 Today I have to speak on the imaging of rotator cuff what to report. So it's basically a very day-to-day topic for everyone So I tried to make it as simplified as possible Everybody has different ways to look at the rotator cuff So MR basically provides explicit details of all the cartilaginous elements, ligaments, tendons and muscles It provides information about marrow edema and bone contusions, which no other modality can. It's multi-planar No contrast is required. It gives information about an ossified cartilage as well Neurovascular bundles and it's however expensive and not readily available So my protocol for rotator cuff tears is coronal sagittal and axial PDFF images. I use the coroner T2 To identify a tear versus tendinosis a sag T1 I use basically for these muscles whether there is any fatty atrophy or Fatty replacement and axial. I do not take a gradient image PDFF I feel is more than enough to see the Articular cartilage and the labrum. The optional images are gradient images 3d PDFF adsat images Which are currently available on some machines, which are good some vendors don't have a good 3d PDFF Some have a good one. So if you have if your machine is giving a good one That is a good idea to use because you can have multiple reformations to see us see small tears So basically supraspinatus tendon is the most important one. It has to be imaged very well The technicians have to be really well trained to be able to give good images of the shoulder So you have to understand that there's a supraspinatus muscle and a supraspinatus tendon This is the myotendinous junction, which is giving rise to the tendon And that tendon inserts over the brator tuberosity. So your angulation of these sections oblique coronal images of the shoulder have to be angulated parallel to this tendon and not the muscle and Definitely not according to the anatomy leg. We don't have a straight sag or a straight coronal It has to be parallel to this tendon and perpendicular to that tendon The field of view has to be in such a way that the Glenohumeral joint is in the center and you are covering adequate portion of the supraspinatus Rotator cuff muscle and also going just beyond the Insertions of the tendons. You shouldn't have a too large FOV Otherwise, you will end up seeing the lung, lung parenchyma and breathing artifacts These should not extend in the air So your FOV has to be perfect around 15 to 16 centimeters FOV The hand has to be placed in neutral position That is the thumb has to be pointing upwards and there should be a Air gap between the arm and the chest If there is an air gap, then there is no transmission of the breathing artifacts to the shoulder You get better images without any movement artifacts One more thing that we remember is the first section has to go through the achromyclavicular joint If it does not go to the achromyclavicular joint You are going to miss or sacromyal and it's different types We are going from top to bottom. This is the supraspinatus muscle and this is the tendon As you go down, you start seeing the long rid of bisects coming out Then you start seeing the subscapularis and the infraspinatus tendons The infraspinatus tendon goes right up to this point and inserts over here does not insert here as it's most commonly thought The subscapularis goes to lesser tuberosity does not go beyond the lesser tuberosity This is one more important thing to remember And this is the small tendon of the teres minor which is much lower down as compared to the infraspinatus tendon Similarly, when you're going from anterior to posterior, these are the multi-pinate appearance of the subscapularis tendon as it inserts over the lesser tuberosity Then you have the long rid of bisects crossing and then you start seeing the supraspinatus tendon So your long rid of bisects is the landmark to tell you on the coronal images whether the subscapularis is finished and The supraspinatus has begun. So this is a supraspinatus muscle and the supraspinatus tendon inserting over the greater tuberosity Lastly as you go more behind you have the infraspinatus tendon on the top and the teres minor tendon at the bottom in the sagittal sections as you go from In the end to outside or from medial to lateral you start seeing the muscle belly and you start seeing a small tendon inside So this is the myotendinous junction of the supraspinatus the subscapularis Infraspinatus and more lower down you start the teres minor So these tendons come together and form the subscapularis tendon. This is the long rid of bisects that is coming out So this is a rotator cuff interval this one on the top you are starting to see the supraspinatus tendon This is the infraspinatus and this is the teres minor. So you should trace them right up to their insertions So as I said when you start seeing the long rid of bisects tendon You have to know that the subscapularis tendon is already over So anything beyond that you it is not going to be a subscapularis. It has to be supraspinatus So you still see the entire insertion of the supraspinatus from here to here This is what you call as a conjoined tendon where you really can't differentiate between the supraspinatus and the infraspinatus This is the infraspinatus and much lower down you see the teres minor This is a societal T1 weighted sequence which shows you a normal muscle belly appearance When you start seeing this bright fat within the muscle belly, you start to identify what is called as a fatty replacement This is further graded as grade 1 2 3 and 4 as we'll see later on So next we start seeing what is called as the rotator cuff The first and the most important tendon that you evaluate is the supraspinatus So this is graded according to the different types of degeneration right up to the tail So what really starts is the degenerative signal, which is called as a supraspinatus tendonosis This appears as a slight swelling of