Date : 00.00.00
Name of the Patient : Abc XyzHamaid Khlmn / M / 65 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Right Shoulder.
CLINICAL PROFILE :
C/O pain in the right shoulder joint since 1 year.
M.R.I of the right shoulder was performed using the following parameters :
5 mm thick T1 Weighted and GRASS axial images.
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted, Proton and T2 Weighted coronal images.
There is slight avulsion of the greater tuberosity of the right humerus. A hyperintense signal on the T2 Weighted images is noted at the base of the greater tuberosity of the right humerus (scans 103.11, 107.8).
There is a complete tear of the tendinous insertion of the supraspinatus muscle on the right from the greater tuberosity of the right humerus. The distal tendon of the right supraspinatus muscle is of intermediate signal on the T1 Weighted images and appears hyperintense on the T2 Weighted images. Slight retraction of the supraspinatus tendon is noted. Minimal fluid is noted in the subacromial bursa. A small right gleno-humeral joint effusion is noted.
There is blunting of the posterior glenoid labrum of the right shoulder joint. The anterior labrum is unremarkable.
The right acromio-clavicular joint shows degenerative changes with osteophytosis along its superior and inferior margins.
Fluid is also noted along the biceps tendon in the bicipital groove.
The acromion process is seen to be sloping posteriorly and laterally.
A Hill Sachs defect is noted along the postero-lateral margin of the right humeral head.
The articular cartilage of the head of the right humerus appears normal.
The muscles around the right shoulder joint appears slightly atrophied.
The visualized axilla is unremarkable.
1. Partial avulsion of the greater tuberosity of the right humeral head with a complete tear of the tendinous insertion of the right supraspinatus muscle from the greater tuberosity.
2. Probable tear of the posterior glenoid labrum.
3. Degenerative changes of the right acromio-clavicular joint.
4. Small right shoulder joint effusion.
5. A Hill Sachs defect along the postero-lateral margin of the right humeral head.