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MR Arthrography of Rotator Interval, Long Head of the Biceps Brachii, and Biceps Pulley of the Shoulder¹

¹ From the Departments of Radiology (Y.M., J.A.J., G.S., R.R., D.A.J., C.W.H.) and Orthopaedic Surgery (B.M.), University of Michigan Medical Center, 1500 E Medical Center Dr, TC 2307, Ann Arbor, MI 48109-0001. Received September 8, 2003; revision requested November 19; revision received February 16, 2004; accepted April 20. Address correspondence to Y.M. (e-mail: yoavm@umich.edu).

View larger version (88K): [in a new window]   Figure 1. Illustration of rotator interval anatomy. Frontal view depicts anatomic boundaries of rotator interval. B = long head of biceps brachii tendon, C = coracohumeral ligament, SSC = subscapularis tendon, SST = supraspinatus tendon, T = transverse humeral ligament.

View larger version (123K): [in a new window]   Figure 2a. Normal anatomy as depicted on coronal oblique T1-weighted magnetic resonance (MR) arthrographic images (repetition time msec/echo time msec = 700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a) Rotator interval is anatomically defined by superior border of subscapularis tendon (*) and anterior border of supraspinatus tendon. Also shown is distal portion of normal coracohumeral-superior glenohumeral ligamentous anchor (arrow) at site of insertion on the lesser tuberosity medial to and intimately associated with the long head of the biceps brachii tendon (arrowhead in a and b). Long head of the biceps brachii tendon slips over the coracohumeral-superior glenohumeral ligamentous anchor to insert on the superior labrum, as shown on (b) subsequent image. The "pulley" effect of this ligamentous anchor can be inferred from a.

View larger version (124K): [in a new window]   Figure 2b. Normal anatomy as depicted on coronal oblique T1-weighted magnetic resonance (MR) arthrographic images (repetition time msec/echo time msec = 700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a) Rotator interval is anatomically defined by superior border of subscapularis tendon (*) and anterior border of supraspinatus tendon. Also shown is distal portion of normal coracohumeral-superior glenohumeral ligamentous anchor (arrow) at site of insertion on the lesser tuberosity medial to and intimately associated with the long head of the biceps brachii tendon (arrowhead in a and b). Long head of the biceps brachii tendon slips over the coracohumeral-superior glenohumeral ligamentous anchor to insert on the superior labrum, as shown on (b) subsequent image. The "pulley" effect of this ligamentous anchor can be inferred from a.

View larger version (126K): [in a new window]   Figure 3. Normal anatomy as depicted on transverse T1-weighted MR arthrographic image (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. Proximal portions of coracohumeral ligament (arrows), superior glenohumeral ligament (large arrowhead), and nearby long head of biceps brachii tendon (small arrowhead) are shown. Coracohumeral ligament is well defined because of adjacent contrast agent. Note normal relationship between the smaller superior glenohumeral ligament as it joins the relatively more robust coracohumeral ligament.

View larger version (150K): [in a new window]   Figure 4. Coracohumeral ligament on nonarthrographic coronal T1-weighted MR image (700/10). A portion of coracohumeral ligament (arrow) can be seen arising from the coracoid process (arrowhead) to insert, in a broad fashion, on lesser tuberosity (star) and on distal portion of subscapularis tendon (*).

View larger version (46K): [in a new window]   Figure 5. Illustration shows distal portion of coracohumeral ligament (C) and superior glenohumeral ligament (SGHL) near their insertions. Sagittal oblique view depicts distal portion of the coracohumeral and superior glenohumeral ligaments superior to lesser tuberosity (LT) and just medial to long head of biceps brachii tendon (B) entering the bicipital groove. H = humeral head, SSC = subscapularis tendon, SST = supraspinatus tendon.

View larger version (130K): [in a new window]   Figure 6. Illustration in coronal plane depicts association between long head of biceps brachii tendon (B), coracohumeral ligament (C), and superior glenohumeral ligament (S) medially. CPSL = glenohumeral capsule, IST = infraspinatus, SSC = subscapularis, SST = supraspinatus.

View larger version (145K): [in a new window]   Figure 7. Normal anatomy depicted on sagittal T1-weighted MR arthrographic image (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. Long head of biceps brachii tendon (arrow) enveloped by contrast agent-distended "sling" (arrowhead) formed by coracohumeral and superior glenohumeral ligaments.

View larger version (135K): [in a new window]   Figure 8. Normal anatomy as depicted on sagittal T1-weighted MR arthrographic image (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. Blended coracohumeral and superior glenohumeral ligaments (arrow) trace inferiorly and medially to long head of the biceps brachii tendon (arrowhead) before inserting on lesser tuberosity.

