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549
Pictorial :
:.
‘
;‘
MR Imaging Radiography D. Lawrence
Burk,
Jr.
,
:
‘
,
.
:
,
,
David
Karasick,
Donald
Correlation
G. Mitchell,
Recent advances in surface-coil technology and scanner software have made high-quality MR examinations of the shoulder a practical reality. The high signal-to-noise ratios provided by local coils designed specifically for the shoulder allow imaging with small fields of view and thin sections. New software provides routine oblique imaging with oft-center fields of view and no wraparound artifacts. With these stateof-the-art techniques, several studies have shown that MR is as accurate as, if not more accurate than, arthrography in detecting rotator cuff tears [1 , 2]. In addition, MR can provide an accurate preoperative assessment of the size of a cuff tear and the condition of the remaining tendon. In the absence of a cuff tear, MR can be useful in evaluating impingement, tendinitis, and bursitis; these cannot be assessed with arthrography. MR also can show other abnormalities such as avascular necrosis, labral tears, tumors, osteomyelitis, and arthritis [3]. Although MR is considerably more expensive than arthrography, it is probable that the additional information obtained in a noninvasive fashion will make MR the procedure of choice for the evaluation of shoulder pain. For these reasons, MR is frequently the next study performed after conventional radiography. Comparison with the radiographs is essential for a complete evaluation of the MR images. Each of these techniques has distinct advantages and limitations. In this essay we will illustrate examples of these features for a variety of clinical conditions.
Received August 21 , 1989; accepted after revision October 16, 1989. , All authors: Department of Radiology. Jefterson Medical College. Thomas PA 19107. Address reprint requests to D. L. Burk, Jr. AJR 154:549-553,
March
1990 0361 -803X/90/1
543-0549
:,
:, ,‘ ‘
of the Shoulder:
© American
and Matthew
Materials
and
Essay
with Plain D. Rifkin
Methods
The images were selected from over 200 studies of the shoulder obtained on a 1 .5-T scanner. Most of the examinations were performed with a loop-gap resonator coil pair (Medical Advances, Muwaukee, WI). The technique has been described in detail [4]. Recent examinations have been performed with an anteriorly positioned, heart-shaped, single-loop coil (Medrad, Pittsburgh, PA, for General Electric Medical Systems, Milwaukee, WI). All studies included coronal oblique spin-echo (SE) 600/25 (TR/TE) and 2000/40,80 Sequences as part of the routine protocol. The other imaging parameters were 5-mm slice thickness, 1-mm interslice gap, 128 x 256 matrix, two
excitations,
and
1 4-cm
field
of view.
Respiratory
and oversampling in the phase- and frequency-encoding used routinely to reduce artifacts.
MR
Imaging-Radiographic
compensation
axes
were
Correlation
For routine cases of impingement syndrome and possible rotator cuff tear the radiographic findings are limited mainly to greater tuberosity and acromioclavicular degenerative changes [5]. These findings are nonspecific, and the diagnosis of a rotator cuff tear requires the use of another imaging technique such as MR. However, in rotator cuff arthropathy, the diagnosis usually can be made on plain radiographs because of marked acromiohumeral narrowing, and MR may be useful in assessing the quality of the remaining cuff before
Jefferson
Roentgen
University
Ray Society
Hospital.
1 033 Main Bldg.
,
10th and Sansom Sts. , Philadelphia,
Downloaded from www.ajronline.org by 201.193.36.226 on 10/13/15 from IP address 201.193.36.226. Copyright ARRS. For personal use only; all rights reserved
550
Fig. 1.-Chronic
BURK
ET AL.
AJA:154, March 1990
rotator cuff arthropathy.
A, Anteroposterior radiograph shows marked narrowing of acromiohumeral space with subacromial spur (white arrows), osteophyte formation (curved arrow), and slightly irregular glenohumeral articular surfaces (straight black arrow). B, SE 600/25 coronal oblique MR image also shows acromiohumeral narrowing with better visualization of secondary subchondral marrow changes in acromion and humeral head (black arrows). Humeral osteophyte is filled with fatty marrow (white arrow). Note marked atrophy of supraspinatus muscle (5). C, SE 2000/80 coronal oblique MR image with arthrogram effect confirms irregularity of glenohumeral articular surfaces (large arrow). Note massive rotator cuff tear with retracted tendon (small arrows) of supraspinatus muscle (5).
