(Radiology. 2000;215:491-496.)
© RSNA, 2000
Direct MR Arthrography of the Shoulder: Is Exercise Prior to Imaging Beneficial or Detrimental?1
Michele L. Brenner, MD,
William B. Morrison, MD,
John A. Carrino, MD,
Christopher A. Nusser, MD,
Timothy G. Sanders, MD,
Richard F. Howard, DO and
Patricia Meier, MD
1 From the Departments of Radiology (M.L.B., W.B.M., T.G.S.), Orthopedic Surgery (R.F.H.), and Medicine (P.M.), Wilford Hall Medical Center, 759th MDTS/MTRD, 2200 Bergquist Dr, Suite 1, Lackland AFB, TX 78236-5300; the Department of Radiology, Brigham and Women's Hospital, Boston, Mass (J.A.C.); and the Department of Radiology, 10th Medical Group Hospital, USAF Academy, Colorado Springs, Colo (C.A.N.). From the 1998 RSNA scientific assembly. Received April 28, 1999; revision requested June 15; revision received August 17; accepted September 3. Address correspondence to W.B.M.
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Abstract
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PURPOSE: To define the beneficial and detrimental effects of adding exercise to direct magnetic resonance (MR) shoulder arthrography.
MATERIALS AND METHODS: Direct, intraarticular, gadolinium arthrography of the shoulder was performed in 41 patients, who underwent 1.5-T MR imaging before and after 1 minute of arm swinging. Fourteen milliliters of dilute gadolinium solution was injected. Two readers blinded to exercise independently graded the randomly distributed images with a five-point scale for capsular contrast material resorption; extraarticular contrast material leakage; rotator cuff, glenoid labrum, and anterior capsule conspicuity; and partial-thickness or full-thickness rotator cuff tear and labral tear detectability. The sign test was performed to evaluate the significance of differences between preexercise and postexercise grading for each reader. A second review was performed, with direct side-by-side comparison of preexercise and postexercise images.
RESULTS: There was evidence of increased capsular resorption after exercise but no alteration in the depiction of the rotator cuff tendons or glenoid labrum. There was no significant extraarticular contrast material leakage after exercise and no alteration in depiction of the anterior capsule. There was no difference in the detectability of rotator cuff or labral tears.
CONCLUSION: Exercise with direct shoulder MR arthrography has no beneficial or detrimental effect on image quality or on the depiction of rotator cuff or labral tears.
Index terms: Magnetic resonance (MR), arthrography, 414.121411, 414.121415, 414.122 • Shoulder, arthrography, 414.122 • Shoulder, injuries, 414.4813, 414.4819 • Shoulder, MR, 414.121411, 414.121415
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Introduction
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Conventional shoulder arthrography incorporates exercise into the diagnosis of rotator cuff tears (1). More recently, magnetic resonance (MR) arthrography has virtually replaced conventional arthrography in the assessment of internal derangements of the shoulder. At literature review, we found that exercise has been incorporated inconsistently into protocols for shoulder MR arthrography and that to our knowledge no literature has addressed the potential detriments and benefits of incorporating exercise into direct MR shoulder arthrography (2–9). The purpose of this study was to define the benefits and detriments of adding exercise to the direct MR arthrographic protocol.
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MATERIALS AND METHODS
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This study was approved by the institutional review board. Informed consent was obtained from all subjects for the intraarticular injection of dilute gadolinium solution and for pre- and postexercise imaging.
Direct MR shoulder arthrography was performed in 41 patients (31 men and 10 women; age range, 18–77 years; mean age, 34 years) from September 1997 to June 1998. Each patient underwent fluoroscopically guided shoulder arthrography with a 23-gauge, 3
-inch spinal needle with a Quincke-type point (Luer-Lok Hub; Becton Dickinson, Franklin Lakes, NJ), which was advanced into the joint with an anterior approach. One milliliter of iodinated contrast material (diatrizoate meglumine and diatrizoate sodium injection [Hypaque-76; Nycomed, New York, NY]) was injected to confirm intracapsular location. Fourteen milliliters of dilute gadolinium solution (1 mL of gadopentetate dimeglumine [Magnevist; Berlex Laboratories, Wayne, NJ] in 100 mL of normal saline) then was injected. The patient was asked to not move his or her arm until instructed to do so by the MR technologist.