View larger version (144K): [in a new window]   Figure 9a. Arthroscopically confirmed partial tear of bicipital sling. (a-c) Transverse and (d) oblique coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a-c) Contrast agent is seen leaking (black arrow) in an irregular fashion through long focal cleft extending superiorly from lateral portion of rotator interval inferiorly and laterally through lateral portion of bicipital sling. Arrowhead = superior glenohumeral ligament, white arrow = coracohumeral ligament. (d) Thickened irregular tissue (arrow) is seen at area of bicipital sling above superior aspect of the lesser tuberosity (*), just medial to long head of biceps brachii tendon (arrowhead).

View larger version (140K): [in a new window]   Figure 9b. Arthroscopically confirmed partial tear of bicipital sling. (a-c) Transverse and (d) oblique coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a-c) Contrast agent is seen leaking (black arrow) in an irregular fashion through long focal cleft extending superiorly from lateral portion of rotator interval inferiorly and laterally through lateral portion of bicipital sling. Arrowhead = superior glenohumeral ligament, white arrow = coracohumeral ligament. (d) Thickened irregular tissue (arrow) is seen at area of bicipital sling above superior aspect of the lesser tuberosity (*), just medial to long head of biceps brachii tendon (arrowhead).

View larger version (159K): [in a new window]   Figure 9c. Arthroscopically confirmed partial tear of bicipital sling. (a-c) Transverse and (d) oblique coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a-c) Contrast agent is seen leaking (black arrow) in an irregular fashion through long focal cleft extending superiorly from lateral portion of rotator interval inferiorly and laterally through lateral portion of bicipital sling. Arrowhead = superior glenohumeral ligament, white arrow = coracohumeral ligament. (d) Thickened irregular tissue (arrow) is seen at area of bicipital sling above superior aspect of the lesser tuberosity (*), just medial to long head of biceps brachii tendon (arrowhead).

View larger version (123K): [in a new window]   Figure 9d. Arthroscopically confirmed partial tear of bicipital sling. (a-c) Transverse and (d) oblique coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. (a-c) Contrast agent is seen leaking (black arrow) in an irregular fashion through long focal cleft extending superiorly from lateral portion of rotator interval inferiorly and laterally through lateral portion of bicipital sling. Arrowhead = superior glenohumeral ligament, white arrow = coracohumeral ligament. (d) Thickened irregular tissue (arrow) is seen at area of bicipital sling above superior aspect of the lesser tuberosity (*), just medial to long head of biceps brachii tendon (arrowhead).

View larger version (131K): [in a new window]   Figure 10a. Arthroscopically proved rotator interval defect after acute injury to shoulder. (a, b) Sagittal, (c) coronal oblique, and (d) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show contrast agent extravasating (arrow) through large defect in the rotator interval anterior to supraspinatus musculotendinous junction (*).

View larger version (136K): [in a new window]   Figure 10b. Arthroscopically proved rotator interval defect after acute injury to shoulder. (a, b) Sagittal, (c) coronal oblique, and (d) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show contrast agent extravasating (arrow) through large defect in the rotator interval anterior to supraspinatus musculotendinous junction (*).

View larger version (131K): [in a new window]   Figure 10c. Arthroscopically proved rotator interval defect after acute injury to shoulder. (a, b) Sagittal, (c) coronal oblique, and (d) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show contrast agent extravasating (arrow) through large defect in the rotator interval anterior to supraspinatus musculotendinous junction (*).

View larger version (132K): [in a new window]   Figure 10d. Arthroscopically proved rotator interval defect after acute injury to shoulder. (a, b) Sagittal, (c) coronal oblique, and (d) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show contrast agent extravasating (arrow) through large defect in the rotator interval anterior to supraspinatus musculotendinous junction (*).

View larger version (117K): [in a new window]   Figure 11a. Anterior extension of supraspinatus tendon tear (arrow) to involve the subscapularis tendon (*). (a, b) Sagittal (a, more medial; b, more lateral) and (c) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. In this setting, rotator interval injury should be suspected.

View larger version (136K): [in a new window]   Figure 11b. Anterior extension of supraspinatus tendon tear (arrow) to involve the subscapularis tendon (*). (a, b) Sagittal (a, more medial; b, more lateral) and (c) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. In this setting, rotator interval injury should be suspected.

View larger version (132K): [in a new window]   Figure 11c. Anterior extension of supraspinatus tendon tear (arrow) to involve the subscapularis tendon (*). (a, b) Sagittal (a, more medial; b, more lateral) and (c) transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. In this setting, rotator interval injury should be suspected.

