12 thoughts on “Shoulder MRI…..Unusual Cuff Tear Throwdown…..Share your best….I dare you!”
tanejamsk
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear
affects solely the myotendinous junction — while the tendon attachment is
preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a *footvolley *
match.
I have seen a similar case that turned out to be horizontal delamination of
the supraspinatus with differential retraction of the torn bursal fibers.
This was proven surgically although I don’t have the intraoperative images
to prove the proof. The surgeon said he could see where the cuff was torn
at the footprint but it wasn’t full thickness resulting in retraction of
only the torn fibers. Very unusual in my opinion.
[image: Horizontal delamination.jpg]
On Mon, Feb 21, 2022 at 7:29 AM Atul K. Taneja, M.D., Ph.D. <
tanejamsk@gmail.com> wrote:
[gallery]
ocad-msk
I think these are variations of the “novel lesion”, a delaminating interstitial tear classically involving the infraspinatus, though I have seen plenty like these that are supraspinatus. The important thing is that some of these can be completely unseen along the bursal and articular surfaces at arthroscopy, so the surgeon must trust you enough to debride into the tendon.
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
avneesh.chhabra
100% Agree with Dr. Awh
Any tendon with multipennate structure and organization can have individual tendon tears and particularly at myotendinous junction in rotator cuff or achilles, etc.
Attached is ppt from my shoulder lecture. 1st two slides- only conservative management. Case 1 came from outside (low field magnet)- someone called full thickness tear- Shoulder surgeon sent for 2nd opinion as these are non-op cases. But aggressive physical therapy is needed as these can develop bad fatty atrophy of IS.
I think these are variations of the “novel lesion”, a delaminating interstitial tear classically involving the infraspinatus, though I have seen plenty like these that are supraspinatus. The important thing is that some of these can be completely unseen along the bursal and articular surfaces at arthroscopy, so the surgeon must trust you enough to debride into the tendon.
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Any tendon with multipennate structure and organization can have individual tendon tears and particularly at myotendinous junction in rotator cuff or achilles, etc.
Attached is ppt from my shoulder lecture. 1st two slides- only conservative management. Case 1 came from outside (low field magnet)- someone called full thickness tear- Shoulder surgeon sent for 2nd opinion as these are non-op cases. But aggressive physical therapy is needed as these can develop bad fatty atrophy of IS.
Case 2- also non-op
Case 3/4- need surgery
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
I think these are variations of the “novel lesion”, a delaminating interstitial tear classically involving the infraspinatus, though I have seen plenty like these that are supraspinatus. The important thing is that some of these can be completely unseen along the bursal and articular surfaces at arthroscopy, so the surgeon must trust you enough to debride into the tendon.
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Dr Graeme Thompson
Consultant Musculoskeletal Radiologist
Oxford University Hospitals
Oxford Musculoskeletal Radiology graemevthompson@gmail.com
Mobile: 07853396430
Office: 0800 170 1245
[gallery]
aguiar.rodrigo
Joining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific
tendinitis. Is it a myotendinous tear with a concomitant calcific
tendinitis (maybe it can facilitate this type of tear) or is it a calcific
tendinitis with intramuscular extension? For me it’s hard to pick a side
and I will probably put the two options on the differential diagnosis
unless there is a clear history of previous trauma. A complementary CT
would be helpful.
I always double check if there is any rotator cuff calcification in cases
like this (after I had beaten my head against the wall many times…)
Take care,
* bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears)
* significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)
Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage
1. calcific myositis
Citation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Joining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.
I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
[Slide1.jpeg]
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
[Slide2.jpeg]
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
[Slide3.jpeg]
The far posterior Cor images show the completely avulsed T Minor tendon
[Slide4.jpeg]
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
[gallery]
aguiar.rodrigo
Thanks for your reply Avneesh!
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Thanks for your reply Avneesh!
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Best,
Rodrigo.
