Ultrasound of the shoulder
Ultrasound of the shoulder is a fast, relatively cheap and dynamic way to examine the rotator cuff and is particularity useful in diagnosing:
The examination requires attention to technique and appropriate patient positioning. A high-frequency probe (7-12 MHz) probe is required to give sufficient anatomical resolution, and the examination can be performed from either in front or behind.
Of course, there is an infinite variety of potential techniques. A 'typical' approach is presented here. It is important to remember about "tendon anisotropy" in MSK ultrasound. Hence each tendon needs to be scanned in multiple projections.
Patient position: arm in neutral position, elbow flexed 90 degrees, forearm supinated (palm up).
- long head of biceps tendon is imaged in the intertubercular groove, as it runs under the transverse humeral ligament, in both transverse and longitudinal sections.
- it is traced superiorly through the rotator cuff interval towards its insertion on the superior labrum and glenoid.
- tendon should be located in the intertubercular groove, with minimal fluid around it (tendon sheath communicates with the shoulder joint).
- the tendon fibres should be seen without tears, heterogeneity or thickening (beware of anisotropy).
- long head of biceps tendon dislocation or subluxation
- long head of biceps tendon tear
- long head of biceps tendinopathy
- shoulder joint effusion
Patient position: the arm is kept in the same position as above and is externally rotated, pulling the insertion of subscapularis tendon with it.
Imaging planes: the subscapularis tendon should be traced both longitudinally and transversely:
longitudinal images: probe is placed in transverse position (mediolaterally) over the humeral head with the marker of the probe away from the patient's torso. Then, the transducer moved from top to bottom to access three portions of the tendon; i.e, superior, middle, and inferior fibres, then:
- dynamic study: by internal and external rotation of the arm while the probe is held still, possible impingement of the tendon can be assessed; as demonstrated by bunching of the tendon during internal rotation while it passes under the coracoid process
- transverse images: by turning the probe 90 degrees (now in craniocaudal direction) with the marker towards the patient's head, the short axis of the three portions of the tendon can be assessed by slow sweeping of the probe from its insertion to lesser tubercle and medial-lateral to medial
- the flat tendon of subscapularis can be seen inserting into the lesser trochanter
- most tears/tendinopathy involve the cranial portions of the tendon, which are also the hardest to visualise
- if the biceps tendon is dislocated then it will lie anterior to the subscapularis tendon which keeps it out of the joint. Indeed long head of biceps tendon dislocation is commonly associated with subscapularis tears, as is with a history of previous anterior shoulder dislocation
Patient position: Shoulder internally rotated and extended (reaching to get wallet from back pocket, or scratching between shoulder blade positions).
- the supraspinatus tendon should be traced both longitudinally and transversely.
- remember that most tears occur in the very distal portion, and therefore this region should be examined with care.
- the tendon parallels the curved contour of the humeral head, flattening out as it inserts into the greater tuberosity
- it has a fibrillary pattern
- the subacromial-subdeltoid bursa should be seen as a single thin hyperechoic line paralleling the tendon superiorly
- presence of fluid (separation of the hyperechoic line by hypoechoic fluid) is abnormal, as is thickening of the bursa
- supraspinatus tendinopathy
- supraspinatus tendon tear
- rotator cuff calcific tendinitis
- subacromial-subdeltoid bursitis
Patient position: Patient reaches across and holds the contralateral shoulder with their hand, across their chest.
Imaging planes: the infraspinatus tendon should be traced both longitudinally and transversely.
- the separation of the tendon of infraspinatus from that of the supraspinatus is difficult, so much so that an arbitrary cut-off of 1.5 cm from the anterior edge of supraspinatus is used; i.e the first 1.5 cm of the rotator cuff is designated to be the supraspinatus, and the next 1.5 cm the tendon of infraspinatus.
- the thickness of the posterior rotator cuff is significantly less than that of the anterior part (3.6 vs 6 mm) and therefore thinning should not be interpreted as partial tears.
- infraspinatus tendinopathy including tears (note: it is rare for infraspinatus to be torn without supraspinatus tears also)
Patient position: Same as for infraspinatus and inferior to this for more inferior part of the posterior labrum. For the anterior part, transverse as for biceps tendon, and for the more inferior part the hand behind the head with shoulder abducted. The literature claims high sensitivity and specificity, especially for the posterior labrum.
