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These are images of a man who

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sustained a fall at work, 52 years old.

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Starting on the left, we have

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oblique coronal T2-weighted sequences.

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The first thing that jumps to the eye

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is the position of the humeral head.

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So we have a humeral head that is

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superiorly translated and is not

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articulating with the glenoid as it should.

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So we call this a high riding

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humerus that is indeed articulating.

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to the acromial and their surface.

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So this is acromial humeral articulation,

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which should never happen unless if there

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is a full thickness rotator cuff tear.

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So this patient sustained a fall and there

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is a massive rotator cuff tear that is

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retracting, retracted tendons all the way

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to the level of the glenohumeral joint.

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If I take my ruler here and I measure the

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distance between the expected attachment of

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the tendon and its retraction, it gives me 5.

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1 centimeters.

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So massive rotator cuff tears, the

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cutoff is 5 centimeters and you want

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to see more than two tendons involved.

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to make the call.

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So in this case we have both the supraspinatus

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and back here the infraspinatus tendons torn and

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retracted to the level of the glenohumeral joint.

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In addition, this patient also

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thought of his subscap tendon.

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So I'm going down here on the axial images to show

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you the coracoid process, the lesser tuberosity,

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and these two are almost opposed to each other.

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There is no soft tissue.

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attaching to the lesser tuberosity, where

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we should expect to see the subscap tendon.

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So, the subscap tendon is

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completely retracted down here.

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have this retracted subscap, so massive

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rotator cuff tear, so far, supraspinatus,

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infraspinatus, and subscap lattice.

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We have to be concerned if there

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was preexisting tendon disease,

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if this patient has muscle atrophy.

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So that's what we're going to do next.

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We take the T1 weighted sequence, and we

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go to the level where The scapula looks

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like a Y, and we are going to look at

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the supraspinatus, the subscapularis,

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the infraspinatus, and the teres minor.

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I'm going to use my pen here.

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And we have the supraspinatus muscle,

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and this is the supraspinous fossa.

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So if I quickly do an occupation ratio,

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this is less than 60 percent occupation

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ratio for the supraspinatus muscle.

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So this patient has volume loss

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atrophy of the supraspinatus muscle.

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There is also fatty infiltration associated

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with it, which is a different grading that

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we do using the Classification of Goutellier.

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In this case, we have some fatty

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infiltration of the fibers.

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You can see the, um, fatty streaks into the

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muscle, but the dominant finding here is the

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loss of volume, uh, with a low occupation ratio.

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Looking at the infraspinatus muscle.

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Outlining the infraspinatus muscle,

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and you can see that there is

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roughly equal fat and muscle fibers.

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This is moderate atrophy of the infraspinatus.

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And if we look at the subscapularis,

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there is more fat than muscle.

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This is severe atrophy of

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the subscapularis muscle.

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So that's the impact that this massive rotator

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cuff tendon, uh, here is having on muscle health.

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has, uh, sizable joint effusion,

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moderate joint effusion, is complex.

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We see some intra-articular bodies within

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the joint space, and what is really

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important here is that the fluid is

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communicating through the subacromial

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subdeltoid bursa, you can see the bursa right

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there, into the acromioclavicular joint.

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So, we have a communication between

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the joint space at the shoulder joint

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level with the acromioclavicular

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joint space, and then a geyser sign.

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So, this is fluid that is present,

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poking over the acromioclavicular joint and

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is the hallmark of the geyser sign where there

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is a massive rotator cuff tendon here allowing

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communication of those fluid-filled spaces.