Em 22 de fev. de 2022 09:07 -0300, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu> escreveu:
Rodrigo,
Go with Ca HADD as primary diagnosis – if • bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears) • significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage 2. calcific myositisCitation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Best!AC
Avneesh Chhabra, M.D. M.B.A.Professor Radiology & Orthopedic SurgeryChief, Division of Musculoskeletal RadiologyUT Southwestern Medical Center, Dallas, Tx5373 Harry Hines Blvd.Dallas, Tx-75390-9178Office: 214-648-2122avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>http://www.utsouthwestern.edu<http://www.utsouthwestern.edu/>
________________________________
EXTERNAL MAILJoining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
dresnick
Interesting discussion.
One other thought. Although I am guilty (as are many others) of referring to such tendon calcification as HADD, a more accurate description is basic calcium phosphate disease (BCP) as many articles, including the one I attach, emphasize that there are a variety of calcium phosphate crystals that can be the real culprit, including but not limited to calcium hydroxyapatite (HA), octacalcium phosphate (OCP), tricalcium phosphate (TCP), and carbonate apatite (CA). Further, in some reports, the last of these, carbonate apatite, has been found to be the most common crystal involved in “calcific tendinitis”, not hydroxyapatite.
EXTERNAL MAIL
Thanks for your reply Avneesh!
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Best,
Rodrigo.
Em 22 de fev. de 2022 09:07 -0300, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu<mailto:Avneesh.Chhabra@utsouthwestern.edu>> escreveu:
Rodrigo,
Go with Ca HADD as primary diagnosis – if • bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears) • significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage 2. calcific myositisCitation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Best!AC
Avneesh Chhabra, M.D. M.B.A.Professor Radiology & Orthopedic SurgeryChief, Division of Musculoskeletal RadiologyUT Southwestern Medical Center, Dallas, Tx5373 Harry Hines Blvd.Dallas, Tx-75390-9178Office: 214-648-2122avneesh.chhabra@utsouthwestern.edu<urldefense.com/v3/__https:/mailto:avneesh.chhabra@utsouthwestern.edu__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mPGQ2q3jQ$>http://www.utsouthwestern.edu<urldefense.com/v3/__http:/www.utsouthwestern.edu/__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mMtxqK9ww$>
________________________________
EXTERNAL MAILJoining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<urldefense.com/v3/__https:/mailto:hilary.umans@gmail.com__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mNH1c6x6g$>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
Moving shoulder-adjacent….saw this case this morning, limited US to
evaluate tender lump x 4 months in a 56F who does yoga.
There is no soft tissue mass, there is an enthesophyte (red arrow) at the
posterolateral margin of the acromion, with hypoechoic thickening of the
deltoid at its origin, and numerous punctate echogenic foci /
calcifications with flow on Doppler indicating reactive inflammation.
It’s a testimony to the relative sensitivity of US, as I can barely see the
enthesophyte on the XR.
I never know what to call something like this.
Would you call this all “enthesitis”?
What do you call the deltoid calcifications? Basic calcium phosphate?
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear
affects solely the myotendinous junction — while the tendon attachment is
preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a *footvolley *
match.
[image: image.png]
[image: image.png]
[image: image.png]
[image: image.png]
[image: image.png]
[image: image.png]
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com>
escreveu:
ajr.13.11474.pdf
[gallery]
the supraspinatus with differential retraction of the torn bursal fibers.
This was proven surgically although I don’t have the intraoperative images
to prove the proof. The surgeon said he could see where the cuff was torn
at the footprint but it wasn’t full thickness resulting in retraction of
only the torn fibers. Very unusual in my opinion.
[image: Horizontal delamination.jpg]
On Mon, Feb 21, 2022 at 7:29 AM Atul K. Taneja, M.D., Ph.D. < tanejamsk@gmail.com> wrote:
[gallery]
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
radsource.us/rotator-cuff-pitfalls/
Mark Awh
Sent: Monday, February 21, 2022 11:07 AM
Cc: hilary umans <hilary.umans@gmail.com>; ocad-msk@googlegroups.com
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
Any tendon with multipennate structure and organization can have individual tendon tears and particularly at myotendinous junction in rotator cuff or achilles, etc.