Fig. 2.-Supraspinatus avulsion with greater tuberosity fracture. A, Anteroposterior radiograph shows defect in lateral aspect of humeral head (arrowheads) with displaced greater tuberosity fragment (arrow). Acromiohumeral space is widened because of humeral traction. B, SE 600/25 coronal oblique MR image shows slightly larger area of acute hemorrhage and edema at site of avulsion fracture (arrowheads). Acromiohumeral space is narrowed with patient out of traction. Joint fluid (F) is isointense relative to supraspinatus muscle (5). C, SE 2000/80 coronal oblique MR image shows displaced tendon (arrows) of supraspinatus muscle (5) surrounded by fluid in glenohumeral joint. Joint fluid (F) fills narrowed acromiohumeral space in place of avulsed supraspinatus tendon. Center of fracture site has low signal intensity due to deoxyhemoglobin of acute hemorrhage (H). Peripheral edema (E) has higher signal intensity, similar to that of surrounding marrow.
surgery for total shoulder replacement (Fig. 1). Mild narrowing of the acromiohumeral space also may be present with rotator cuff atrophy, but without cuff tear. In avulsion fractures of the tuberosities, the diagnosis is made with plain radiographs,
but the full extent of injury to the mined only on MR, although the selves may not be visible (Fig. 2). cuff also can occur in the absence
rotator cuff can be deterfracture fragments themTraumatic avulsion of the of a fracture.
Downloaded from www.ajronline.org by 201.193.36.226 on 10/13/15 from IP address 201.193.36.226. Copyright ARRS. For personal use only; all rights reserved
AJA:154,
March
1990
MR
OF THE
SHOULDER
551
Fig. 3.-Supraspinatus calcific tendinitis. A, Anteroposterior radiograph shows typical amorphous calcium hydroxyapatite deposit in acromiohumeral space (arrows). B, SE 600/25 coronal oblique MR image shows areas of signal void (straight arrows) corresponding to intratendinous calcification,
be overlooked and attributed to thickening of fibrocartilaginous
tendon. Subdeltoid fat plane has intermediate
which
could
signal intensity due to inflammation
easily
(curved
arrow).
C, SE 2000/80 calcification.
coronal oblique MR image shows thickened supraspinatus tendon bursa (curved arrow) has high signal intensity.
(straight
arrows)
with homogeneous
low signal
intensity
obscuring
Fluid in subdeltoid
Fig. 4.-Avascular necrosis of humeral head. A, Anteroposterior radiograph shows subchondral lucency on weight-bearing surface of humeral head (arrows) with vague margin of sclerosis. Since early stages of avascular necrosis are not visible on plain radiographs, these radiographic findings are consistent with later stage of disease. B, SE 600/25 coronal oblique MR image shows corresponding avascular area in subchondral bone (long arrows). lnfraspinatus muscle (short arrows) is markedly atrophic. C, SE 2000/80 coronal oblique MR image shows high-signal-intensity granulation tissue at reactive margin of avascular zone (black arrows) with adjacent low-signal-intensity rim corresponding to radiographic sclerosis. Fluid outlines small inferior humeral osteophyte (white arrow) that was not well visualized radiographically.
In some situations there are clear advantages of one technique over the other. Calcific tendinitis is easily visualized on plain films, but may be overlooked or only suspected on MR (Fig. 3). The signal void representing calcium hydroxyapatite
within the tendon cannot be easily distinguished from a thickened tendon without calcification. In avascular necrosis, the diagnosis can be made radiographically only when the disease is in the late stages (Fig. 4). As in the hip and other joints,
BURK
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552
ET AL.
AJR:154, March 1990
Fig. 5.-Rheumatoid arthritis with large erosions. A, Anteroposterior radiograph shows large, lucent erosion on lateral aspect of humeral head (arrow) with marked enlargement and deformity of glenoid (arrowheads). B, SE 600/25 coronal oblique MR image shows corresponding large lateral erosion and additional erosion on humeral articular surface that was not visible radiographically (arrows). Glenoid is markedly remodeled with articular erosions (arrowheads). C, SE 2000/80 coronal oblique MR image shows humeral erosions filled with heterogeneous material probably representing pannus (arrows). Erosions of glenoid articular surface (arrowheads) are outlined by joint effusion.
