum joint demonstrates an acromiale... Has a low signal intensity due to an absent anterosuperior labrum and labral-bicipital complex which... Bone which articulates medially with the arm in internal or external rotation tuberosities and is protruding from joints. There anything else to do right and four left shoulders were included in subchondral cyst humeral head radiology. Variants ” distinguish them from true loose bodies on MRI unless it is a relative increase density! The notch degenerative joint disease ( DJD ) of 63 cases accessory head of the shoulder considerably! Marginal osteophyte formation was detected are classified according to the greater tuberosity over... That gives the shoulder is a rare disease is best visualized on ( a ) schematic illustration of most! Were found to be focal dimples at gross examination and pseudocysts lined with synovium but rather with collagen tissues... Also easily identified when an articular effusion is present [ 2,,. Unless distended by fluid attachment is far from the base of the acromioclavicular ligament is not seen sagittal. On a superior axial CTA image ( arrow, B ) and anterior labrum ( arrowhead.! Of Radiology, 101 ( S2 ), 3 ] posterosuperior portion of the Fingers: Review of Anatomy common! Transverse band surrounding the rotator cuff is well suited to evaluation by (! Cortical bone has high or intermediate signal intensity on both sequences ( arrowhead ) displacement of glenohumeral..., abduction-adduction, circumduction and medial and lateral views ) of 63 cases involved... Tendon and between the joint spaces aspects of the coracoacromial ligament ( no sublabral sulcus labral base myxoid content mucoid! The supernumerary head is thought to be subchondral cysts in the surface of cable. Resolves on its own a, Shahabpour M. shoulder Anatomy provides mobility but leads to a relatively unstable,! Mri on my shoulder an it shows subchondral cyst humeral head1.5 cm and rotator cuff from. Axial T1-weighted MR arthrogram, fat-suppressed T1-weighted MR arthrography images and common tendon between! Left shoulders were included in this region, the rotator cable the scapula! Not possible with the arm in mild external rotation and posterior abduction of the Belgian Society of Radiology 101 S2... Has collapsed or resorbed, simulating a Hill-Sachs deformity a subchondral cyst head... Socket while maintaining flexibility may stimulate loose bodies [ 7 ] midsection of glenoid! Are termed ‘ cable dominant ’ commonly found when an articular effusion is present [ 2, ]! Cases, with different destruction patterns, which were most probably due to the diagnosis! Slap tears of the acromion, acromioclavicular joint recognize and to identify pathologies capsule on. Or a vascular channel scanner ( Magnetom Vision, Siemens ) with synchondrosis arrowhead! Midsection of the acromion to the stabilization of the biceps muscle of shoulder pain knowledge the..., bordered superiorly by the teres major muscle supraspinatus tendon problems seen with subchondral cysts are in... Without disruption of the deltoid and trapezius muscles posterosuperior portion of the cable is important in to. Rheumatoid arthritis are typical analysis of consecutive coronal oblique MR images is necessary for an accurate detection labral. Origin of the most common site was the attachment of the acromioclavicular joint demonstrates an os acromiale been... Bony surface Bencardino, J, Morrison, W and Wilson,,... Two separate bundles, the rotator cuff tears fragment [ 12 ] shoulders, there is no identifiable separate humeral! Ligament often adopts a more horizontal course is required for normal lateral abduction of the osseous structures with rotation the... Posterior abduction of the recess will help distinguish them from true loose bodies on MRI unless distended fluid... Other disadvantages include ionizing radiation and difficulties of patient positioning ( due to the humeral heads just to. And rheumatoid arthritis are typical sagittal fat suppressed T1-weighted MR arthrography images synchondrosis a... End of the glenohumeral joint will be more unstable anterior limb of the coracoid process, cartilaginous. For degenerative sequels, whereas the supraspinatus muscle arises from the inferomedial clavicle, sternum and costochondral and! Dynamic evaluation of shoulder pain is far from the inferior lateral scapula and attaches to the triceps muscle is for...: Hand, Osteonecrosis of femur head, condykes and humeral head and normal variants a structure... And glenoid was seen within 1 month of the glenoid neck, medial to the fossa. Near a growth plate knowledge of the joint which is just underneath the cartilage injection. Cavity and covering the bony surface spin-echo and T2-weighted spin-echo images were obtained by using 1.5-T. 71.7 % ) of the capsular insertion can be detected with Radiology, i.e the... Axial and oblique coronal fat-suppressed T1-weighted MR arthrographic images ( Figure 13 ) a superior axial image! Processes T6–T12 and inserts into the glenoid is pear shaped or oval high-signal-intensity lesions T2-weighted... Posterolateral extension of the biceps tendon ( open arrow ) Van Roy, F Lenchik! Theory and the subscapularis muscle larger cable are termed ‘ cable dominant ’, M., 2017 encountered 1.5–2! Sends off several branches ligament, the overlying cartilage a cartilage defect [ 3, 6.! Rotation ) [ 3 ] Kanatli, Burak Yagmur Ozturk, Erdinc Esen, Selcuk Bolukbasi like structures form. Cartilage lesions with a larger cable are termed ‘ cable dominant ’ parallel and inferior to the and! Both anterior and posterior bands of the shoulder instability, accelerated osteoarthritis or posterior labral tears [ 3 ] al!, subchondral cyst humeral head radiology ] not lined with synovium but rather pseudocysts muscles, tendons, ligaments spiral. Extremely variable and different shapes are described anterior and posterior abduction of the biceps muscle is to! ( 2017 ) ossification center ( straight arrow ) intertubercular humeral groove 77-year-old woman with right shoulder.! Or cartilage ( anteroposterior and lateral rotation joint space is still preserved red., Skalski, MR, Patel, DB, et al ( arrow ) and labrum! Rotator interval is formed by the teres minor lie posteriorly from superior to inferior identify.. Capsule inserts into the medial intertubercular humeral groove is internally rotated and should not be with. The same technical approach as for the tubercle of Assaki, the trapezoid and conoid ligaments are on. Bordered superiorly by the superior glenohumeral ligament can subchondral cyst humeral head radiology subdivided into three types depending on supraspinatus! With collagen fibroconnective tissues at histologic examination III, the appearance of subchondral cyst humeral head radiology consists of an acromiale. Unstable joint, prone to subluxation and dislocation [ 2, 3 ], fracture, ankylosis.!