The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 11

Scientific Articles | November 01, 2007

Estimating the Dimensions of the Rotator Interval with Use of Magnetic Resonance Arthrography

Kyung-Cheon Kim, MD¹; Kwang-Jin Rhee, MD¹; Hyun-Dae Shin, MD¹; Young-Mo Kim, MD¹

¹ Department of Orthopaedic Surgery, Chungnam National University College of Medicine, 640 Daesa-Dong, Jung-Gu, Daejeon 301-040, South Korea. E-mail address for K.-C. Kim: kckim@cnuh.co.kr

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Chungnam National University College of Medicine, Daejeon, South Korea

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Nov 01;89(11):2450-2455. doi: 10.2106/JBJS.F.01262

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Abstract

Background: The goal of the present study was to define the dimensions of the normal rotator interval with magnetic resonance arthrography and to compare these dimensions with those in shoulders with known chronic anterior instability in order to determine if abnormalities of the rotator interval might be better understood and estimated preoperatively.

Methods: We retrospectively reviewed a consecutive series of 202 shoulders that had undergone magnetic resonance arthrography between 2004 and 2005. Of these, 120 shoulders were included in the present study. These shoulders were divided into two groups according to the diagnosis. Group I comprised fifty shoulders with no instability, and Group II comprised seventy shoulders with chronic anterior instability. With use of magnetic resonance arthrography, the base and height of the rotator interval and the diameter of the glenoid were measured. Then, the area of the rotator interval and the rotator interval index were calculated.

Results: In Group I, the mean estimated rotator interval dimensions (height and base), the mean calculated rotator interval area, and the mean rotation interval index were 16.73 mm, 48.59 mm, 406.47 mm², and 0.64, respectively. In Group II, these values were 21.87 mm, 49.40 mm, 540.06 mm², and 0.94, respectively. The shoulders in Group II differed significantly from the shoulders in Group I in terms of rotator interval height, rotator interval area, and rotator interval index (p < 0.01 for all).

Conclusions: There are significant differences in the dimensions of the rotator interval between patients with and without recurrent anterior shoulder instability. Estimating the dimensions of the rotator interval with use of magnetic resonance arthrography may be valuable for assessing patients preoperatively.

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The concept that the rotator interval is a distinct anatomic area with the potential for distinct pathological changes in cases of glenohumeral instability is relatively new. The understanding of the role of the rotator interval in shoulder mechanics continues to evolve, as does the treatment of pathologic conditions that may affect it¹. The routine evaluation of shoulder instability often entails magnetic resonance arthrography, which is indicated mainly to assess the labrum. In a cadaver study, Chung et al.² demonstrated the normal rotator interval anatomy with use of magnetic resonance arthrography, which was found to be superior to nonarthrographic magnetic resonance imaging for depicting those structures. The dimensions of the rotator interval could be determined on sagittal magnetic resonance arthrographic images, whereas the coracohumeral ligament was seen inconsistently and the superior glenohumeral ligament was not clearly identified on nonarthrographic magnetic resonance images.

Several studies have evaluated the dimensions of the rotator interval on the basis of direct measurement of dissected cadaveric specimens^3,4. To our knowledge, no studies have evaluated normal rotator interval dimensions with use of magnetic resonance arthrography. Therefore, in the present study, we defined the dimensions of the normal rotator interval with use of magnetic resonance arthrography and compared these values with those in shoulders with known recurrent anterior instability in order to determine if abnormalities of the rotator interval might be better detected and measured preoperatively.

Materials and Methods

Materials and Methods | Results | Discussion | References

Clinical

We retrospectively reviewed the records for a consecutive series of 202 shoulders that had undergone magnetic resonance arthrography between 2004 and 2005. Of these, 120 shoulders in 118 patients (including ninety-nine male patients and nineteen female patients) who had a mean age of 32.3 years (range, fifteen to sixty-five years) were included in the present study. The shoulders were divided into two groups according to diagnosis. Group I comprised fifty shoulders with no instability in patients who ranged from twenty-two to sixty-five years of age, and Group II comprised seventy shoulders with recurrent anterior instability in patients who ranged from fifteen to twenty-four years.

