DATE OF STUDY: MM/DD/YYYY
NAME OF STUDY: Left shoulder MRI.
TECHNIQUE: Routine MRI was performed. There were several reattempts and then fast-scan imaging was performed due to the patient’s pain and difficulty holding still.
STUDY FINDINGS: There was much abnormality noted around the humerus. We see complete retraction of the supraspinatus and infraspinatus muscle and tendon. This would suggest a full tear of both of those tendons near the insertion site. We also see a significant tear, although not all of the tendon is torn, of the subscapularis tendon. The biceps tendon is not normally located at its most superior components. It may be either partially torn or minimally displaced towards the joint space. This is noted on both the axial and coronal imaging.
Significantly, we see abnormal signal within the humerus itself. It is located predominantly just below the humeral head and crosses midline. This would suggest the possibility of small incomplete fractures, bone contusion around them all or related contusion.
The humeral head is located slightly higher in the glenoid than normally seen and occupies the subacromial space. This is again probably secondary to the retraction of the muscle and tendons of the supraspinatus and infraspinatus structures.
There is moderate degenerative disease of the AC joint with fluid in the joint space. No significant caudal or cephalad spurring is noted, just some mild inferior spurring.
There is some degenerative change noted of the anterior glenoid labral regions. No full detachment of the labrum is present.
IMPRESSION:
1. Full muscle and tendon retraction of the supraspinatus and infraspinatus structures.
2. Partial muscle and tendon retraction of the superior aspect of the subscapularis structure.
3. Other partial tearing or dislocation of the superior aspect of the biceps tendon, which is not normally identified. It may be dislocated to the anterior joint space area.
4. Bruising and possible microfractures to the humerus just below the humeral head.