Attached is ppt from my shoulder lecture. 1st two slides- only conservative management. Case 1 came from outside (low field magnet)- someone called full thickness tear- Shoulder surgeon sent for 2nd opinion as these are non-op cases. But aggressive physical therapy is needed as these can develop bad fatty atrophy of IS.
Case 2- also non-op
Case 3/4- need surgery
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
Dallas, Tx-75390-9178
Office: 214-648-2122
avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>
http://www.utsouthwestern.edu<http://www.utsouthwestern.edu/>
________________________________
Sent: Monday, February 21, 2022 1:03 PM
Cc: hilary umans <hilary.umans@gmail.com>; ocad-msk@googlegroups.com <ocad-msk@googlegroups.com>
EXTERNAL MAIL
I think these are variations of the “novel lesion”, a delaminating interstitial tear classically involving the infraspinatus, though I have seen plenty like these that are supraspinatus. The important thing is that some of these can be completely unseen along the bursal and articular surfaces at arthroscopy, so the surgeon must trust you enough to debride into the tendon.
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
radsource.us/rotator-cuff-pitfalls/
Mark Awh
Sent: Monday, February 21, 2022 11:07 AM
Cc: hilary umans <hilary.umans@gmail.com>; ocad-msk@googlegroups.com
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
Controversial and probably varied pathogenesis…
Don
Sent: Monday, February 21, 2022 12:21 PM
Cc: hilary umans <hilary.umans@gmail.com>; ocad-msk@googlegroups.com
100% Agree with Dr. Awh
Any tendon with multipennate structure and organization can have individual tendon tears and particularly at myotendinous junction in rotator cuff or achilles, etc.
Attached is ppt from my shoulder lecture. 1st two slides- only conservative management. Case 1 came from outside (low field magnet)- someone called full thickness tear- Shoulder surgeon sent for 2nd opinion as these are non-op cases. But aggressive physical therapy is needed as these can develop bad fatty atrophy of IS.
Case 2- also non-op
Case 3/4- need surgery
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
Dallas, Tx-75390-9178
Office: 214-648-2122
avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>
http://www.utsouthwestern.edu<urldefense.com/v3/__http:/www.utsouthwestern.edu/__;!!LLK065n_VXAQ!3lmRCyPcRD-i-FnelYTrNptSzambGRlUugKvvYbkejRkoxBjf63xWuciYu02t9ekJQ$>
________________________________
Sent: Monday, February 21, 2022 1:03 PM
Cc: hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>>; ocad-msk@googlegroups.com<mailto:ocad-msk@googlegroups.com> <ocad-msk@googlegroups.com<mailto:ocad-msk@googlegroups.com>>
EXTERNAL MAIL
I think these are variations of the “novel lesion”, a delaminating interstitial tear classically involving the infraspinatus, though I have seen plenty like these that are supraspinatus. The important thing is that some of these can be completely unseen along the bursal and articular surfaces at arthroscopy, so the surgeon must trust you enough to debride into the tendon.
The first case in this web clinic describes it, along with a nice 3D illustration and an operative pic.
radsource.us/rotator-cuff-pitfalls/<urldefense.com/v3/__https:/radsource.us/rotator-cuff-pitfalls/__;!!LLK065n_VXAQ!3lmRCyPcRD-i-FnelYTrNptSzambGRlUugKvvYbkejRkoxBjf63xWuciYu2UbhJ9GA$>
Mark Awh
Sent: Monday, February 21, 2022 11:07 AM
Cc: hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>>; ocad-msk@googlegroups.com<mailto:ocad-msk@googlegroups.com>
I have seen a similar case that turned out to be horizontal delamination of the supraspinatus with differential retraction of the torn bursal fibers. This was proven surgically although I don’t have the intraoperative images to prove the proof. The surgeon said he could see where the cuff was torn at the footprint but it wasn’t full thickness resulting in retraction of only the torn fibers. Very unusual in my opinion.
Great and complex case!
On the unusual rotator cuff case track, I share below a case where the tear affects solely the myotendinous junction — while the tendon attachment is preserved.
We have written our thoughts on such types of lesions in the paper attached.
