 So we're back to our discussion of the six components of the rotator cuff and we've got a case here where it's just lights out Everything's here dogs and cats living together ten days of darkness the plague mass hysteria and all the cuff Structures are involved. So we start up high in the axial projection and we see a giant curvilinear Crescent or you that's this right here. In fact, it's so beautiful. I've got to put some colors on it It's too tempting There it is right there All of those structures should be over here Peripherally on the humeral head. This is a giant hole right here Of course, everybody forgets to look at the poor axial projection Let's work our way down And as we come down we see a large hole, which means the capsule is ruptured You've got lots of fluid leaking out anteriorly. So the capsule is torn and there is our poor Caracohumeraligament the retracted edge of it which should have gone all the way over and inserted on the humeral head the Caracohumeraligament so the Caracohumeraligament and the capsule are torn Here's our biceps anchor coming in to the labrum It forms very often when you can see it with high-quality imaging such as this a V or a Y We said the biceps can come in anteriorly and plug right into the tip here Or it can parallel the labrum for a bit anteriorly or it can come off in the mid or it can come off in the back There's quite a bit of variability in the takeoff of the biceps labral anchor So let's keep working our way down and as we do we run into the rest of the biceps Let's follow it with our scroll. Here it is. There it is. There it is and it never comes back to the proper location ever again Keep watching it. It always stays perched on the lesser tuberosity And that's because the fibers that normally keep it in over here namely the subscapularis fibers and The transverse humor ligament which inserts here, which is formed mostly by the already known torn Caracohumor ligament is gone allowing the biceps to displace Into the arms the loving arms of the subscapularis It can go all the way through into the joint It can stay in the subscapularis Sometimes it can ride over the top of the subscapularis three types of biceps subluxation But we're talking about the biceps because it is the third component now of the rotator cuff that we've seen That is damaged torn or ruptured Let's keep going shall we? We're moving on down. Let's pay attention to the subscapularis moving on down moving on up We are missing the subscapularis fibers right here At least the deep ones the superficial ones are intact, but the deeper ones are torn and With those fibers runs the middle glenium ligament which attaches right there. It's intact So the deep fibers of the subscapularis are injured the superficial fibers are intact So at least we've got some of the cuff still present, but what about that large? Gaping hole that we saw the axial projection. What's that about? Let's get some coronals going here Probably the most favored nation status projection for the rotator cuff the one that everyone likes and Let's see if we can scroll them together we've got on the far right a Water-weighted image a PD spur in the center of t2 and on the left of t1. Let's start scrolling We've got our biceps which is right here under my little magnifying glass Well, it's still there, but we already know it's mal positioned We already know it's sublux, so it's not doing its job of helping to keep the humoral head depressed But what about the supraspinatus? Well, that explains our massive hole, right? There's our hole and where is the supraspinatus? Oh, it's migrated all the way over here. Here's a piece of it. Here's another floppy piece of it Just kind of lying in that space Attaching to absolutely nothing if we try and follow this back a little bit It's bunched up over here at the myotendinous junction So the subscapularis is just a bloody mess with massive retraction accounting in part for that hole Now let's go back to the infraspinatus There's the tip of the infraspinatus. I use the word tip somewhat Cavalierly because it's not really a tip. It's a broad based fan shaped structure But this is the free edge of it and it should be all the way over here So that's toast and then we go to the end to the to the teres And we still have a teres. So the good news is we have a teres We have much of these subscapularis intact the deep fibers injured, but everything else is gone We've gone through our checklist supraspinatus blown retracted complete Infraspinatus blown retracted and complete from front to back subscapularis deep fibers injured biceps subluxed Caracohumor ligament ruptured capsule torn