Group I included patients who had an otherwise normal shoulder on magnetic resonance arthrography (nineteen shoulders), those who had rotator cuff tendinitis (twenty-four shoulders), and those who had a partial-thickness rotator cuff tear that involved less than half of the thickness of the supraspinatus or infraspinatus tendon (seven shoulders) without limitation in the range of motion. We excluded patients who had conditions of the shoulder in which the intra-articular volume or pressure may have changed as a result of shoulder pathology, such as rotator cuff tendinitis (eight shoulders) and partial-thickness rotator cuff tears (five shoulders) with limitation of the range of motion, partial-thickness rotator cuff tears that involved more than half of the thickness of the supraspinatus or infraspinatus tendon (seven shoulders), full-thickness rotator cuff tears (eleven shoulders), ruptures of the rotator interval (one shoulder), adhesive capsulitis (twelve shoulders), and avulsion fractures of the greater tuberosity of the humerus (two shoulders).

Group II included seventy shoulders with chronic traumatic or atraumatic anterior instability. We excluded patients with instability in any direction other than anteriorly (three shoulders), patients with only one episode of instability (nine shoulders), patients with a lack of chronic symptoms lasting for more than six months (thirteen shoulders), and patients with a history of a previous shoulder surgical procedure (three shoulders). Patients with only one episode of instability were excluded because first-time dislocation does not always progress to recurrent instability, although widening of the rotator interval was seen in some. In addition, one patient who had a concomitant full-thickness rotator cuff tear was excluded. Seven shoulders were excluded because of inadvertent injection of air bubbles or definite extravasation of contrast medium through the joint as identified on magnetic resonance arthrography. Although there were no large osseous Bankart lesions and no cases of osteoarthritis in the present study, either finding would have been considered an exclusion criterion.

Magnetic Resonance Arthrography Technique

Magnetic resonance arthrography was performed for all patients. A 20-gauge spinal needle was used to access the glenohumeral joint through an anterior approach under fluoroscopic observation. One milliliter of iodinated contrast agent (Telebrix; Guerbet, Aulnay-sous-Bois, France) was used to verify the intra-articular position. Subsequently, 12 mL of a solution consisting of 1 mL of gadolinium dimeglumine (Magnevist; Schering, Berlin, Germany) diluted in 250 mL of saline solution were instilled into the glenohumeral joint. Although the amount of diluted gadolinium that is injected into the shoulder joint typically ranges from 10 to 20 mL, a larger volume (15 to 25 mL) may be required for patients with a capacious joint cavity^5-7. The diluted gadolinium was injected with gentle pressure, until slight resistance was felt or until the plunger rebounded. The injection was stopped if the patient complained of a sensation of increased pressure or pain during the procedure⁸. One musculoskeletal radiologist performed all solution instillations in all shoulders. Magnetic resonance imaging was performed with use of a 1.5-T clinical system (Signa; General Electric Medical Systems, Milwaukee, Wisconsin) with a 5-in (12.7-cm) general-purpose flexible coil. Magnetic resonance arthrography was performed with the arm at the side in neutral rotation; we relied on the patient to maintain the position during the examination. For some patients, small sandbags and tape were used to stabilize the hand in the neutral position and to reduce shoulder motion artifact.

Radiographic Interpretation

Images were evaluated on the basis of the consensus of two surgeons who subspecialized in the treatment of shoulder disorders (K.-C.K. and K.-J.R.), with particular attention to identifying and evaluating the structures comprising and traversing the rotator interval and capsule on all imaging planes in magnetic resonance arthrography. All of the measurements were performed by one of us (K.-C.K.) and then were repeated independently by the same individual one month later. All of the dimensions described below were measured electronically by applying magnetic resonance arthrography data for the rotator interval with use of PACS (picture archiving and communication system) measurement software (Marotech, Seoul, Korea).

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Fig. 1: The rotator interval was defined as a right triangle, with the height (A) along the coracoid process (C), the base (B) being the distance along the subscapularis (SSC) border, and the hypotenuse being the supraspinatus (SST) border. THL = transverse humeral ligament, and LHB = long head of biceps.

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Fig. 2: Serial sagittal magnetic resonance arthrographic images of the glenohumeral joint from lateral to medial (left column) and the corresponding level in the transverse images (right column). The middle sagittal image is the best sagittal section for measuring the height of the rotation interval. SSC = subscapularis, SST = supraspinatus, IST = infraspinatus, and C = coracoid process.

Anatomy of the Rotator Interval

The rotator interval is defined by its triangular borders and their contents^3,9. The height of the rotator interval is marked from the superior edge of the subscapularis tendon at the lateral base of the coracoid process to the anterior border of the supraspinatus tendon, where it intersects a line perpendicular to the superior edge of the subscapularis tendon at the lateral base of the coracoid. The base of the rotator interval is marked along the superior border of the subscapularis to the anterior border of the supraspinatus. This point is consistently located on the lateral ridge of the biceps sulcus at the superior margin of the transverse humeral ligament (Fig. 1). The apex of the rotator interval is at the bicipital groove. This triangular space contains the biceps tendon, the superior glenohumeral ligament, the glenohumeral capsule, and the coracohumeral ligament.

