0:00

Okay, so this is a 68-year-old woman

0:04

who sustained an injury while swimming.

0:07

So we have oblique coronal images.

0:10

This is a T1 FAT SAT sequence, and this

0:15

is a T2 non FAT SAT sequence, all right?

0:20

And we have contrast inside the joint space on the left

0:25

that is bright because we have injected a solution with

0:29

gadolinium that is causing that shortening of the T1.

0:33

The contrast is extending from the joint space.

0:37

along the articular surface of the supraspinatus.

0:40

So we see it tracking inside the supraspinatus.

0:43

And then we have this bursal surface of

0:46

the supraspinatus, which is still intact.

0:49

So we have a partial thickness here because the bursal surface

0:54

is still intact, but the articular surface is disrupted.

0:58

And this is the hallmark of the bursal.

1:00

Past the lesion, partial articular surface

1:03

tear of the supraspinatus due to avulsion.

1:08

And we know that there was an avulsion because this

1:10

patient was doing overhead activity during swimming.

1:15

Now, very important.

1:17

to correlate the findings seen on the T1 weighted images

1:21

with the T2 weighted images, because now we are seeing some

1:25

fluid on the bursal side of the tendon, right here, that

1:29

linear laminar collection of fluid, It's actually bursitis.

1:35

So we have some fluid that is reacting to the presence

1:39

of a tear in the supraspinatus tendon, but because on

1:43

T1 weighted images we don't have bright signal spilling

1:47

into the bursa, we know that this is a contained wound.

1:50

Partial thickness tear.

1:52

It is high grade.

1:53

It's more than 50 percent of the tendon substance.

1:56

So if you take the articular surface here and we do

2:00

a quick calculation, it's at least 75 percent of the

2:04

tendon substance, the tendon fibers are involved.

2:07

So high grade, partial thickness, articular surface tear of the

2:13

supraspinatus due to avulsion and we have then a PASTA lesion.

2:22

images, we notice that the long head of biceps

2:25

tendon is perching over the lesser tuberosity.

2:29

There is extension of contrast material into the footprint

2:34

of the subscapularis tendon at the lesser tuberosity.

2:38

Let's track this on the sagittal images.

2:41

So we have the cranial margin of the subscapularis here.

2:46

This is your coracoid process.

2:48

superior glenohumeral ligament.

2:50

And we have a contrast deposit within the sub

2:54

scap tendon that we can track all the way to

2:58

the attachment into the lesser tuberosity.

3:01

So these highlights the importance of assessing

3:05

the health of the subscapularis tendon.

3:07

When we see perching of the long head of biceps, typically

3:12

we're going to have injury to the medial stabilizing structures

3:16

of the long head of biceps tendon along with a tear of the

3:20

subscapularis at the insertion into the lesser tuberosity.

3:25

So, in summary, long head of biceps tendon instability

3:29

with perching of the tendon or over the lesser tuberosity.

3:33

The tendon itself is mildly tendinotic.

3:36

There is no evidence of a tear.

3:38

There is a tear of the subscapularis tendon

3:41

which is allowing this instability to happen.