Fig. 6.-Septic arthritis and osteomyelitis. A, Anteroposterior radiograph shows incongruity of glenohumeral in region involved by osteomyelitis (0). B, SE 600/25 coronal oblique MR image better shows extensive marrow in region of osteomyelitis (0) is better evaluated also. C, SE 2000/80 coronal oblique MR image shows destruction osteomyelitis shows some areas of high signal intensity (0).
MR
is the
most
sensitive
technique
of diseases
and conventional radiographs Erosions and subchondral
MR
will
and
collapse
detection
show
of the articular
of
of subchondral of articular
later
of a joint
effusion.
bone
surfaces of glenoid
surfaces
Stages
(arrow)
of joint
destruction
(arrow).
and humerus outlined
infection,
of the
Humerus
(arrow).
by large
both
articular
has mottled
joint
Extent
effusion.
techniques
surfaces,
images
may
provide
In
tant
for
differential
a more
diagnosis,
staging purposes. In some nonspecific and a diagnosis
diagnosis
specific
on morphologic plain radiographs
Humeral
will
but
can
radiographs based (Fig. 7). However,
appearance of abnormal
most sensitive for detecting associated osteomyelitis In some bone lesions such as those filled with
also be detected with MR. are seen on radiographs,
presence
of articular
MR
(Fig. 5), but plain radiographs information. Associated rotator
cysts can no changes the
surfaces,
frequently are complementary. cysts in rheumatoid arthritis
better with MR of the necessary
cuff tears and synovial In early septic arthritis, whereas
destruction
strate
avascular necrosis. For the diagnosis
be evaluated provide most
for early
joint with poor definition
demon-
MR
is the
(Fig. 6). fluid, MR
than
plain
and signal characteristics are usually more imporand
MR
is most
useful
for
unusual tumors, both studies are may not be made before surgery
MR
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AJR:154, March 1990
OF THE
SHOULDER
553
Fig. 7.-Extraosseous ganglion cyst with glenoid erosion. A, Anteroposterior radiograph shows nonspecific appearance B, SE 600/25 coronal oblique MR image shows corresponding
C, SE 2000/80 point of origin
of radiolucent glenoid lesion (arrow). extraosseous lesion eroding into glenoid with well-defined inferolateral margin (arrow). coronal oblique MR image shows septation partially separating main cyst (straight arrow) from smaller component, which extends toward
near superior
aspect
of glenoid
(curved
arrow).
This appearance
is highly
suggestive
of ganglion
cyst.
Fig. 8.-Adenocarcinoma metastasis to humeral head. A, Anteroposterior radiograph shows nonspecific lytic lesion in humeral subchondral bone with incomplete sclerotic margin (arrow). B, SE 600/25 coronal oblique MR image shows large subchondral marrow lesion (arrow), which is slightly larger than radiographic abnormality because of rapid growth over a period of several weeks. C, SE 2000/80 coronal oblique MR image shows area of inhomogeneous high signal intensity in center of lesion with rim of low signal intensity (arrow) corresponding to radiographically visible sclerosis. Appearance is nonspecific, and diagnosis was not made before biopsy as patient had no known primary tumor.
(Fig. 8). MR and radiography of the shoulder are complementary studies, and appropriate correlation will be of benefit to both the patient and the radiologist.
REFERENCES
1 . Burk DL Jr. Karasick
D, Kurtz AB, et al. Rotator cuff tears: prospective comparison of MA imaging with arthrography. sonography, and surgery. AJR 1989:153:87-92
2. Zlatkin MB, lannotti JP, Roberts MC, et al. Rotator cuff tears: diagnostic performance of MR imaging. Radiology 1989;172:223-229 MB, Dalinka MK, Kressel HY. Magnetic resonance imaging of the shoulder. Magn Reson 0 1989:5 : 3-22 4. Aquilone LF, Burk DL Jr. Blob AD, Brown DL, Rifkin MD, Mitchell 0G. Technical optimization of surface coil MAI of the rotator cuff. Presented at the annual meeting of the Society of Magnetic Resonance in Medicine, San Francisco, August. 1988 5. Hardy DC, vogler JB. White RH. The shoulder impingement syndrome: prevalence of radiographic findings and correlation with response to therapy. AJR 1986:147:557-561
3. Zlatkin
549
Pictorial :
:.
‘
;‘
MR Imaging Radiography D. Lawrence
Burk,
Jr.
