Ultrasound of the Shoulder

ULTRASOUND OF THE SHOULDER 

1- TRV BIC TEND 

SAG BIC TEND LONG 

2- SUBSCAPULARIS SAG 

3 –

4 -Supraspinatus  sag

 supraspinatus

Subdeltoid bursa fluid  .SDB.

TRV – SUPRASPINATUS.

SAG

TRV

ACJ.ACROMIOCLAVICULAR JOINT, do one with arm along side of the body and one view with abduction , check stability.

Infraspinatus SAG

Do the GH Notch 

Teres minor  , Trv and Sag 

 

Ultrasound is essentially used for the rotator cuff complex of the shoulder. Ultrasound is a valuable diagnostic tool in assessing the following indications;

• Muscular, tendinous and some ligamentous damage (chronic and acute)
• Bursitis
• Joint effusion
• Vascular pathology
• Haematomas
• Soft tissue masses such as ganglia, lipomas
• Classification of a mass eg solid, cystic, mixed
• Post surgical complications eg abscess, oedema
• Guidance of injection, aspiration or biopsy
• Some bony pathology.

Try to take Burwins MSK course.Increase your skills and take Hands on MSK courses.

It is recognised that ultrasound offers little or no diagnostic information for internal structures such as the glenohumeral ligaments. Ultrasound is complementary with other modalities, including plain X-ray, CT, MRI and arthroscopy.

Use of a high resolution probe (7-15MHZ) is essential when assessing the superficial structures of the shoulder. Careful scanning technique to avoid anisotropy (and possible misdiagnosis) Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

Patient seated on chair in front of ultrasound machine. Have the patient’s chair at an appropriate height to be ergonomically comfortable for you to scan.

LONG HEAD BICEPS (BT)

• Patient rests hand palm up on thigh.
• Scan transversely over the anterior humeral head.
• Visualize the bicipital groove. Identify the biceps tendon in the groove (if not identified it may be either torn or subluxed medially out of the groove). Follow down to the muscle belly.
• Rotate into longitudinal and re-examine.
• The tendon should be a uniform fibrillar structure, generally less than 5 mm thick.
• Examine dynamically in a transverse plane during internal/external rotation to ensure it doesn’t sublux medially.

SUBSCAPULARIS (SSC)

• Again in a transverse plane at the bicipital groove, externally rotate the patient’s arm.
• The SSC tendon will be visible inserting medial to the groove.
• It will be seen as an elongated slightly convex tendon

SUPRASPINATUS (SSP)

• Position the patient palm up with their elbow flexed and pulled back passed their side so their hand is near their hip.

Identify the SSP tendon supero-lateral to the bicipital groove. In a coronal plane, the tendon emerges from beneath the acromion to insert on the greater tuberosity of the humerus.It should be uniform, fibrillar & ‘beak shaped’ (convex superiorly).

 

INFRASPINATUS (ISP)

• Ask the patient to place their affected hand across their chest towards the contralateral shoulder.

The ISP can be seen by placing the probe immediately inferior to the spine of the scapula and following the tendon to it’s insertion postero-laterally on the humeral head.It will have a similar appearance to subscapularis.

                                                                   ACJ 

DYNAMIC ASSESSMENT

• Biceps: assess its stability within the bicipital groove during external rotation.
• Subscapularis: assess for any overlying subdeltoid bursal bunching against coracoid during internal rotation
• Supraspinatus: assess for bunching of the tendon &/or overlying subacromial bursa against the acromion or coraco-acromial ligament during abduction.
• Ensure the patient does NOT hunch their shoulder or lean towards the contralateral side during abduction.
• Posterior joint recess: during internal/external rotation, assess for a glenohumeral joint effusion. This will be most evident during external rotation
• Acromioclavicular joint: During forward flexion with internal rotation look for boney contact or ganglia of the ACJ.

Use your hand to create resistant so the patient can push and you can see the fiber changes ,some times you can see small tears otherwise hidden if you dont do this maneuver.  

Injection into the supraspinatus bursa.       Full thickness tear, FTT.

Thinning at the SS insertion.

Calcification mostly seen at the insertion of the rotator cuff tendons but it can be located anywhere.

 Document the normal anatomy and any pathology found, including measurements and vascularity if indicated.

A shoulder series should include the following minimum images:

• Long head biceps tendon – long, trans
• Subscapularis tendon
• Coraco-acromial ligament
• Supraspinatus tendon
• Infraspinatus tendon
• Acromioclavicular joint
• Posterior joint recess
• Pre & post abduction views
• Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity. Detail any limitation to range of movement and degree that pain or symptoms begin. 

 Thank you for reading

Steve Ramsey, PhD- Public Health.

MSc – Medical Ultrasound.

Calgary, Alberta- Canada.

Have a good day.