Best regards,
Atul
49 yo male, shoulder pain after a fall 3 days ago during a footvolley match.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
Consultant Musculoskeletal Radiologist
Oxford University Hospitals
Oxford Musculoskeletal Radiology
graemevthompson@gmail.com
Mobile: 07853396430
Office: 0800 170 1245
[gallery]
The same pattern of the myotendinous junction tear and associated calcific
tendinitis. Is it a myotendinous tear with a concomitant calcific
tendinitis (maybe it can facilitate this type of tear) or is it a calcific
tendinitis with intramuscular extension? For me it’s hard to pick a side
and I will probably put the two options on the differential diagnosis
unless there is a clear history of previous trauma. A complementary CT
would be helpful.
I always double check if there is any rotator cuff calcification in cases
like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com>
escreveu:
[gallery]
Go with Ca HADD as primary diagnosis – if
* bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears)
* significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)
Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage
1. calcific myositis
Citation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
Dallas, Tx-75390-9178
Office: 214-648-2122
avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>
http://www.utsouthwestern.edu<http://www.utsouthwestern.edu/>
________________________________
Sent: Monday, February 21, 2022 7:35 PM
Cc: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com>
EXTERNAL MAIL
Joining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.
I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
[Slide1.jpeg]
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
[Slide2.jpeg]
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
[Slide3.jpeg]
The far posterior Cor images show the completely avulsed T Minor tendon
[Slide4.jpeg]
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
[gallery]
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Best,
Rodrigo.
Em 22 de fev. de 2022 09:07 -0300, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu> escreveu:
even in solid quiescent phase- if calcium removed- one will find the tear- can send such a case sometime later
once there is bursitis/muscle edema- one should call it active unless there is a very good reason such as muscle denervation in my opinion
Last comment from me on this topic- as to not fill several mailboxes
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Thanks for your reply Avneesh!
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Best,
Rodrigo.
Em 22 de fev. de 2022 09:07 -0300, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu> escreveu:
Rodrigo,
Go with Ca HADD as primary diagnosis – if • bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears) • significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage 2. calcific myositisCitation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Best!AC
Avneesh Chhabra, M.D. M.B.A.Professor Radiology & Orthopedic SurgeryChief, Division of Musculoskeletal RadiologyUT Southwestern Medical Center, Dallas, Tx5373 Harry Hines Blvd.Dallas, Tx-75390-9178Office: 214-648-2122avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>http://www.utsouthwestern.edu<http://www.utsouthwestern.edu/>
________________________________
EXTERNAL MAILJoining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<mailto:hilary.umans@gmail.com>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
One other thought. Although I am guilty (as are many others) of referring to such tendon calcification as HADD, a more accurate description is basic calcium phosphate disease (BCP) as many articles, including the one I attach, emphasize that there are a variety of calcium phosphate crystals that can be the real culprit, including but not limited to calcium hydroxyapatite (HA), octacalcium phosphate (OCP), tricalcium phosphate (TCP), and carbonate apatite (CA). Further, in some reports, the last of these, carbonate apatite, has been found to be the most common crystal involved in “calcific tendinitis”, not hydroxyapatite.
Don
Sent: Tuesday, February 22, 2022 5:39 AM
Cc: hilary umans <hilary.umans@gmail.com>; ocad-msk@googlegroups.com
Its v v rare for ca hadd to be present without a bursal tear
even in solid quiescent phase- if calcium removed- one will find the tear- can send such a case sometime later
once there is bursitis/muscle edema- one should call it active unless there is a very good reason such as muscle denervation in my opinion
Last comment from me on this topic- as to not fill several mailboxes
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<urldefense.com/v3/__https:/www.utsouthwestern.edu/education/medical-school/departments/radiology/__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mMS_P-3Gw$>
EXTERNAL MAIL
Thanks for your reply Avneesh!
Generally speaking I don’t see a problem to diagnose calcific tendinitis in cases like yours.
What bugs me in my cases is the calcific tendinitis looks like it is in the quiescent phase….no distortion of the tendon around the deposit or inflamation around it.
It just happened to be there at the same time the patients had the right mechanism of injury for MT juction tear. Probably this is just a coincidence but I wonder if calcific tendinitis can play a role in some cases.