,
:
‘
,
.
:
,
,
David
Karasick,
Donald
Correlation
G. Mitchell,
Recent advances in surface-coil technology and scanner software have made high-quality MR examinations of the shoulder a practical reality. The high signal-to-noise ratios provided by local coils designed specifically for the shoulder allow imaging with small fields of view and thin sections. New software provides routine oblique imaging with oft-center fields of view and no wraparound artifacts. With these stateof-the-art techniques, several studies have shown that MR is as accurate as, if not more accurate than, arthrography in detecting rotator cuff tears [1 , 2]. In addition, MR can provide an accurate preoperative assessment of the size of a cuff tear and the condition of the remaining tendon. In the absence of a cuff tear, MR can be useful in evaluating impingement, tendinitis, and bursitis; these cannot be assessed with arthrography. MR also can show other abnormalities such as avascular necrosis, labral tears, tumors, osteomyelitis, and arthritis [3]. Although MR is considerably more expensive than arthrography, it is probable that the additional information obtained in a noninvasive fashion will make MR the procedure of choice for the evaluation of shoulder pain. For these reasons, MR is frequently the next study performed after conventional radiography. Comparison with the radiographs is essential for a complete evaluation of the MR images. Each of these techniques has distinct advantages and limitations. In this essay we will illustrate examples of these features for a variety of clinical conditions.
Received August 21 , 1989; accepted after revision October 16, 1989. , All authors: Department of Radiology. Jefterson Medical College. Thomas PA 19107. Address reprint requests to D. L. Burk, Jr. AJR 154:549-553,
March
1990 0361 -803X/90/1
543-0549
:,
:, ,‘ ‘
of the Shoulder:
© American
and Matthew
Materials
and
Essay
with Plain D. Rifkin
Methods
The images were selected from over 200 studies of the shoulder obtained on a 1 .5-T scanner. Most of the examinations were performed with a loop-gap resonator coil pair (Medical Advances, Muwaukee, WI). The technique has been described in detail [4]. Recent examinations have been performed with an anteriorly positioned, heart-shaped, single-loop coil (Medrad, Pittsburgh, PA, for General Electric Medical Systems, Milwaukee, WI). All studies included coronal oblique spin-echo (SE) 600/25 (TR/TE) and 2000/40,80 Sequences as part of the routine protocol. The other imaging parameters were 5-mm slice thickness, 1-mm interslice gap, 128 x 256 matrix, two
excitations,
and
1 4-cm
field
of view.
Respiratory
and oversampling in the phase- and frequency-encoding used routinely to reduce artifacts.
MR
Imaging-Radiographic
compensation
axes
were
Correlation
For routine cases of impingement syndrome and possible rotator cuff tear the radiographic findings are limited mainly to greater tuberosity and acromioclavicular degenerative changes [5]. These findings are nonspecific, and the diagnosis of a rotator cuff tear requires the use of another imaging technique such as MR. However, in rotator cuff arthropathy, the diagnosis usually can be made on plain radiographs because of marked acromiohumeral narrowing, and MR may be useful in assessing the quality of the remaining cuff before
Jefferson
Roentgen
University
Ray Society
Hospital.
1 033 Main Bldg.
,
10th and Sansom Sts. , Philadelphia,
Downloaded from www.ajronline.org by 201.193.36.226 on 10/13/15 from IP address 201.193.36.226. Copyright ARRS. For personal use only; all rights reserved
550
Fig. 1.-Chronic
BURK
ET AL.
AJA:154, March 1990
rotator cuff arthropathy.
A, Anteroposterior radiograph shows marked narrowing of acromiohumeral space with subacromial spur (white arrows), osteophyte formation (curved arrow), and slightly irregular glenohumeral articular surfaces (straight black arrow). B, SE 600/25 coronal oblique MR image also shows acromiohumeral narrowing with better visualization of secondary subchondral marrow changes in acromion and humeral head (black arrows). Humeral osteophyte is filled with fatty marrow (white arrow). Note marked atrophy of supraspinatus muscle (5). C, SE 2000/80 coronal oblique MR image with arthrogram effect confirms irregularity of glenohumeral articular surfaces (large arrow). Note massive rotator cuff tear with retracted tendon (small arrows) of supraspinatus muscle (5).
