Diagnosis:
Medial biceps dislocation with an intact subscapularis, grade 3 outlet related impingement. (See Table 1 – MRI Grade III impingement) with a large gaping supraspinatous complete 2 x 3 centimeter rotator cuff tear and superior humeral migration, mild AC joint hypertrophy with medial arch stenosis and proliferation.

Table 1: Clinical Stages of Impingement

Stage I Excessive overhead use in sports Patients under 25 years old Edema and hemorrhage in cuff, tendons This type of impingement is usually reversible Stage II Fibrosis and thickening of subacromial, subdeltoid bursa and/or tendon Frank rotator cuff tendonitis Athletes over 24 years old Less common than Stage I Conservative therapy 18 months is the more common treatment Surgery: Coracoacromial ligament transaction or bursal stripping (not usually necessary) Stage III The most common stage of impingement Most often seen in patients over 40 years old Degeneration and inflammation of biceps long head tendon with rotator cuff tear Secondary bone erosion and arthropathy of coracoacromial arch

Discussion:
There is a large complete rotator cuff tear labeled in red on Coronal T1 (image 01a) and Sagittal T2 (images 02a and 03a). Note the presence of a dislocated long head biceps tendon which is perched on the lesser tuberosity with an empty biciptal groove. This finding was not seen on arthroscopy. Note the slightly hyperintense labrum due to magic angle effect and anatomic variation (image 07). Mild acromioclavicular arthropathy creates medial arch stenosis.

Axial T1 – Images 04, 05 and 06
Axial GRE – Image 07