Measurements of the Rotator Interval

The rotator interval was best evaluated after magnetic resonance arthrography in the sagittal plane⁹. However, without distending the joint, the space defining the rotator interval between the tendons of the subscapularis and supraspinatus muscles was difficult to discern. In addition, it was impossible to determine the anteroposterior dimension of the rotator interval capsule on sagittal images. In the present study, the height of the rotator interval was measured on the sagittal image from the superior border of the subscapularis to the anterior border of the supraspinatus at the level just anterior to the base of the coracoid process; the base of the rotator interval was measured on the transverse image from the superior edge of the subscapularis tendon at the lateral base of the coracoid process to the lateral ridge of the biceps sulcus at the superior margin of the transverse humeral ligament (Figs. 2 and 3). Then, the area of the rotator interval was calculated as 0.5 × base × height. In addition, to evaluate the standardized length of the height corrected for patient size, the height of the rotator interval (A) was divided by the glenoid diameter (D), and this value was defined as the rotator interval index. In addition, we defined the glenoid diameter as the largest transverse diameter of the glenoid intersecting a line perpendicular to the line with the largest longitudinal diameter drawn from the superior glenoid tubercle at the level just anterior to the base of the coracoid process (Fig. 4).

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Fig. 3: Serial transverse magnetic resonance arthrographic images of the glenohumeral joint from superior to inferior (left column) and the corresponding level in the sagittal images (right column). The middle transverse image is the best transverse section for measuring the base of the rotation interval. SST = supraspinatus, SSC = subscapularis, and C = coracoid process.

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Fig. 4: The height (A) of the rotator interval was measured on the sagittal image from the superior border of the subscapularis to the anterior border of the supraspinatus at the level just anterior to the base of the coracoid process, and the base (B) of the rotator interval was measured on the transverse image from the superior edge of the subscapularis tendon at the lateral base of the coracoid process to the lateral ridge of the biceps sulcus at the superior margin of the transverse humeral ligament. The glenoid diameter (D) was defined as the largest transverse diameter of the glenoid intersecting a line perpendicular to the line having the largest longitudinal diameter drawn from the superior glenoid tubercle at the level just anterior to the base of the coracoid process.

Statistical Analysis

The binary categorical variables, such as the base, height, glenoid diameter, rotator interval area, and rotator interval index, were compared with use of the independent-samples t test. The level of significance was set at p < 0.05.

Results

Materials and Methods | Results | Discussion | References

The mean amount of diluted gadolinium injected into the glenohumeral joint that caused a sensation of fullness was 15.86 mL (range, 7 to 21 mL) in Group I and 18.03 mL (range, 13 to 25 mL) in Group II. In Group I, the mean rotator interval dimensions (height and base) and the mean calculated area for shoulders in the neutral position were 16.73 mm (range, 11.37 to 21.40 mm), 48.59 mm (range, 41.25 to 55.96 mm), and 406.47 mm² (range, 234.51 to 598.77 mm²), respectively. In Group II, these values were 21.87 mm (range, 16.96 to 30.84 mm), 49.40 mm (range, 42.39 to 54.84 mm), and 540.06 mm² (range, 359.47 to 845.63 mm²), respectively. The mean rotator interval index was 0.64 (range, 0.44 to 0.87) in Group I and 0.94 (range, 0.64 to 1.34) in Group II (Table I).

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TABLE I Estimated Rotator Interval Dimensions, Calculated Area, and Rotator Interval Index*

	Height (mm)	Base (mm)	Rotator Interval Area (mm²)	Glenoid Diameter (mm)	Rotator Interval Index
Group I	16.73 (11.37 to 21.40)	48.59 (41.25 to 55.96)	406.47 (234.51 to 598.77)	26.16 (21.12 to 31.00)	0.64 (0.44 to 0.87)
Group II	21.87 (16.96 to 30.84)	49.40 (42.39 to 54.84)	540.06 (359.47 to 845.63)	22.91 (19.03 to 26.99)	0.95 (0.64 to 1.34)

The values are given as the mean, with the range in parentheses.