Fig. 2.-Supraspinatus avulsion with greater tuberosity fracture. A, Anteroposterior radiograph shows defect in lateral aspect of humeral head (arrowheads) with displaced greater tuberosity fragment (arrow). Acromiohumeral space is widened because of humeral traction. B, SE 600/25 coronal oblique MR image shows slightly larger area of acute hemorrhage and edema at site of avulsion fracture (arrowheads). Acromiohumeral space is narrowed with patient out of traction. Joint fluid (F) is isointense relative to supraspinatus muscle (5). C, SE 2000/80 coronal oblique MR image shows displaced tendon (arrows) of supraspinatus muscle (5) surrounded by fluid in glenohumeral joint. Joint fluid (F) fills narrowed acromiohumeral space in place of avulsed supraspinatus tendon. Center of fracture site has low signal intensity due to deoxyhemoglobin of acute hemorrhage (H). Peripheral edema (E) has higher signal intensity, similar to that of surrounding marrow.
surgery for total shoulder replacement (Fig. 1). Mild narrowing of the acromiohumeral space also may be present with rotator cuff atrophy, but without cuff tear. In avulsion fractures of the tuberosities, the diagnosis is made with plain radiographs,
but the full extent of injury to the mined only on MR, although the selves may not be visible (Fig. 2). cuff also can occur in the absence
rotator cuff can be deterfracture fragments themTraumatic avulsion of the of a fracture.
Downloaded from www.ajronline.org by 201.193.36.226 on 10/13/15 from IP address 201.193.36.226. Copyright ARRS. For personal use only; all rights reserved
AJA:154,
March
1990
MR
OF THE
SHOULDER
551
Fig. 3.-Supraspinatus calcific tendinitis. A, Anteroposterior radiograph shows typical amorphous calcium hydroxyapatite deposit in acromiohumeral space (arrows). B, SE 600/25 coronal oblique MR image shows areas of signal void (straight arrows) corresponding to intratendinous calcification,
be overlooked and attributed to thickening of fibrocartilaginous
tendon. Subdeltoid fat plane has intermediate
which
could
signal intensity due to inflammation
easily
(curved
arrow).
C, SE 2000/80 calcification.
coronal oblique MR image shows thickened supraspinatus tendon bursa (curved arrow) has high signal intensity.
(straight
arrows)
with homogeneous
low signal
intensity
obscuring
Fluid in subdeltoid
Fig. 4.-Avascular necrosis of humeral head. A, Anteroposterior radiograph shows subchondral lucency on weight-bearing surface of humeral head (arrows) with vague margin of sclerosis. Since early stages of avascular necrosis are not visible on plain radiographs, these radiographic findings are consistent with later stage of disease. B, SE 600/25 coronal oblique MR image shows corresponding avascular area in subchondral bone (long arrows). lnfraspinatus muscle (short arrows) is markedly atrophic. C, SE 2000/80 coronal oblique MR image shows high-signal-intensity granulation tissue at reactive margin of avascular zone (black arrows) with adjacent low-signal-intensity rim corresponding to radiographic sclerosis. Fluid outlines small inferior humeral osteophyte (white arrow) that was not well visualized radiographically.
In some situations there are clear advantages of one technique over the other. Calcific tendinitis is easily visualized on plain films, but may be overlooked or only suspected on MR (Fig. 3). The signal void representing calcium hydroxyapatite
within the tendon cannot be easily distinguished from a thickened tendon without calcification. In avascular necrosis, the diagnosis can be made radiographically only when the disease is in the late stages (Fig. 4). As in the hip and other joints,
BURK
Downloaded from www.ajronline.org by 201.193.36.226 on 10/13/15 from IP address 201.193.36.226. Copyright ARRS. For personal use only; all rights reserved
552
ET AL.
AJR:154, March 1990
Fig. 5.-Rheumatoid arthritis with large erosions. A, Anteroposterior radiograph shows large, lucent erosion on lateral aspect of humeral head (arrow) with marked enlargement and deformity of glenoid (arrowheads). B, SE 600/25 coronal oblique MR image shows corresponding large lateral erosion and additional erosion on humeral articular surface that was not visible radiographically (arrows). Glenoid is markedly remodeled with articular erosions (arrowheads). C, SE 2000/80 coronal oblique MR image shows humeral erosions filled with heterogeneous material probably representing pannus (arrows). Erosions of glenoid articular surface (arrowheads) are outlined by joint effusion.