Best,
Rodrigo.
Em 22 de fev. de 2022 09:07 -0300, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu<mailto:Avneesh.Chhabra@utsouthwestern.edu>> escreveu:
Rodrigo,
Go with Ca HADD as primary diagnosis – if • bursal sided predominant tear and calcification without history of recent fall or impingement anatomy (other causes of bursal tears) • significant inflammation and bursitis with calcification plus bursal leakage (fall is other cause of bursal rupture)Attached are two such cases for you-
1. calcific bursitis/tendinitis and tears plus bursal leakage 2. calcific myositisCitation for bursal rupture-
Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol. 2011 Oct;18(5):395-402. doi: 10.1007/s10140-011-0973-4. Epub 2011 Jul 7. PMID: 21735271.
Best!AC
Avneesh Chhabra, M.D. M.B.A.Professor Radiology & Orthopedic SurgeryChief, Division of Musculoskeletal RadiologyUT Southwestern Medical Center, Dallas, Tx5373 Harry Hines Blvd.Dallas, Tx-75390-9178Office: 214-648-2122avneesh.chhabra@utsouthwestern.edu<urldefense.com/v3/__https:/mailto:avneesh.chhabra@utsouthwestern.edu__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mPGQ2q3jQ$>http://www.utsouthwestern.edu<urldefense.com/v3/__http:/www.utsouthwestern.edu/__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mMtxqK9ww$>
________________________________
EXTERNAL MAILJoining the wagon, look at these two cases:
The same pattern of the myotendinous junction tear and associated calcific tendinitis. Is it a myotendinous tear with a concomitant calcific tendinitis (maybe it can facilitate this type of tear) or is it a calcific tendinitis with intramuscular extension? For me it’s hard to pick a side and I will probably put the two options on the differential diagnosis unless there is a clear history of previous trauma. A complementary CT would be helpful.I always double check if there is any rotator cuff calcification in cases like this (after I had beaten my head against the wall many times…)
Take care,
Rodrigo.
Em seg., 21 de fev. de 2022 às 11:06, hilary umans <hilary.umans@gmail.com<urldefense.com/v3/__https:/mailto:hilary.umans@gmail.com__;!!LLK065n_VXAQ!07miFXRoD-sD-Pv8z68ioQ-UTua56jGkWGWi6CLu7V0L7DpOOZO0t2Ih3mNH1c6x6g$>> escreveu:
This is one of the crazier Rotator Cuff injuries I’ve seen…though a certain Dr. Tirman seems to have published a series of injuries just like this recently (1998).
I’ve attached an open access surgical case report.
Does anybody have a similar case to share?
How about sharing your most unusual or biggest, craziest cuff tear?
Just for fun on this Monday morning….
This is a 31 yo male who fell last skiing and has pain on range of motion.
The white arrow points to the avulsed T Minor tendon.
The yellow arrow points to an injury of the subscap fascia, though the tendon seems to be intact.
Sag images show T Minor tendon avulsion and muscle tear with capsular distention and posteroinferior intra and intermuscular edema.
The far posterior Cor images show the completely avulsed T Minor tendon
And these show the Reverse HAGL (red arrows).
The attached article reports the surgical repair….though I was not certain that isolated T Minor injury would require repair?
Is it more the R-HAGL that requires repair?
Thoughts?
evaluate tender lump x 4 months in a 56F who does yoga.
There is no soft tissue mass, there is an enthesophyte (red arrow) at the
posterolateral margin of the acromion, with hypoechoic thickening of the
deltoid at its origin, and numerous punctate echogenic foci /
calcifications with flow on Doppler indicating reactive inflammation.
It’s a testimony to the relative sensitivity of US, as I can barely see the
enthesophyte on the XR.
I never know what to call something like this.
Would you call this all “enthesitis”?
What do you call the deltoid calcifications? Basic calcium phosphate?
[image: 1.jpg]
[image: 2.jpg]
[image: 3.jpg]
On Tue, Feb 22, 2022 at 10:00 AM Resnick, Donald <dresnick@health.ucsd.edu>
wrote:
[gallery]