After conventional arthrography, the patient walked down the hall to the MR imager for further imaging, which began within 30 minutes of shoulder injection. The patient was placed in a supine position, with the arm by the side and with the hand in a supine position. Imaging was performed with a 1.5-T MR unit (Signa; GE Medical Systems, Milwaukee, Wis) and with a phased-array shoulder coil (MRI Devices, Waukesha, Wis). Preexercise imaging consisted of transverse and oblique coronal, T1-weighted, spin-echo, fat-suppressed imaging (repetition time msec/echo time msec, 400-800/9-20) and of oblique coronal, T2-weighted, fat-suppressed, fast spin-echo imaging (3,000-4,300/60-80 [effective]). Postexercise, transverse and oblique coronal, T1-weighted, fat-suppressed, spin-echo imaging was performed after 1 minute of arm swinging in a circular motion. All images were acquired with a 256 x 192 matrix, a 3-mm section thickness, a 1-mm skip, two signals acquired, and a 15-cm field of view. The total preexercise MR examination time was 45–50 minutes, with an additional 15 minutes for postexercise imaging.
The images were reviewed retrospectively by two reviewers (W.B.M., C.A.N.) who were blinded to the time of the study and series number and who were reading separately. The reviewers evaluated pre- and postexercise, T1-weighted, fat-suppressed images and preexercise, T2-weighted images that were randomized according to both patient and preexercise versus postexercise images.
Image characteristics were evaluated by using a five-point scale. The capsular resorption of contrast material was defined as the distinctness of the posterior capsular margin on transverse images. A grade of 1 indicated that the posterior capsular margin was very distinct; 2, distinct; 3, neither distinct nor indistinct; 4, indistinct; or 5, very indistinct.
Extraarticular contrast material leakage was defined as contrast material visualized in the soft tissues outside the anterior capsule on transverse or oblique coronal images. A grade of 1 indicated that no contrast material was visualized; 2, a minimal amount; 3, a small amount; 4, a moderate amount; and 5, a large amount.
The conspicuity of rotator cuff, labral, and anterior capsular structures was defined as the quality of depiction of these structures on transverse or oblique coronal images. A grade of 1 indicated poor depiction of the structures; 2, satisfactory depiction; 3, good depiction; 4, very good depiction; and 5, excellent depiction.
A partial-thickness, undersurface rotator cuff tear was defined as the extension of contrast material into but not through the rotator cuff tendons, with an absence of contrast material in the subacromial and/or subdeltoid bursa. A grade of 1 indicated a definite lack of extension; 2, probable lack of extension; 3, neither extension nor lack of extension; 4, probable extension; and 5, definite extension.
A full-thickness rotator cuff tear was defined as contrast material extension through the rotator cuff into the subacromial and/or subdeltoid bursa. A grade of 1 indicated a definite lack of extension; 2, probable lack of extension; 3, neither extension nor lack of extension; 4, probable extension; and 5, definite extension.
A labral tear was defined as contrast material extension through the glenoid labrum. A grade of 1 indicated a definite lack of extension; 2, probable lack of extension; 3, neither extension nor lack of extension; 4, probable extension; and 5, definite extension.
The oblique coronal, T2-weighted, fat-suppressed, fast spin-echo images also were evaluated for contrast material in the subacromial and/or subdeltoid bursa. The sign test (a test used to compare two matched samples, with observed values measured on an ordinal scale with three to five ranks or levels) was performed to compare preexercise with postexercise results for each reader.
In another review session, each reader independently examined preexercise and postexercise images that were hung side by side; readers were blinded to whether images were obtained before exercise or after exercise. The results of this side-by-side comparison were used to resolve potentially significant differences detected at the initial review. Conflicting results between the readers were evaluated further with a retrospective consensus review of the associated images. A review of patient records was performed to document the results of orthopedic examination and surgery.
