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Here's a 68-year-old male.

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Sixty eight.

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Pain for a month.

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Do 68-year-olds get instability?

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Are they moving their arm enough to get it?

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Of course, they are.

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This patient plays golf, and he's got pain

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in the mid to latter portion of his golf

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swing, and he's got good reason for it.

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The first thing you do is you look

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at the anatomy on the T1-weighted.

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Bone, fat-weighted sequence, and you see the

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patient has a goatee or a goat-beard deformity.

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There's glenohumeral arthropathy.

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This patient complains of inability

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to complete his golf swing.

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His backswing is diminished.

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His follow-through is diminished.

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So, in some respects, he's got decreased range of motion.

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Why?

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This spur is inhibiting his range of motion.

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So, it is not uncommon for you to hear, especially in

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middle-aged and elderly patients, or in individuals who

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are young and are guarding the shoulder, that even though

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they have instability, they have decreased range of motion.

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This is a very counterintuitive clinical concept.

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Let's look at the sequela of this

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patient's instability on MR imaging.

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The first thing you might notice in the

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axial projection is we've got a wave.

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The wave is out, the wave is in, the wave is out again.

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In other words, an undulating glenoid.

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There's glenoid remodeling, yes, with arthrosis, penetrating

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erosions, bone hibernation, and dark signal sclerosis.

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But look at that posterior labrum.

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It is macerated into many little pieces.

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There's not a nice tight attachment

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between it and the glenoid.

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A little bit of periosteal stripping.

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There's a little bit of redundancy of the capsule.

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And as a byproduct of all these things.

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Incongruity of the head and the

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cup, and these are stabilizers.

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Yes, the cup and its rims are passive stabilizers.

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Loss of the labral mechanism.

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Capsular irregularity and plasticity.

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The humeral head is sagging posteriorly.

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So there's multi-directional micro-instability

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with the posterior geography predominating.

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How do I know it's multi-directional?

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Because other directions are involved.

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Let's look at the anterior inferior labrum.

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The labrum is there, it's a little bit swollen,

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there's a small pseudocyst right here, which

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suggests that this is being impacted by some

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other structure, perhaps the coracoid, an

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external rotation, but look at your subscapularis.

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There's an intrasubstance abnormality of your

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subscapularis, and have a look at that biceps.

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Big, fat, gray biceps.

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Let's go down and look at the biceps again.

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Biceps dark, biceps fat and gray, with deficiency of

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the medial transverse ligament, which should insert

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firmly right there, transverse ligament made up of the

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coracohumeral ligament in part, should insert right

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there, tamp down with the subscapularis, and prevent

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the biceps from coming out prematurely, which it is,

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it's medialized, and being injured, and resulting

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in tendinosis, an intrasubstance, partial thickness.

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Chronic hypertrophic tear.

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So we have an anterior problem.

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The entire anterior capsule is diffusely swollen.

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There are innumerable pseudocysts in the front

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from coracoid abutment and internal rotation.

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There are innumerable pseudocysts in the back from

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internal impingement and abduction and internal rotation.

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The so-called A bear position.

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And part of the triad of internal impingement is penetrating

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pseudocysts, labral fraying, and even a slap lesion.

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And this patient has a slap lesion.

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The third part of the triad, by the way, is

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infraspinatus tendinopathy, and tendinosis.

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So it goes labral tear, with or without cysts, pseudocysts

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in the humeral head, infraspinatus tendinopathy.

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Do we have infraspinatus tendinopathy?

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We sure do.

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Bart Simpson's hair is on fire.

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It's too bright.

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And the pseudocysts.

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And the labral tear with a nice, large

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saddlebag set of paralabral cysts.

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Let's bring down our water-weighted

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image in the coronal projection.

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Here is our paralabral saddlebag

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pseudocyst arising from our labral tear.

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We've already seen our posterior labral pathology.

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We've already seen our posterior humeral head sagging.

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We've already seen failure of the medial

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biceps pulley mechanism at the junction of

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the subscapularis and the transverse humeral

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ligament, resulting in injury to the biceps.

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Weightlifter, 60 plus years old, multi

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directional instability, multiple

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problems, all co-mingled, all co-related.