Reason: assess for rotator cuff injury History: shoulder pain Examination is slightly limited by patient motion artifact.ROTATOR CUFF: There is a full thickness tear of the supraspinatus tendon, with retraction to the level of the top of the humeral head. The tear appears to involve the majority of the supraspinatus tendon at its insertion on the greater tuberosity, although we suspect that the posteriormost portion of the tendon remains intact. The supraspinatus muscle appears normal. Increased signal intensity within the infraspinatus tendon reflects a combination of tendinosis and interstitial tearing, with mild atrophy of the infraspinatus muscle. The teres minor muscle and tendon appear intact. There is also a complete tear of the subscapularis tendon with retraction to the level of the glenohumeral joint. There is mild atrophy of the subscapularis muscle. SUPRASPINATUS OUTLET: Mild osteoarthritis affects the acromioclavicular joint. There is a small amount of fluid within the subacromial/subdeltoid bursa, reflecting known rotator cuff tear, but there is no large bursal effusion. GLENOHUMERAL JOINT AND GLENOID LABRUM: Thin linear increased signal intensity incompletely traversing the posterior inferior labrum suggests a tear (best seen on series 4, image 16). Mild increased signal within the superior labrum suggests degeneration and degenerative fraying. There is a small glenohumeral joint effusion. BICEPS TENDON: The tendon of the long head of the biceps is not visualized within the rotator interval, suggesting rupture. Low signal intensity within the bicipital groove may reflect remnants of the torn biceps tendon. A band of low signal intensity within the anterior portion of the glenohumeral joint is favored to represent a large middle glenohumeral ligament, although could conceivably represent a displaced fragment of torn biceps tendon.
Full thickness tears of the supraspinatus and subscapularis tendons and other findings as above. Findings were discussed by telephone with Dr. Havlin (at pager 5876) on 11/7/2016 11:10 AM.