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RESULTS
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Evaluation of Potentially Detrimental Effects
Capsular resorption of contrast material.—A significant difference in the degree of capsular resorption, or distinctness, was detected on the preexercise versus the postexercise images by reader 2 (P = .03) but not by reader 1 (P = .12). The readers agreed that there was a difference in capsular resorption before versus after exercise in seven of the 41 patients, six of whom had evidence of more capsular resorption of contrast material on the postexercise images (Fig 1). This effect appeared to be relatively minor, with only a one- or two-grade difference in most patients (reader 1, seven of seven patients; reader 2, five of seven patients).
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Figure 1a. Capsular contrast material resorption. (a) Preexercise, transverse, fat-suppressed, T1-weighted, spin-echo (783/12) and (b) postexercise, transverse, fat-suppressed, T1-weighted, spin-echo (733/12) MR arthrograms show slight blurring of the posterior capsular margin (arrows in b) after exercise.
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Figure 1b. Capsular contrast material resorption. (a) Preexercise, transverse, fat-suppressed, T1-weighted, spin-echo (783/12) and (b) postexercise, transverse, fat-suppressed, T1-weighted, spin-echo (733/12) MR arthrograms show slight blurring of the posterior capsular margin (arrows in b) after exercise.
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Extraarticular contrast material leakage.—There was a large discrepancy between the readers in the grading of extraarticular leakage of contrast material in the preexercise versus the postexercise studies (reader 1, P > .99; reader 2, P = .06). There was agreement between the readers in six patients, with more extraarticular contrast material seen after exercise in four of the six patients and with more seen before exercise in two of the six patients. However, there was only a one- or two-grade difference in all six patients, and at side-by-side comparison of their images, no difference in the amount of extraarticular contrast material was detected. Therefore, there did not appear to be a significant effect of exercise on capsular leakage. At retrospective review, the discrepancy between readers at initial evaluation appears to have been related to the redistribution of contrast material within the capsular recesses, which was interpreted as leakage by one reader (Fig 2).
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Figure 2a. Redistribution of contrast material in the anterior capsular recesses, which simulates extraarticular leakage. (a) Preexercise, transverse, fat-suppressed, T1-weighted, spin-echo (550/9) and (b) postexercise, transverse, fat-suppressed, T1-weighted, spin-echo (650/9) MR arthrograms demonstrate more contrast material anteriorly (arrow in b) after exercise, which likely represents the redistribution of contrast material within the joint recesses rather than true capsular leakage. There is no difference in depiction of the anterior glenoid labrum and capsular structures.
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Figure 2b. Redistribution of contrast material in the anterior capsular recesses, which simulates extraarticular leakage. (a) Preexercise, transverse, fat-suppressed, T1-weighted, spin-echo (550/9) and (b) postexercise, transverse, fat-suppressed, T1-weighted, spin-echo (650/9) MR arthrograms demonstrate more contrast material anteriorly (arrow in b) after exercise, which likely represents the redistribution of contrast material within the joint recesses rather than true capsular leakage. There is no difference in depiction of the anterior glenoid labrum and capsular structures.
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Conspicuity of rotator cuff tendons, glenoid labrum, and anterior capsular structures.—Evaluation of preexercise and postexercise images by readers 1 and 2 showed no significant difference in the quality of the depiction of the rotator cuff tendons (P > .99 and P = .80, respectively), the glenoid labrum (P = .51 and P >.99, respectively), or the anterior capsular structures (P = .99 and P = .37, respectively). There was agreement between readers on a difference in the depiction of the rotator cuff tendons in only two of 41 patients, one with better depiction before exercise and one with better depiction after exercise. Both readings differed by only one grade. The readers agreed that there was a difference in the depiction of the glenoid labrum in only one patient, in which there was one grade of improved depiction in preexercise images compared with postexercise images. The readers agreed on a difference in anterior capsular structure depiction in eight patients: Five of the eight had better depiction before exercise and three of the eight had better depiction after exercise. Nearly all patients showed only a one- or two-grade difference before exercise versus after exercise (eight of eight patients and seven of eight patients for readers 1 and 2, respectively).