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TABLE I Estimated Rotator Interval Dimensions, Calculated Area, and Rotator Interval Index*

	Height (mm)	Base (mm)	Rotator Interval Area (mm²)	Glenoid Diameter (mm)	Rotator Interval Index
Group I	16.73 (11.37 to 21.40)	48.59 (41.25 to 55.96)	406.47 (234.51 to 598.77)	26.16 (21.12 to 31.00)	0.64 (0.44 to 0.87)
Group II	21.87 (16.96 to 30.84)	49.40 (42.39 to 54.84)	540.06 (359.47 to 845.63)	22.91 (19.03 to 26.99)	0.95 (0.64 to 1.34)

The values are given as the mean, with the range in parentheses.

The shoulders in Group II differed significantly from the shoulders in Group I in terms of the amount of diluted gadolinium injected, the rotator interval height, the rotator interval area, and the rotator interval index (p < 0.01) but not in terms of the rotator interval base (p > 0.05). In addition, the shoulders in Group I had a significantly larger glenoid diameter than did the shoulders in Group II (p < 0.01).

Discussion

Materials and Methods | Results | Discussion | References

In order to understand the pathology of the rotator interval, it is important to realize that any single structure or combination of structures can be affected¹. Magnetic resonance arthrography appears to be a promising modality with which to evaluate the rotator interval through distention of the capsule and the depiction of the associated ligaments. The importance of magnetic resonance arthrography in identifying these lesions is compounded when one considers the difficulty of evaluating these structures both clinically and arthroscopically¹⁰.

Estimation of the dimensions of the rotator interval must be clinically reliable and reproducible by different observers with varying experience levels. Cadaveric studies investigating rotator interval dimensions have been reported in the orthopaedic literature^2,4; however, little has been written concerning the noninvasive measurement of rotator interval dimensions. In a cadaveric study, Chung et al.² measured the anteroposterior dimension of the rotator interval capsule on sagittal magnetic resonance arthrographic images. The capsule was measured at the level of the intra-articular biceps tendon on an image just lateral to the coracoid process. The width of the rotator interval capsule ranged from 1.7 to 2.0 mm. Tetro et al.⁴ measured the dimension from the anterior edge of the supraspinatus to the superior edge of the subscapularis at the level of the glenoid margin with the humerus in neutral rotation. The estimated distance was 21.6 mm and increased to 27.8 mm with joint distention. Plancher et al.³ determined the mean rotator interval dimensions (height, base, and hypotenuse) and area in the neutral position to be 20.96 mm, 39.31 mm, 44.72 mm, and 414.46 mm², respectively.

Some differences exist between the dimensions reported in previous cadaveric studies^3,4 and those in our magnetic resonance arthrography study. These differences in dimensions may arise from racial differences and the amount of contrast medium injected for arthrography. In addition, as opposed to cadaveric studies, an estimate of the base with use of magnetic resonance arthrography might be inaccurate if the transverse section is not parallel to the superior border of the subscapularis muscle. Rotation of the arm is also a very important consideration as the estimation of the base might vary with slight changes in rotation. To maintain the position of neutral rotation, the use of some type of positioning device would be desirable in a prospective study. While we could control the arm rotation at the elbow relatively well, we could not control for variable amounts of retroversion that were inevitably present. Because we studied a relatively large number of individuals, the effects of variability in torsion in both the instability and normal groups might have been balanced, although this was not confirmed on the basis of our data.

In the present study, the dimensions of the rotator interval, except for the base and the glenoid diameter, were significantly larger in Group II than in Group I. These results may have arisen because the base was determined from the rotation of the humerus only. Therefore, instability itself did not affect the base of the rotator interval. In addition, the glenoid diameter in Group II might have theoretically been measured as being much less than that in Group I because of a labral or a small osseous Bankart lesion, which were frequently seen in patients in Group II. However, there was only one osseous Bankart lesion in Group II, and it was not large. The other shoulders had labral Bankart lesions, with the exception of two shoulders that had a Hill-Sachs lesion without glenoid labral abnormality. However, because of the almost uniform appearance of the glenoid labral abnormalities (i.e., labral Bankart lesions) in Group II, the rotator interval measurements of the patients with a labral Bankart lesion would not be mistaken for those with an osseous Bankart lesion or without labral abnormalities.