the supraspinatus tendon with bright signal on pdfats at images You may or may not find inflammatory fluid in the subacromial bursa But definitely you start seeing a signal change Now this signal change is because of a mild tendonosis This further progresses into moderate and severe tendonosis And later on when the tendon acquires a signal which is as bright as the joint fluid or the bursal fluid Then you start calling it as a tail The earlier textbooks you may find the term tendonitis But nowadays we don't use the word tendonitis because there is no inflammation in the supraspinatus or any tendon Basically so you start calling it as mild moderate and severe tendonosis and then followed by a tail This is an articular surface tail One more thing that we need to understand is this is the insertion of the foot plate of the supraspinatus That is inserting more of the greater tuberosity There is no articular cartilage over the greater tuberosity The articular cartilage starts in the humeral head and ends at the humeral head, neck, junction So this is the articular surface From here to here is the insertion And from the top is your bursal surface So this in the illustration that I am showing you is a partial thickness tail Involving the articular surface So because of the partial thickness tail involving the articular surface and there is slight retraction of the tendon This is called as a pasta lesion or partial articular surface Tendon avelgen So when you mean to say tendon avelgen means the tendon has come off and it has avelgen traveled a little bit of distance from the insertion Then you start calling it as a pasta tail. This is how you see it diagrammatically This is an example of a bursal surface tail Now you are seeing that this is the articular cartilage. This black line is your supraspinatus tendon, articular surface This is the insertion But here you see that there is discontinuity of the bursal surface and this is a bursal surface tail Whenever there is a bursal surface tail There is what is called as a puddle sign or fluid collection along the lateral aspect of the greater tuberosity going down there That is because there is a rupture of a wall of the cervical means of deltoid bursa And that fluid leaks into this space and forms what is called as the puddle sign So whenever you have a suspicion of whether you should give a bursal surface tail or not Identify this fluid if there is fluid you can definitely give it as a bursal surface tail The third variety is an interstitial tail. In this patient you see this black line Which is an intact articular surface a black line on top Which is the intact bursal surface and in the center of this bright signal which is as bright as fluid is Intra substance tail or interstitial tail This is how you see it in this sagittal image and this is a diagrammatic representation Now there is something called as a rim rent or an insertional tail Now insertional tails which can be full thickness or like this which can be small and partial thickness You need to identify sometimes by enlarging the image and seeing that there is a very very small tail there This is an insertional tail not involving the bursal or articular surface and there is no retraction So this is not pasta. This is not any averse tail But there is a very very small focal tail at the insertion and that is what you call as a rim rent or a focal Partial thickness insertional tail Sometimes they may be complete. Sometimes they are partial Then when you start seeing the tails whether they are partial or full thickness tails You start seeing or something called as retraction So whenever the retraction is less than 10 millimeters, it is called as grade 1 retraction Whenever it goes up to the mid-humeral head or about 1.5 centimeters to 2.5 centimeters It becomes a grade 2 retraction when it goes up to the glenohumeral joint or more than 3.5 centimeters It becomes a grade 3 retraction You don't see a tendon at all when you're imaging the mid portion of the humeral head And sometimes when it goes beyond the glenohumeral joint, it becomes a grade 4 Retraction next we move on to what is fatty replacement fatty replacement is the replacement of the supraspinus fossa or any muscle belly by bright signal on T1 weighted images, which is called as fatty replacement They are further graded into less than 25 25 to 50 50 to 75 and more than 75 as grade 1 2 3 and 4 In this you see that the teres minor muscle is completely replaced. So this is grade 4 fatty replacement This is around grade 1 fatty replacement of supraspinus. This is grade 2 fatty replacement of the infraspinus Then you move on to calcified tendonitis. Now here you can notice that there is itis This is because there is inflammation because of deposition of calcification within the tendon substance or The calcification within the tendon substance has just extruded and gone out into the subacromial space Subacromial bursa and that is what is incited in inflammation or inflammatory response That is when it is called as calcified tendonitis and it becomes painful And when you start doing a lot of rotator cuff ultrasound You will find that there are calcifications in a lot of people But all of them do not have tendonitis because all of them do not have symptomatic calcifications So whenever the symptoms are there there is tendonitis because the rotator cuff tendons are susceptible to External impingement. You have to look for types of acromion Type 1 is the flat under surface. Type 2 is concave or some under surface which is parallel to the humeral head Type 3 is type 2 morphology with an anterior inferiorly directed spur and type 4 is when the under surface is convex Then there is something called as a keels spur in which the spurring is seen on the lateral aspect as well as the medial aspect on the coronal images This is what is called as a keels spur and keels spur is almost always associated