Evaluation of Potentially Beneficial Effects
Detection of rotator cuff tears.—In the 41 patients, reader 1 identified four with full-thickness and nine with partial-thickness rotator cuff tears; reader 2 identified five with full-thickness and 14 with partial-thickness rotator cuff tears. Twenty-four (59%) patients had contrast material in the subacromial and/or subdeltoid bursa on oblique coronal, T2-weighted images. The majority of these 24 patients (20 [83%] and 19 [79%] for readers 1 and 2, respectively) had no gadolinium detected in the subacromial and/or subdeltoid bursa on preexercise images. In these situations, there is a potential benefit of exercise for the detection of small rotator cuff tears (Fig 3).
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Figure 3a. Bursal fluid with surgically proved, large, partial-thickness rotator cuff tear. (a) Preexercise, oblique coronal, fat-suppressed, T2-weighted, fast spin-echo (3,000/66 [effective]) MR arthrogram demonstrates contrast material within the subacromial and/or subdeltoid bursa (arrows). (b, c) Oblique coronal, fat-suppressed, T1-weighted, spin-echo (516/14) MR arthrograms acquired (b) before exercise and (c) after exercise demonstrate a large, partial-thickness, undersurface tear of the supraspinatus tendon (arrow in b). There is no difference in detectability of the tear on the preexercise versus the postexercise image, and no contrast material extends into the bursa after exercise to indicate a full-thickness tear.
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Figure 3b. Bursal fluid with surgically proved, large, partial-thickness rotator cuff tear. (a) Preexercise, oblique coronal, fat-suppressed, T2-weighted, fast spin-echo (3,000/66 [effective]) MR arthrogram demonstrates contrast material within the subacromial and/or subdeltoid bursa (arrows). (b, c) Oblique coronal, fat-suppressed, T1-weighted, spin-echo (516/14) MR arthrograms acquired (b) before exercise and (c) after exercise demonstrate a large, partial-thickness, undersurface tear of the supraspinatus tendon (arrow in b). There is no difference in detectability of the tear on the preexercise versus the postexercise image, and no contrast material extends into the bursa after exercise to indicate a full-thickness tear.
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Figure 3c. Bursal fluid with surgically proved, large, partial-thickness rotator cuff tear. (a) Preexercise, oblique coronal, fat-suppressed, T2-weighted, fast spin-echo (3,000/66 [effective]) MR arthrogram demonstrates contrast material within the subacromial and/or subdeltoid bursa (arrows). (b, c) Oblique coronal, fat-suppressed, T1-weighted, spin-echo (516/14) MR arthrograms acquired (b) before exercise and (c) after exercise demonstrate a large, partial-thickness, undersurface tear of the supraspinatus tendon (arrow in b). There is no difference in detectability of the tear on the preexercise versus the postexercise image, and no contrast material extends into the bursa after exercise to indicate a full-thickness tear.
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There was no significant difference in the amount of contrast material in the subacromial and/or subdeltoid bursa on preexercise versus postexercise images (reader 1, P = .99; reader 2, P = .52). The readers agreed that there was a difference in the quantity of contrast material in the bursa on the postexercise images of only one patient (one-grade difference for both readers). At retrospective review of this patient's images, there was a minimal difference in the amount of contrast material in the bursa, with no difference in the detectability of the underlying full-thickness tear (Fig 4).
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Figure 4a. Full-thickness rotator cuff tear. Oblique coronal, fat-suppressed, T1-weighted, spin-echo (483/16) MR arthrograms acquired (a) before exercise and (b) after exercise show no difference in the detectability of the full-thickness tear (arrow in a), although there is slightly more contrast material in the subacromial and/or subdeltoid bursa on the postexercise image (arrows in b).
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Figure 4b. Full-thickness rotator cuff tear. Oblique coronal, fat-suppressed, T1-weighted, spin-echo (483/16) MR arthrograms acquired (a) before exercise and (b) after exercise show no difference in the detectability of the full-thickness tear (arrow in a), although there is slightly more contrast material in the subacromial and/or subdeltoid bursa on the postexercise image (arrows in b).
