Patient History
70-year-old male with left shoulder pain and decreased range of motion after fall 2 months ago.
Findings
ROTATOR CUFF: A 5cm x 5cm full-depth, full-length tear of the supraspinatus and infraspinatus with footprint detachment and medial retraction to the level of the AC joint.
Near full-thickness split tear of the superior subscapularis.
SUBACROMIAL/SUBDELTOID BURSA: Diffuse fluid distention of the subacromial/subdeltoid bursa with reactive synovitis and internal debris.
A 1cm ossified body at the subcoracoid bursa.
MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Grade 3+ fatty infiltration and volumetric atrophy with interstitial delamination of the supraspinatus and infraspinatus. Diffuse reactive edema.
BICEPS TENDON: Dislocation of the arcuate or intraarticular segment of the long head of the biceps tendon with severe interstitial delamination and hematoma formation. Anchor fraying without detachment.
AC JOINT: Moderate to severe osteoarthrosis.
CORACOCLAVICULAR LIGAMENTS: Intact.
SUBACROMIAL ARCH/OUTLET: Thickened coracoacromial ligament. Type 3/hooked acromion.
SUBCORACOID ARCH: Narrowed. No coracoid dysplasia.
GLENOHUMERAL JOINT: Moderate reactive effusion with reactive synovitis and internal debris with ossified bodies. Bare humeral head with craniad decentering and malalignment.
GLENOID LABRUM: Superior labral fraying without displaced labral tears or paralabral cysts.
BONES: Benign-appearing sclerotic lesion or bone island at the glenoid cup. No fracture or dislocations.
SUBCUTANEOUS SOFT TISSUES: Mild diffuse periarticular soft tissue swelling.
AXILLA: No space-occupying lesions.
Impressions
1. Massive rotator cuff tear of the left shoulder.
2. A 5cm x 5cm full-depth and full-length tear with medial retraction of the supraspinatus and infraspinatus; bare humeral head with craniad decentering and glenohumeral malalignment; early rotator cuff arthrosis with abutment of the humeral head at the acromial undersurface.
3. Severe biceps pulley mechanism injury with near full-thickness split tear of the superior subscapularis, derangement of the coracohumeral and transverse ligaments, medial dislocation of the arcuate or intraarticular segment of the long head of the biceps tendon with a prominent interstitial hematoma formation.
4. Moderate glenohumeral joint effusion communicating with a distended subacromial/subdeltoid bursa. Reactive synovitis, internal debris and metaplastic ossified bodies.
