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This is a 15-year-old man

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with right shoulder pain.

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He's got decreased range of motion

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after a wrestling injury.

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Now, wrestling is a pretty unique sport.

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There are certain classic injuries

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that you see in wrestlers.

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Probably the most classic is the medial

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collateral ligament of the knee.

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For those of you that are familiar with wrestling,

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you know that they often have a situation where

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there's a person on top, a person on the

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bottom, and the person on top is riding the person on the

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bottom, and they grab their leg and pull it,

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and they actually turn it or twist it.

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Another common problem in wrestling

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is labral pathology.

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They don't get a lot of rotator cuff tears.

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It's more labral associated.

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So I'm dialed into the labrum.

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I'm going to put up the axial,

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which is a common practice for me.

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And then I usually put up my coronal.

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So I'm going to three this one up.

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So three up. I put up my axial and two coronals.

1:04

It is no accident that the sagittal is sort

1:07

of a stepchild, but I have to have it.

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But it's not my primary sequence of evaluation.

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It is more of a refiner to see how long a

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rotator cuff tear is from front to back

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how a mass is behaving.

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And sometimes I'll use it for adhesive

1:25

capsulitis. So it definitely has a role,

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just not as critical as these.

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So let's keep looking and let's deal

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with some of your comments.

1:35

Somebody said that there's a biceps pulley injury

1:38

and edema within the rotator interval.

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So here's the rotator interval up higher.

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It's very common to have trace amounts of fluid

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in the interval because it's a space.

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The joint likes to have a little lubrication.

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As long as I don't have anything that's distended

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over a centimeter, I'm fine with that.

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And here's the interval.

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It's this sort of triangular space that is bounded

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by the superior aspect of the glenoid,

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the coracoid,

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and the superior glenohumeral ligament.

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The anterior boundary is right here.

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I'm going to draw over it for you now.

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I'm going to take my text off here for a minute,

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and I'm going to draw over the anterior boundary.

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Here's the anterior boundary,

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the coracohumeral ligament.

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There's an extra-articular portion.

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And there's an intra-articular portion.

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This is the extra-articular portion.

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Within this interval is the biceps, right there.

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I colored it in; there's a medial boundary

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of the rotator interval,

2:44

and then the lateral boundary is formed

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by the humeral head and its cartilage.

2:48

So within this space is going to be the biceps,

2:52

the superior glenohumeral ligament,

2:54

and a bunch of fibroelastic tissue,

2:56

which makes for the triangular-shaped

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rotator interval.

3:03

All right, let's keep looking.

3:05

And somebody said that there was a problem in the

3:08

interval. This gray tissue is totally normal.

3:11

This amount of fluid is totally normal.

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Now, in this patient, we don't have a sulcus.

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You can see there's quite a bit of variability in

3:19

the anterosuperior quadrant. No sulcus this time.

3:23

Here is the superior glenohumeral ligament, right

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there. Here's the biceps, right there.

3:29

Here's the coracohumeral ligament, right there.

3:32

And there's the supraspinatus.

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It's like a turkey Reuben sandwich.

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Let's draw them one more time.

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I'll blow them up for some anatomy.

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Okay, here is your tendon of your supraspinatus.

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Here's your coracohumeral ligament.

3:51

Here's your biceps coming off the labral anchor.

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And here's your SGHL. So four layers,

3:59

kind of stripy looking, but nothing.

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No sulcus. This is normal right here.

4:06

I'm really windowing it and blowing it up.

4:08

So there's no spaces in this person.

4:10

So you can see how different each shoulder is.

4:13

It's a kid. Growth plate is pretty open looking.

4:18

It's a 15-year-old,

4:21

and he's got decreased range of motion

4:24

after a wrestling injury. Now,

4:25

don't say that this depression is a dislocation.

4:29

That's silly, right? There's no swelling.

4:33

Even if you wondered about it,

4:35

that's a normal depression in the humeral head.

4:38

That would be silly because there's no swelling.

4:40

How do you dislocate your shoulder without

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swelling? On an MRI, it's impossible.

4:46

Unless the dislocation was two years ago.

4:48

So that's ridiculous.

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What else is ridiculous about it?

4:52

By Ozzy rules,

4:54

what's ridiculous is he has

4:56

decreased range of motion.

4:58

I can't tell you how many times I look

5:00

at a fellow in astonishment.

5:02

The patient should have instability,

5:04

and they're saying he's got restricted motion,

5:06

so that just shouldn't be.

5:09

Use your common sense. And then we said,

5:12

particularly common to get labral tears.

5:14

Well, let's check that out.

5:16

We know the sport. And yes,

5:18

if you're going to do ortho MRI,

5:20

you've got to know the sports.

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So here's our SGHL. It's gorgeous.

5:27

Now, that's a normal SGHL.

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That's a normal glenoid labral

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ligamentous complex, nice and confluent and dark,

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makes a big fat triangle.

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Glenoid limb, axillary limb.