Fig. 6.-Septic arthritis and osteomyelitis. A, Anteroposterior radiograph shows incongruity of glenohumeral in region involved by osteomyelitis (0). B, SE 600/25 coronal oblique MR image better shows extensive marrow in region of osteomyelitis (0) is better evaluated also. C, SE 2000/80 coronal oblique MR image shows destruction osteomyelitis shows some areas of high signal intensity (0).
MR
is the
most
sensitive
technique
of diseases
and conventional radiographs Erosions and subchondral
MR
will
and
collapse
detection
show
of the articular
of
of subchondral of articular
later
of a joint
effusion.
bone
surfaces of glenoid
surfaces
Stages
(arrow)
of joint
destruction
(arrow).
and humerus outlined
infection,
of the
Humerus
(arrow).
by large
both
articular
has mottled
joint
Extent
effusion.
techniques
surfaces,
images
may
provide
In
tant
for
differential
a more
diagnosis,
staging purposes. In some nonspecific and a diagnosis
diagnosis
specific
on morphologic plain radiographs
Humeral
will
but
can
radiographs based (Fig. 7). However,
appearance of abnormal
most sensitive for detecting associated osteomyelitis In some bone lesions such as those filled with
also be detected with MR. are seen on radiographs,
presence
of articular
MR
(Fig. 5), but plain radiographs information. Associated rotator
cysts can no changes the
surfaces,
frequently are complementary. cysts in rheumatoid arthritis
better with MR of the necessary
cuff tears and synovial In early septic arthritis, whereas
destruction
strate
avascular necrosis. For the diagnosis
be evaluated provide most
for early
joint with poor definition
demon-
MR
is the
(Fig. 6). fluid, MR
than
plain
and signal characteristics are usually more imporand
MR
is most
useful
for
unusual tumors, both studies are may not be made before surgery
MR
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AJR:154, March 1990
OF THE
SHOULDER
553
Fig. 7.-Extraosseous ganglion cyst with glenoid erosion. A, Anteroposterior radiograph shows nonspecific appearance B, SE 600/25 coronal oblique MR image shows corresponding
C, SE 2000/80 point of origin
of radiolucent glenoid lesion (arrow). extraosseous lesion eroding into glenoid with well-defined inferolateral margin (arrow). coronal oblique MR image shows septation partially separating main cyst (straight arrow) from smaller component, which extends toward
near superior
aspect
of glenoid
(curved
arrow).
This appearance
is highly
suggestive
of ganglion
cyst.
Fig. 8.-Adenocarcinoma metastasis to humeral head. A, Anteroposterior radiograph shows nonspecific lytic lesion in humeral subchondral bone with incomplete sclerotic margin (arrow). B, SE 600/25 coronal oblique MR image shows large subchondral marrow lesion (arrow), which is slightly larger than radiographic abnormality because of rapid growth over a period of several weeks. C, SE 2000/80 coronal oblique MR image shows area of inhomogeneous high signal intensity in center of lesion with rim of low signal intensity (arrow) corresponding to radiographically visible sclerosis. Appearance is nonspecific, and diagnosis was not made before biopsy as patient had no known primary tumor.
(Fig. 8). MR and radiography of the shoulder are complementary studies, and appropriate correlation will be of benefit to both the patient and the radiologist.
REFERENCES
1 . Burk DL Jr. Karasick
D, Kurtz AB, et al. Rotator cuff tears: prospective comparison of MA imaging with arthrography. sonography, and surgery. AJR 1989:153:87-92
2. Zlatkin MB, lannotti JP, Roberts MC, et al. Rotator cuff tears: diagnostic performance of MR imaging. Radiology 1989;172:223-229 MB, Dalinka MK, Kressel HY. Magnetic resonance imaging of the shoulder. Magn Reson 0 1989:5 : 3-22 4. Aquilone LF, Burk DL Jr. Blob AD, Brown DL, Rifkin MD, Mitchell 0G. Technical optimization of surface coil MAI of the rotator cuff. Presented at the annual meeting of the Society of Magnetic Resonance in Medicine, San Francisco, August. 1988 5. Hardy DC, vogler JB. White RH. The shoulder impingement syndrome: prevalence of radiographic findings and correlation with response to therapy. AJR 1986:147:557-561
3. Zlatkin
