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Left Shoulder MRI Medical Transcription Transcribed Sample Report / Example

INDICATION: Pain and weakness, rule out rotator cuff tear.

TECHNIQUE: Routine images of the left shoulder are performed. There is significant hypertrophy and inflammation at the AC joint. Both superior and inferior spurring are present. There is loss of the normal subacromial space with elevation of the humeral head. There is a large extracapsular fluid collection and an intracapsular effusion. There is a full-thickness tear of the infraspinatus tendon with retraction of the muscle and tendon. There is modeling of the supraspinatus tendon but not a complete or full-thickness tear is seen. There is some depression of the spurring from the AC joint on that tendon. The modeling of the distal supraspinatus tendon can indicate that there is a longstanding or chronic injury that is not readily apparent. In a very longstanding chronic change, the changes might not be present with edema to be easily recognized on the examination. Therefore, there could be changes to the distal supraspinatus tendon that are not readily apparent on this examination but would be suggested by the loss of the subacromial space. The modeling does indicate at least some partial tearing has occurred in the past. There is, however, retraction of the infraspinatus tendon that is suggested. There is also fluid around the biceps tendon, which may indicate some element of chronic tendinitis. It is grossly intact however. There is also a mild concavity of the medial and anterior humeral head, which may indicate that there had been some trauma in this region against the anterior glenoid structures. Mild high signal within the humeral head is seen indicating a possible contusion. No frank fractures are seen.

1. There is a full-thickness tear suggested of the infraspinatus tendon with muscle and tendon retraction noted. There is also modeling of the distal supraspinatus tendon indicating what may be a chronic or old injury and partial tearing, which is simply not as apparent now because much of the inflammation or edema is now not present. There is some height loss of the subacromial space indicating injury to the underlying structures as well.
2. There is acromioclavicular joint spurring in both the cephalad and caudal motion with inflammation. Part of this does impress upon the underlying supraspinatus structures. No significant edema is noted, however, in that area at this time.
3. Fluid is seen around the biceps tendon, which could indicate some inflammation in that area.
4. Some cortical concavity of the anteromedial humeral head is noted. It is closely related to the anterior glenoid bony structure, and there is some contusion or edema of the humerus in that area indicating what may be the result of some trauma.

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