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There was borderline significance in the detection of partial-thickness rotator cuff tears on preexercise versus postexercise images (reader 1, P = .049; reader 2, P = .090). The readers agreed on a difference in the amount of contrast material extending into but not through the rotator cuff tendons on preexercise versus postexercise images in four patients (each reader interpreted only a one-grade difference in three of these four patients). However, at retrospective review, these differences could be explained by differences in artifact and in window width and level settings between the preexercise and post-exercise images. Increased signal intensity within the cuff tendons that was related to artifact was noted on the postexercise images in two patients. For the other two patients, adjustment of the preexercise and postexercise window and level settings to similar values resulted in no apparent difference in the amount of contrast material within the rotator cuff tendons.
Detection of labral tears.—At patient record review, 22 (54%) of the 41 patients had clinical concern for labral tear prior to imaging. There was no significant difference in the detection of contrast material that extended through the glenoid labrum on preexercise versus postexercise images (reader 1, P = .35; reader 2, P = .77). There were four patients in whom the readers agreed on a difference before exercise versus after exercise (two with more contrast material through the glenoid labrum before exercise and two with more contrast material through the glenoid labrum after exercise). Side-by-side image comparison showed no difference in these patients.
Surgical correlation.—Of the 41 patients, 17 (41%) underwent shoulder arthroscopy. The surgical reports were compared retrospectively with the preoperative MR arthrograms, and in all patients in whom both readers agreed on a rotator cuff tear or labral tear, the finding was confirmed at arthroscopy. There were seven patients with superior labral anterior-to-posterior lesions, one with a full-thickness rotator cuff tear, one with a partial-thickness rotator cuff tear, two with labral tears, two with mixed-cuff tears and superior labral anteroposterior lesions, one with a full-thickness rotator cuff tear and a labral tear, one with a mixed full-thickness supraspinatus tear with a partial-thickness subscapularis and infraspinatus tear, and two with reverse capsular shifts. When there was disagreement in MR arthrogram interpretation between the readers (always by only a one- or two-grade difference), the surgical result reflected the more certain finding. There were no surgically proved lesions that were identified on only the postexercise images.
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DISCUSSION
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MR arthrography has been proved to have higher sensitivity and specificity compared with routine MR imaging for the detection of shoulder joint abnormalities (2,10–12). Researchers in many studies have investigated how differences in imaging parameters, in types and concentrations of contrast material, and in arm position alter the sensitivity and specificity for the diagnosis of disease (3,4,11,13–18). It has been shown that exercise added to an indirect (intravenous administration of gadolinium-based contrast material) MR arthrographic protocol does improve the enhancement and homogeneity of distribution (19). However, to our knowledge exercise has not been added consistently to direct MR arthrographic protocols described in the literature. To our knowledge, no investigators have addressed the potential beneficial and detrimental effects of exercising the arm as part of the protocol for direct MR arthrography, as has been the standard for conventional arthrography.
A review of direct MR arthrographic protocols from articles in the literature revealed numerous techniques, some incorporating exercise, some not. In 1992, Hodler et al (20) stated that the main advantage of MR arthrography, compared with conventional MR imaging, was better depiction of partial tears of the articular surface of the rotator cuff. Chandnani et al (12) published results in 1993 that stated that MR arthrography and conventional MR imaging demonstrated labral tears with better sensitivity than CT arthrography and that MR arthrography was the most sensitive of the three in depicting detached labral fragments and degeneration. Glenohumeral ligament, glenoid labrum, and cartilage integrity have been well defined with MR arthrography (3,5–8) from 1995 through 1999. Exercise was not incorporated to prove the benefits of MR arthrography in these studies.
Differences in MR arthrographic protocols with regard to exercise appear to be related to the individual radiologist's preferences. At review of two MR arthrographic studies from Tirman et al (4,9), we noted that their protocol consisted of contrast material injection into the joint, exercise, then MR imaging. Flannigan et al (2) used the same protocol of conventional shoulder MR imaging, injection into the joint, exercise, then MR arthrography in their study, the results of which demonstrated that MR arthrography has improved accuracy compared with conventional MR imaging for evaluation of the glenoid labrum and the rotator cuff tendons.
