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MRI of Shoulder Medical Transcription Sample Report

MRI OF THE LEFT SHOULDER

Left shoulder MRI was performed in the usual fashion. There is no evidence of a full-thickness rotator cuff tear. No high signal within the distal supraspinatus tendon of marked significance to indicate a significant tendinitis. There is only a very small amount of high signal directly at the insertion site of the distal supraspinatus tendon, which may indicate a very small amount of tendinosis directly at that insertion site area.  There is some moderate hypertrophy of the AC joint. There is inflammatory increase of fluid in the joint space itself. There is spurring both caudally and superiorly. The caudal spurring impresses upon the underlying supraspinatus structures somewhat. This may be producing some type of mild entrapment symptoms. One may want to correlate clinically to that entity.  Also, the most distal component of the acromion suggests what may be a small loose joint body or spur, which minimally depresses the underlying structures as well.

In neither of these two areas do I see significant edema or irritation of the underlying supraspinatus structures, radiographically.  The remaining rotator cuff tendons are intact. The glenoid and humeral bony structures do not show lytic or blastic disease or microfractures.  There is a focal area of high signal involving the inferior and anterior glenoid labral area. One may want to perform a CT arthrogram to rule out labral injury.

IMPRESSION:
1.  No full-thickness rotator cuff tendon tear or muscle or tendon retraction. Minimal high signal at the distal supraspinatus tendon insertion site to indicate possible mild tendinosis.
2.  Acromioclavicular degenerative joint disease with cephalad and caudal spurring. The caudal spurring does impress upon the underlying supraspinatus structures minimally. Also, there is possible loose joint body near the inferior and lateral acromion, which may be depressing the underlying structures somewhat.
3.  Questionable injury to the inferior, anterior glenoid labrum. Focal area of high signal is noted in that area. One may need to do an arthroscopic examination or perhaps a CT arthrogram to rule out labral injury.

MRI OF THE RIGHT SHOULDER:

Rule out short biceps tendon tear.

The tendons of both the long head of the biceps and the short head of the biceps appear intact.  We see no focal edema within those structures or around them to indicate partial strain or definite focal injury.  Both show an intact course.  It is also noted that the coracobrachialis muscle is intact, adjacent to the short head of the biceps tendon.  We see no injury to the coracoid process as well.

No full-thickness rotator cuff tear with muscle or tendon retraction is seen.  No significant injury is noted of the subscapularis muscle or tendon.

There is very minimal AC joint hypertrophy.  No significant spurring is seen.

No significant joint effusion is noted.  The humerus and glenoid bony structures are grossly intact.

IMPRESSION:
1.  No definite evidence of rupture of the short head tendon biceps or of the long tendon of the biceps.  Also, there is no injury to the coracobrachialis muscle nearby or the coracoid process.
2.  No rotator cuff tears are noted as well.

MRI OF THE RIGHT SHOULDER

Multiplanar images were obtained.  There are some degenerative changes involving the AC joint that do cause some inferior impingement on the supraspinatus muscle/tendon junction.  There is some fluid along the superior aspect of the subscapularis suggestive of at least a partial tear.  There is fluid along the posterior aspect of the deltoid.  There is some edema in the posterior superolateral humeral head suggestive of contusion in this area.  This is low signal on T1.

Biceps tendon is well located within the groove.  There is some fluid around the biceps tendon that may represent tendinosis or partial tear.  There is no significant fluid in the subacromial/subdeltoid bursa.  There is some fluid along the posterior aspect of the humeral head.  The supraspinatus muscle/tendon appears fairly intact with some minimal high signal in it, inferior to the AC joint that may represent some edema in this area.

IMPRESSION:
1.  Fluid along the superior aspect of the subscapularis suggestive of at least a partial tear.  Some of this fluid is seen along the posterior aspect of the deltoid.
2.  Some degenerative joint disease involving the acromioclavicular joint that does cause some inferior impingement on the supraspinatus muscle/tendon.  There is some edema in this area.
3.  There is some contusion/edema in the posterior superolateral aspect of the humeral head.

RIGHT SHOULDER MRI

Routine right MRI of the shoulder reveals no full-thickness tear of the rotator cuff tendons.  No retraction of muscle or tendons.  There is a very small amount of signal change at the most distal component of the supraspinatus tendon, which may indicate a very minimal tendinosis.

What is noted is a focal area of signal change in the biceps tendon as it courses up to the humeral head.  There is a pocket of fluid noted approximately 3 cm from the superior aspect of the humeral head.  Question whether there may be a strain or even small tear.  Biceps tendon is grossly intact however.

There is no contusion of the bony structures noted.  No fractures seen.  The glenoid structures appear grossly intact.  There is moderate hypertrophy of the AC joint with some inflammation in that area.  This minimally depresses the underlying supraspinatus structures but there is not any edema of the underlying structures.

IMPRESSION:
1.  No full-thickness rotator cuff tear with or without muscle and/or tendon retraction.
2.  Very small high signal is seen at the distal supraspinatus tendon insertion site, which could indicate a very small amount of tendinosis.
3.  Possible small injury to the biceps tendon, approximately 3 cm distal to the humeral head.  There is a focal area of high signal in this area, which may indicate some partial strain or even a very small tear.  It is grossly intact however.  There is focal fluid collection directly in that area as well.  Please correlate to exam.
4.  Minimal to moderate hypertrophy with high signal within the joint space of the acromioclavicular joint.  Minimal but not significant compression of the underlying structures is seen.

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