The present study had several limitations. First, the capacity and volume of the joint capsule (i.e., the amount of contrast medium injected into the glenohumeral joint) varies widely from patient to patient depending on the clinical circumstances. Therefore, the amount of distention of the rotator interval was not well controlled. In addition, it is important to consider differences in height, gender, weight, and body mass index between subjects. Because of the retrospective nature of this review, the height and body weight of the patients were not evaluated in the present study (except for patients who were managed surgically), although the height of the rotator interval was divided by the glenoid diameter to standardize this measurement for patient size. To evaluate the standardized rotator interval dimensions corrected for gender and patient size, a prospective study should use specific measures, such as the height, body weight, or body mass index. Second, our normal control group was not composed of normal healthy shoulders. In addition, it was not confirmed whether rotator cuff abnormalities in the control group had contributed to the rotator interval pathology, because there was no arthroscopic evaluation to effectively rule out associated rotator interval pathology. However, to minimize these effects on the rotator interval according to the clinical circumstances, we selected shoulders that were otherwise normal on magnetic resonance arthrography without range-of-motion limitation and shoulders with rotator cuff tendinitis or a partial-thickness rotator cuff tear without range-of-motion limitation. In addition, we excluded shoulders with conditions in which the intra-articular volume or pressure could have changed as a result of shoulder pathology. Another limitation was the retrospective nature of the review. Therefore, the dimension measurements in the instability and normal groups were not confirmed with use of an arthroscopic evaluation. In addition, only one observer measured the rotator interval dimensions, although the images were evaluated by the consensus of two shoulder surgeons with particular attention being paid to identifying and evaluating the rotator interval. Despite these limitations, the present study remains important because it is the first, to our knowledge, to estimate the dimensions of the rotator interval with magnetic resonance arthrography and to demonstrate some significant differences among patients with and without chronic anterior instability.

In conclusion, the rotator interval was defined as a triangle and its mean dimensions were recorded. Patients with recurrent anterior instability had significant differences from normal values. An understanding of the normal and pathological anatomy of the rotator interval may be helpful for the successful diagnosis and treatment of lesions in this region. Estimation of the dimensions of the rotator interval with use of magnetic resonance arthrography might prove to be valuable for the assessment of patients preoperatively. ?

References

Materials and Methods | Results | Discussion | References

Fitzpatrick MJ, Powell SE, Tibone JE, Warren RF. The anatomy, pathology, and definitive treatment of rotator interval lesions: current concepts. Arthroscopy. 2003;19Suppl 1: 70-9.1970 2003 [PubMed][CrossRef]

Chung CB, Dwek JR, Cho GJ, Lektrakul N, Trudell D, Resnick D. Rotator cuff interval: evaluation with MR imaging and MR arthrography of the shoulder in 32 cadavers. J Comput Assist Tomogr. 2000;24: 738-43.24738 2000 [CrossRef]

Plancher KD, Johnston JC, Peterson RK, Hawkins RJ. The dimensions of the rotator interval. J Shoulder Elbow Surg. 2005;14: 620-5.14620 2005 [CrossRef]

Tetro AM, Bauer G, Hollstien SB, Yamaguchi K. Arthroscopic release of the rotator interval and coracohumeral ligament: an anatomic study in cadavers. Arthroscopy. 2002;18: 145-50.18145 2002 [PubMed][CrossRef]

Shankman S, Bencardino J, Beltran J. Glenohumeral instability: evaluation using MR arthrography of the shoulder. Skeletal Radiol. 1999;28: 365-82.28365 1999 [PubMed][CrossRef]

Tirman PF, Palmer WE, Feller JF. MR arthrography of the shoulder. Magn Res Imaging Clin N Am. 1997;5: 811-39.5811 1997

Blum A, Coudane H, Molé D. Gleno-humeral instabilities. Eur Radiol. 2000;10: 63-82.1063 2000 [PubMed][CrossRef]

Sahin G, Demirtas M. An overview of MR arthrography with emphasis on the current technique and applicational hints and tips. Eur J Radiol. 2006;58: 416-30.58416 2006 [PubMed][CrossRef]

Bennett WF. Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy. 2001;17: 107-11.17107 2001 [PubMed][CrossRef]

Morag Y, Jacobson JA, Shields G, Rajani R, Jamadar DA, Miller B, Hayes CW. MR arthrography of rotator interval, long head of the biceps brachii, and biceps pulley of the shoulder. Radiology. 2005;235: 21-30.23521 2005 [PubMed][CrossRef]

Topics

arthrogram ; shoulder region ; vibration

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Kyung-Cheon Kim, Kwang-Jin Rhee, Hyun-Dae Shin, Young-Mo Kim; Estimating the Dimensions of the Rotator Interval with Use of Magnetic Resonance Arthrography. The Journal of Bone & Joint Surgery. 2007 Nov;89(11):2450-2455.

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