untitled image
39000 Bob Hope Drive
Lower Level
Rancho Mirage CA 92270
760-674-3876
 
 
Name:  
Botts, Bill Joseph
DOB/Age/Sex:
3/13/1958 / 62 y.o. / M
MRN:
5917838
Ordering Location:
EAHC SPORTS MEDICINE
Ordering Physician:
Rajiv H Tailor
Patient Location:
 
Order Date/Time:
12/24/2020 6:07 AM
Account Number:
 
Study Description:
MRI Shoulder Right Wo Contrast
 
 
Service Date/Time:
12/24/2020 6:40 AM
 
 
 
 
Report Status: Final
Accession Number: 
311216486
 
 
 
 
EXAMINATION: MRI SHOULDER RIGHT WO CONTRAST
 
INDICATION: Biceps tendinitis of right shoulder
M75.101: Rotator cuff syndrome of right shoulder
Z98.890: History of repair of right rotator cuff
 
TECHNIQUE: Multisequence, multiplanar MRI of the right shoulder was
performed.
 
CONTRAST: None
 
COMPARISON: None available.
 
FINDINGS:
Rotator cuff: High grade focal full-thickness partial width tear of the
infraspinatus tendon at/near the footprint (coronal image 11, sagittal 
image
20).  Moderate grade partial-thickness partial width tearing of the 
supraspinous
tendon at/near the footprint.  Low-grade articular sided partial tearing 
of the
upper fibers of the subscapularis tendon.  Unremarkable teres minor 
tendon.
 
Glenohumeral Joint: Alignment is normal. Possible tear versus sublabial 
recess
at the superior labrum (coronal image 14). Small joint effusion. There is 
no
significant chondral loss.
 
Inferior Glenohumeral Ligaments/Axillary Pouch: The axillary pouch is 
normal in
thickness and signal.
 
Long Head of Biceps Tendon: The long head of the biceps tendon is present 
within
the bicipital groove and intact.
 
Coracoacromial Arch: There is scattered micrometallic susceptibility 
artifact
about the acromion, possibly related to prior surgery.  There is mild
acromioclavicular joint osteoarthrosis. There is no os acromiale or 
subacromial
enthesophyte. The acromion is non-hook in morphology and lie in neutral
position, as displayed on the sagittal images. The coracoacromial ligament 
is
normal.
 
Subacromial-Subdeltoid Bursa: Fluid in the bursal space, in keeping with
full-thickness rotator cuff tendon tear.
 
Musculature: Muscle bulk is preserved with no evidence of denervation or 
fatty
atrophy. There is no soft tissue mass.
 
Bone: No acute fracture, stress reaction, avascular necrosis, or 
aggressive
appearing bone lesion.
 
IMPRESSION:
 
1.  High-grade partial width full-thickness tear, infraspinatus tendon.
2.  Moderate grade partial thickness partial width tear, supraspinatus 
tendon.
3.  Low-grade articular sided partial tear, upper subscapularis tendon.
4.  Possible tear versus sublabial recess, superior labrum.
5.  Small glenohumeral joint effusion.
6.  Mild AC joint osteoarthrosis.
 
Signed by: Alvin Wyatt, MD
Signed By:  Alvin Wyatt, MD on 12/24/2020 11:53 AM