View larger version (145K): [in a new window]   Figure 12a. Arthroscopically proved rotator interval defect with thickened, scarred, and redundant rotator interval tissue. The subscapularis tendon was partially torn, with long head of the biceps brachii tendon encased by bone. (a-c) Transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show thickened tissue of rotator interval (black arrowhead). High-signal-intensity cleft in a is consistent with contrast agent extension (white arrowhead). Long head of biceps brachii tendon (arrow) is almost completely encased by bone.

View larger version (147K): [in a new window]   Figure 12b. Arthroscopically proved rotator interval defect with thickened, scarred, and redundant rotator interval tissue. The subscapularis tendon was partially torn, with long head of the biceps brachii tendon encased by bone. (a-c) Transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show thickened tissue of rotator interval (black arrowhead). High-signal-intensity cleft in a is consistent with contrast agent extension (white arrowhead). Long head of biceps brachii tendon (arrow) is almost completely encased by bone.

View larger version (146K): [in a new window]   Figure 12c. Arthroscopically proved rotator interval defect with thickened, scarred, and redundant rotator interval tissue. The subscapularis tendon was partially torn, with long head of the biceps brachii tendon encased by bone. (a-c) Transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show thickened tissue of rotator interval (black arrowhead). High-signal-intensity cleft in a is consistent with contrast agent extension (white arrowhead). Long head of biceps brachii tendon (arrow) is almost completely encased by bone.

View larger version (141K): [in a new window]   Figure 13. Arthroscopically confirmed injury with fraying of superior glenohumeral ligament. Transverse T1-weighted MR arthrographic image (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. Superior glenohumeral ligament (black arrow) is thickened and slightly irregular. A normal superior glenohumeral ligament is usually smaller than the coracohumeral ligament (white arrow).

View larger version (122K): [in a new window]   Figure 14. Arthroscopically proved bicipital sling injury with intact subscapularis tendon. Sagittal T1-weighted MR arthrographic image (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound. Bicipital sling (arrow) is thickened and inhomogeneous, with high signal intensity. Arrowhead = long head of biceps brachii tendon, * = subscapularis tendon. Compare with Figure 4.

View larger version (149K): [in a new window]   Figure 15a. Arthroscopically confirmed injury to superior glenohumeral ligament on T1-weighted MR arthrographic images (700/10) obtained with intraarticular administration of dilute gadolinium compound. (a, b) Transverse images and (c) sagittal image obtained with fat saturation show attenuated and slightly irregular superior glenohumeral ligament (arrow). Compare with normal anatomy in Figure 2.

View larger version (156K): [in a new window]   Figure 15b. Arthroscopically confirmed injury to superior glenohumeral ligament on T1-weighted MR arthrographic images (700/10) obtained with intraarticular administration of dilute gadolinium compound. (a, b) Transverse images and (c) sagittal image obtained with fat saturation show attenuated and slightly irregular superior glenohumeral ligament (arrow). Compare with normal anatomy in Figure 2.

View larger version (139K): [in a new window]   Figure 15c. Arthroscopically confirmed injury to superior glenohumeral ligament on T1-weighted MR arthrographic images (700/10) obtained with intraarticular administration of dilute gadolinium compound. (a, b) Transverse images and (c) sagittal image obtained with fat saturation show attenuated and slightly irregular superior glenohumeral ligament (arrow). Compare with normal anatomy in Figure 2.

View larger version (144K): [in a new window]   Figure 16a. Intraarticular dislocation of long head of biceps brachii tendon (black arrow). (a) Transverse and (b) coronal oblique T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show medial displacement of tendon of long head of the biceps brachii. Also shown is torn and retracted subscapularis tendon (white arrow).

View larger version (141K): [in a new window]   Figure 16b. Intraarticular dislocation of long head of biceps brachii tendon (black arrow). (a) Transverse and (b) coronal oblique T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show medial displacement of tendon of long head of the biceps brachii. Also shown is torn and retracted subscapularis tendon (white arrow).

View larger version (166K): [in a new window]   Figure 17a. Arthroscopically confirmed subluxated and partially torn long head of biceps brachii tendon (arrow) and partially torn subscapularis tendon. (a, b) Transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show long head of biceps brachii tendon is surrounded by contrast agent anterior to the superficial subscapularis tendon fibers (*), deep to the coracohumeral ligament (white arrowheads). Black arrowhead = bicipital groove.

View larger version (158K): [in a new window]   Figure 17b. Arthroscopically confirmed subluxated and partially torn long head of biceps brachii tendon (arrow) and partially torn subscapularis tendon. (a, b) Transverse T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show long head of biceps brachii tendon is surrounded by contrast agent anterior to the superficial subscapularis tendon fibers (*), deep to the coracohumeral ligament (white arrowheads). Black arrowhead = bicipital groove.