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And there's the humeral attachment.

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Let's go to the front.

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Anterior band, IGHL. Middle band, IGHL,

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posterior band, a little more lax as it should be.

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IGHL.

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Humeral attachment, glenoid attachment.

5:58

That is clearly not his problem.

6:01

No SLAP lesions, no inferior labral tears,

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no anterior labral tears, no posterior labral tears.

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And as you go from top to bottom,

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the labrum should get bigger.

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And it is getting bigger.

6:15

So that's not a problem.

6:16

Let's return to your colleague's question

6:18

about the biceps. I have to admit,

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the biceps is a little fuzzy looking,

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and I think that's a product of the scan itself.

6:28

And maybe there's a tiny bit of swelling

6:31

right here, but that's about it.

6:33

So if you said a little bit of tendinopathy of the

6:36

intra-articular biceps, I could live with that.

6:38

The rest of it is actually perfect.

6:41

It's a little grainy, I will admit that.

6:44

So you're saying. Well, then, what's the problem?

6:49

One of you said that there was a focal partial

6:51

tear of the anterior glenoid labrum.

6:54

I've already addressed that. No,

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this is just hyaline cartilage right here,

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intertwining or intersecting with the

7:03

fibrous glenoid. That's normal.

7:06

That's all normal. The shape is normal.

7:09

The architecture is normal.

7:10

The smoothness of it is normal.

7:12

The size of it is normal.

7:14

The IGHL is normal. There's no Hill-Sachs.

7:18

So you're barking up the wrong tree when you are

7:21

going after the labrum. In this particular case,

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somebody said moderate joint effusion.

7:27

No way.

7:28

This is just fluid expressed into the

7:31

recesses where it likes to live.

7:33

Is it a little more fluid than should be expected?

7:37

Well, here it's not. Here it is.

7:39

So there is a little more fluid there.

7:41

He's a wrestler.

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He's probably got a little bit of capsular

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swelling from his wrestling activities,

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but that is not his major problem.

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That can go into "buyer the report" trace to

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one plus effusion. Fine, but moderate.

7:54

No way.

7:55

Moderate effusion should distend the capsule

7:59

in a generalized fashion, which it is not doing.

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Moderate associated joint effusion

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is way too strong a statement.

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Trace to one plus would be appropriate.

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So now we're down to.

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Okay,

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what is wrong with this patient?

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Certainly it's not the bone marrow.

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Red marrow, yellow marrow.

8:20

That's common in a youngster.

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So now we're going to turn to our sagittal,

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which we said we don't do that often.

8:28

We always use it,

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but we use it to refine, to define, to augment.

8:35

We can see our rotator cuff.

8:36

There's our supraspinatus.

8:38

There's our infraspinatus. There's our subscap.

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And as we scroll on this gorgeous detection

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oriented, water-weighted image, we find something.

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This is your bone scan.

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This is your soft tissue scan.

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This is your. I'm a beginner,

8:56

and I'm going to look for hot spots on the scan.

9:00

Scan.

9:02

Where are the hot spots?

9:04

There's a little swelling right there.

9:06

There's a little swelling right there.

9:08

He's getting bumped around on the wrestling mat,

9:10

that's for sure. So low-grade contusions,

9:13

but he's also got that

9:15

right. When you're wrestling, you're pulling,

9:18

you're pushing. You're internally rotating,

9:20

you're externally rotating,

9:21

and that is the answer.

9:23

Love is not the answer.

9:25

Sometimes it is, but the Terry's is the answer.

9:28

There's the Terry's minor,

9:31

and there is a strain at the myotendinous

9:34

junction of the Terry's.

9:35

So what would we look for in a case like this?

9:38

We'd look for a gap,

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not we'd look for retraction.

9:46

This is true of any muscular injury or myotendon

9:49

injury. Not, is it near the myotendinous junction?

9:54

Yes, it is. That's the myotendonous junction.

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Is the tendon intact? In other words,

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is it still attached? Yes, it is.

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It's still attached.

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So there's no tendonous detachment.

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Do we have a collection of either blood hemorrhage

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or fluid? And the answer is not,

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we'd look at the area of involvement in the muscle,

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what percent in cross-section,

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and then we'd look at the volume of involvement,

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and then finally, we'd look at the length.

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And this is how all of our colleagues in

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Great Britain, in Italy and Germany,

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and the United States grade their myotendinous

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unit injuries. This one is a minor one.

10:41

It's ill-defined. There's no focal fluid defect.

10:45

That's just swelling, interstitial swelling.

10:48

You can see the same muscle fibrils running

10:51

through it. So we're pretty good in that respect.

10:54

So this would be considered a grade one or low

10:57

grade strain of the Terry's minor

11:01

myotendinous junction,

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and I would give those pertinent negative

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findings as they relate to this case.

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15-year-old with a Terry's minor strain with a

11:12

normal labrum with a trace to one plus effusion

11:16

with an excellent looking glenohumeral

11:19

articulation and cup.