Why is this patient having pain years after shoulder surgery?

This 61-year-old female presents with right shoulder pain for 2-3 months. She has a history of surgery on the same shoulder 3-4 years prior, and is being evaluated for a rotator cuff re-tear.

Q1 – Is the rotator cuff torn?

Q2 – What is the name of the sign highlighted by the red arrow on image 1?

Q3 – What is indicated by the pink arrows on image 2?

Q4 – What is the most likely diagnosis?

Q5 – What is the differential diagnosis?

Coronal T2

Coronal T2


A1 – The rotator cuff is intact, as highlighted by the green arrows on images 1 and 2, and it has a straight course. No perforation or defects are identified.

A2 – The red arrow (image 1) depicts distention of the subacromial and subdeltoid space containing synovial hypertrophy, a so-called rice body sign of hypertrophic synovial reaction.

A3 – The pink arrows on image 2 depict areas of intermediate signal intensity along the margins of the capsule and bursa. The highest of the three pink arrows points to a coalescent area of pannus!

A4 – The most likely diagnosis in this 61-year-old female is rheumatoid arthritis.

A5 – The differential diagnosis is narrow. Statistically, rhuematoid arthritis is overwhelmingly the most likely diagnosis. The patient is a woman. She is in a reasonable age range. There are no destructive or invasive signs that suggest an aggressive process such as a joint space infection. A nonaggressive pseudocyst is identified on image 1 (no arrows) in the humeral head. While other inflammatory arthritides are a consideration (infectious ones are not), rheumatoid arthritis is the diagnosis and should be favored by the reader. The history might have been a bit misleading with the emphasis on a potential rotator cuff tear, but that is not this patient’s problem.

For more shoulder case review, check out MRI Online.

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