View larger version (135K): [in a new window]   Figure 18a. Anterior supraspinatus tendon tear with associated medial subluxation of long head of biceps brachii tendon. (a) Sagittal and (b) transverse intermediate-weighted MR images (2500/28) obtained with fat saturation. (a) Distal anterior supraspinatus tendon tear (arrow) is visible. (b) Long head of biceps brachii tendon (black arrow) shows medial subluxation superficial to the subscapularis tendon (white arrow). Intermediate-signal-intensity linear structure (arrowheads) superficial to subscapularis tendon and deep to biceps tendon is compatible with coracohumeral ligament. Empty bicipital groove is fluid filled.

View larger version (169K): [in a new window]   Figure 18b. Anterior supraspinatus tendon tear with associated medial subluxation of long head of biceps brachii tendon. (a) Sagittal and (b) transverse intermediate-weighted MR images (2500/28) obtained with fat saturation. (a) Distal anterior supraspinatus tendon tear (arrow) is visible. (b) Long head of biceps brachii tendon (black arrow) shows medial subluxation superficial to the subscapularis tendon (white arrow). Intermediate-signal-intensity linear structure (arrowheads) superficial to subscapularis tendon and deep to biceps tendon is compatible with coracohumeral ligament. Empty bicipital groove is fluid filled.

View larger version (151K): [in a new window]   Figure 19a. Extensive subscapularis tendon tear with nondislocated tendon of long head of the biceps brachii. (a, c) Transverse and (b) coronal intermediate-weighted MR images (2500/28) obtained with fat saturation. (a, b) Acute shoulder injury with "natural" arthrogram effect due to intraarticular fluid. Complete tear of subscapularis tendon (*) is visible, but long head of biceps brachii tendon (arrow) is still held in the groove by thickened pulley ligaments (arrowhead). (c) Section cranial to a shows superior portion of lesser tuberosity covered by thickened irregular tissue (arrowhead), consistent with injured but not completely disrupted medial pulley ligament complex, with partial volume averaging of long head of biceps brachii tendon proximal to entrance to the groove. Lateral portion of sling appears to be injured (arrow).

View larger version (145K): [in a new window]   Figure 19b. Extensive subscapularis tendon tear with nondislocated tendon of long head of the biceps brachii. (a, c) Transverse and (b) coronal intermediate-weighted MR images (2500/28) obtained with fat saturation. (a, b) Acute shoulder injury with "natural" arthrogram effect due to intraarticular fluid. Complete tear of subscapularis tendon (*) is visible, but long head of biceps brachii tendon (arrow) is still held in the groove by thickened pulley ligaments (arrowhead). (c) Section cranial to a shows superior portion of lesser tuberosity covered by thickened irregular tissue (arrowhead), consistent with injured but not completely disrupted medial pulley ligament complex, with partial volume averaging of long head of biceps brachii tendon proximal to entrance to the groove. Lateral portion of sling appears to be injured (arrow).

View larger version (143K): [in a new window]   Figure 19c. Extensive subscapularis tendon tear with nondislocated tendon of long head of the biceps brachii. (a, c) Transverse and (b) coronal intermediate-weighted MR images (2500/28) obtained with fat saturation. (a, b) Acute shoulder injury with "natural" arthrogram effect due to intraarticular fluid. Complete tear of subscapularis tendon (*) is visible, but long head of biceps brachii tendon (arrow) is still held in the groove by thickened pulley ligaments (arrowhead). (c) Section cranial to a shows superior portion of lesser tuberosity covered by thickened irregular tissue (arrowhead), consistent with injured but not completely disrupted medial pulley ligament complex, with partial volume averaging of long head of biceps brachii tendon proximal to entrance to the groove. Lateral portion of sling appears to be injured (arrow).

View larger version (144K): [in a new window]   Figure 20a. Arthroscopically proved delamination-type tear of subscapularis tendon with extremely degenerative and frayed long head of biceps brachii tendon subluxated into y-shaped split. (a) Transverse and (b) coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show split subscapularis tendon (*) with subluxated long head of biceps brachii tendon (black arrow). White arrow = bicipital groove.

View larger version (135K): [in a new window]   Figure 20b. Arthroscopically proved delamination-type tear of subscapularis tendon with extremely degenerative and frayed long head of biceps brachii tendon subluxated into y-shaped split. (a) Transverse and (b) coronal T1-weighted MR arthrographic images (700/10) obtained with fat saturation after intraarticular administration of dilute gadolinium compound show split subscapularis tendon (*) with subluxated long head of biceps brachii tendon (black arrow). White arrow = bicipital groove.