Another typical protocol encountered in the literature is the injection of contrast material into the shoulder joint, with preexercise and postexercise radiography followed by conventional MR imaging within 30 minutes of injection. This sequence was used by Palmer et al in four studies (7,16,21,22). Tirman and Bost also used this protocol when writing with Cvitanic and colleagues (15). Numerous review articles describe different techniques as well: Flannigan et al (2) describe conventional MR imaging, conventional arthrography, then MR arthrography; Beltran et al (23,24), Rafii and Minkoff (1), and Fritts and Craig (10) describe MR arthrography without exercise; and Palmer et al (7) and Helgason et al (25) describe conventional arthrography with exercise followed by MR arthrography.
Our protocol sequence (shoulder injection followed by MR imaging, exercise, then repeat MR imaging) was designed to determine if there are any beneficial or detrimental effects of exercise itself, which could have influenced the results of prior studies, and to see if exercise should be incorporated into the standard MR arthrographic protocol.
Our data (Tables 1, 2) show that exercise does not significantly alter the visualization of the rotator cuff tendons, glenoid labrum, or anterior capsular structures. Exercise did not change the extent of capsular leakage. Exercise did not alter the detection of full-thickness or partial-thickness rotator cuff tears or the detection of labral tears. Exercise did seem to increase capsular contrast material resorption. However, this finding may be related to imaging timing, as more time obviously had elapsed from preexercise imaging to postexercise imaging.
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TABLE 1. P Values for the Difference between Grading of Capsular Resorption of Contrast Material, Extraarticular Contrast Material Leakage, and Visualization of the Rotator Cuff Tendons, Labrum, and Anterior Capsular Structures on Preexercise and Postexercise MR Images
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TABLE 2. P Values for the Difference between Grading of Conspicuity of Rotator Cuff Tear and Labral Tear on Preexercise and Postexercise MR Images
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The limitations of our study included the time between pre- and postexercise imaging that allowed for the redistribution and resorption of contrast material, as no intraarticular epinephrine was used. However, all patients underwent imaging within 30 minutes of injection. Also, there was variability in the time from shoulder injection to MR imaging, which may have influenced the capsular resorption of the contrast material. There may have been variable effectiveness of exercise on the basis of the patient's degree of pain and range of motion. Although the duration of exercise was limited to 1 minute, it was similar to that in the arthrographic technique. There may also have been slight differences in coil positioning, which were evident at the comparison of the detectability of partial-thickness rotator cuff tears, that would have altered the signal in some patients. These differences appeared initially to be borderline significant but were shown to be related to technical differences between the preexercise and postexercise images.
It is unfortunate that surgical follow-up was too limited for comment on the accuracy of the readers in the detection of rotator cuff and labral tears; however, this may be considered a relative limitation, given the absence of a difference between preexercise and postexercise images. The low number of patients also limited the evaluation of the significance of differences between preexercise and postexercise images; however, these patients represented all MR shoulder arthrographic examinations performed over greater than 1 year at our institution, and there was no demonstrable difference over that period. In addition, a five-point scale was used for the evaluation of MR findings, which magnified potential differences between the images.
In conclusion, there is no significant detrimental or beneficial effect of adding exercise to an MR arthrographic protocol. Thus, patients can perform normal activities on their way to the imager without affecting image quality, and exercise appears unnecessary for the detection of disease.
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Footnotes
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The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Air Force, the Department of Defense, or the U.S. government.
Author contributions: Guarantor of integrity of entire study, W.B.M.; study concepts and design, W.B.M., J.A.C., M.L.B.; definition of intellectual content, W.B.M., J.A.C.; literature research, W.B.M., M.L.B.; clinical studies, R.F.H.; data acquisition, W.B.M., C.A.N., M.L.B., R.F.H.; data analysis, W.B.M., C.A.N.; statistical analysis, P.M.; manuscript preparation, M.L.B., W.B.M., T.G.S.; manuscript editing and review, W.B.M., T.G.S.
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J. A. Jacobson, J. Lin, D. A. Jamadar, and C. W. Hayes
Aids to Successful Shoulder Arthrography Performed with a Fluoroscopically Guided Anterior Approach
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March 1, 2003;
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[Abstract]
[Full Text]
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Abstract
Introduction