with a tear of the underlying suprasmanidus tendon You have a down sloping acromion in which the horizontal Appearing bone is the clavicle and the acromion has gone down or it is down sloping and that is what reduces the space For the suprasmanidus to move and that becomes a factor for external impingement Acromion clavicle arthrosis itself because of presence of osteophytes and synable hypertrophy can cause reduction in this space in the critical zone And thereby leading to a tear of the rotator cuff Pass acromion if there is a formation of the pseudo arthrosis because of assacromion Then this fragment moves with every abduction and adduction and that gives rise to impingement or external impingement of the suprasmanidus tendon Similar to the suprasmanidus tendon you have partial thickness in complete or full thickness tears Which are seen in the infrasmanidus subscapularis in the rest of the tendons Whenever there is a tear of the tendon you should measure the tendon tear from anterior to the posterior aspect And whenever there is a partial thickness there you have to measure the percentage of the thickness that is involved That is whether the partial thickness involves 50% of the tendon thickness 30% or more than 70% or whether it is near full thickness tear In this patient you are seeing that there is full thickness tear of the infrasmanidus tendon with retraction of the tendon up to the glenohumeral joint Next is subscapularis tears subscapularis tears you have to remember that subscapularis Tears subscapularis inserts from in a vertical fashion from top to bottom along the placer tuberosity So you have tears involving the upper portion mid portion and the entire subscapularis This has been further classified by left force as type 1 2 3 4 and 5 tears Type 1 is upper one-third which is partial tear type 2 is upper one-third which is a complete tear type 3 is upper two-third type 4 is The entire suprasmanidus subscapularis tendon But there is fatty infiltration of 1 to 3 and more than 3 is Type 5 so these are the left force subscapularis tears Now why you need to identify that is if the upper portion is involved then you are going to look for long head of biceps dislocation or subluxation They usually are not involved in lower subscapularis tendon tears and Second most important thing is there is different treatment for the different types So this is an example of left force type 1 in which you have a tear Which is partial thickness involving only the upper portion of the subscapularis Type 2 when there is full thickness tear, but only involving the upper portion This is type 3 and this is type 3 But it's almost upper two-third and lower portion of this tendon is still intact and type 4 in which there is complete Or superior to inferior entire subscapularis tear is there in this patient and that's why the humerus has subluxed anteriorly In the intrasmanidus tendons the sub the humeral head sublux is posteriorly Now whenever you must have Seen terms that people have described as massive rotator cuff tear The massive rotator cuff tear is called when the tear is more than five centimeters in size and involves at least two muscles So it usually involves the combination of supra spinners and infraspanidus tendons and the tears are more than five centimeters in size So in this patient you can see that subscap is intact the teres minor is intact But there is a tear of the supra as well as infraspanidus So this is what you call as a massive tear and whenever there is complete tear of all the tendons around the Humerus except may be the Teres minor tendon the subscap supra and infra all of them are torn Then you call it as a global rotator cuff tear Sometimes because of chronic complete tears of the supraspanidus What happens is the humerus has shifted upwards or there is superior migration and that Constantly irritates the acrylamide clavicular joint which undergoes a diastasis or dislocation and then the fluid in the subacrylamide Bursa goes out and forms what is called as a subcutaneous Swelling cystic swelling, but you identify this subcutaneous swelling clinically, but what is actually a problem is a full thickness complete tear which is Kind of a neglected tear and that is what is called as a geezer sign So whenever you see a subcutaneous swelling Overlying the acrylamide clavicular joint you should always look for a tear in the supra's penitentus tendon Adhesive capsulitis is almost always mistaken for rotator cuff tears. That's why I just put one slide Strict scene, adhesive capsulitis the findings are the anteroinfra joint capsule is thickened and bright and there is dirty Looking soft tissue in the rotator cuff interval. If you find these two or either of these two then you can give a diagnosis of adhesive capsulitis Firstly, let me conclude by take home points. What to report in a supra's penitentus or basically a rotator cuff tear? First identify if there is a tear If there is no tear then you can call it as tendinosis and grade it as mild moderate or severe If there is a tear try to identify whether it is an industrial partial thickness or full thickness tear If it's a partial thickness tear identify whether it is a Barsal surface tear, which is also called as anti-pasta Articular surface tear, which is called as the pasta and insertional tear and whenever there's a partial thickness tear Identify what thickness of the tendon it is involved in. If it's a full thickness tear then look out for retraction Measure the APN transverse dimension of the tear identify any muscle bulk loss Identify the grid of fatty infiltration look for tears of other cuff tendons Rotator cuff arthropathy if there are if there is any chronic change like Intraucous cystic changes and I try to identify what caused the tear in the first place like types of acromion or any other factors of external impingement Thank you very much for your kind attention