Imaging planes: transverse is most useful.
Normal findings: the normal labrum is a sharply demarcated hyperechoic triangle continuous with the underlying glenoid.
- Hill-Sachs lesion
- labral tear: > 2mm hypoechoic zone; vacuum phenomenon between labrum and glenoid; absent labrum; movement of the labrum during dynamic examination
- sublabral foramen (unknown sensitivity/specificity)
- Buford complex (unknown sensitivity/specificity)
Patient position: as for infraspinatus
Normal findings: small notch in the scapular spine
Patient position: either position is fine
Normal findings: the problematic under surface of the AC joint is, unfortunately, not visible.
- degenerative change of the joint: osteophytes; subchondral cyst formation
- Os acromiale
- joint instability 2
Patient position: depends on which tendon is being interrogated. Chicken flapping (abduction and adduction) can demonstrate the supraspinatus tendon sliding under the AC joint.
Imaging planes: typically longitudinally along the tendon.
Normal findings: a thin hyperechoic subacromial-subdeltoid bursa should be seen sliding effortlessly between the ACJ and the tendon of the supraspinatus.
Ultrasound - musculoskeletal
- ultrasound (introduction)
- shoulder ultrasound
- elbow ultrasound
- wrist ultrasound
- hand ultrasound
- hip ultrasound
- knee ultrasound
- ankle/foot ultrasound
- paediatric musculoskeletal ultrasound
- skin/soft tissue ultrasound
- ultrasound of arthropathies
- 1. Davies AM, Hodler J. Imaging of the shoulder, techniques and applications. Springer Verlag. (2006) ISBN:3540262482. Read it at Google Books - Find it at Amazon
- 2. Singh JP. Shoulder ultrasound: What you need to know. Indian J Radiol Imaging. 2012;22 (4): 284-92. doi:10.4103/0971-3026.111481 - Free text at pubmed - Pubmed citation
- 3. Taljanovic MS, Carlson KL, Kuhn JE et-al. Sonography of the glenoid labrum: a cadaveric study with arthroscopic correlation. AJR Am J Roentgenol. 2000;174 (6): 1717-22. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Jacobson JA. Fundamentals of musculoskeletal ultrasound. W B Saunders Co. (2007) ISBN:1416035931. Read it at Google Books - Find it at Amazon
- 5. Arend CF, da Silva TR. Comparison between exclusively long-axis and multiple-axis sonographic protocols for screening of rotator cuff lesions in symptomatic shoulders. J Ultrasound Med. 2010;29 (12): 1725-32. J Ultrasound Med (full text) - Pubmed citation
- 6. Martinoli C, Bianchi S, Prato N et-al. US of the shoulder: non-rotator cuff disorders. Radiographics. 2003;23 (2): 381-401. Radiographics (full text) - doi:10.1148/rg.232025100 - Pubmed citation
- 7. Tracy MR, Trella TA, Nazarian LN et-al. Sonography of the coracohumeral interval: a potential technique for diagnosing coracoid impingement. J Ultrasound Med. 2010;29 (3): 337-41. Pubmed citation
- 8. Middleton WD, Teefey SA, Yamaguchi K. Sonography of the rotator cuff: analysis of interobserver variability. AJR Am J Roentgenol. 2004;183 (5): 1465-8. doi:10.2214/ajr.183.5.1831465 - Pubmed citation
- 9. Bureau NJ, Beauchamp M, Cardinal E et-al. Dynamic sonography evaluation of shoulder impingement syndrome. AJR Am J Roentgenol. 2006;187 (1): 216-20. doi:10.2214/AJR.05.0528 - Pubmed citation
- 10. Strobel K, Hodler J, Meyer DC et-al. Fatty atrophy of supraspinatus and infraspinatus muscles: accuracy of US. Radiology. 2005;237 (2): 584-9. doi:10.1148/radiol.2372041612 - Pubmed citation
- 11. Khoury V, Cardinal E, Brassard P. Atrophy and fatty infiltration of the supraspinatus muscle: sonography versus MRI. AJR Am J Roentgenol. 2008;190 (4): 1105-11. doi:10.2214/AJR.07.2835 - Pubmed citation
- 12. Ok JH, Kim YS, Kim JM et-al. Learning curve of office-based ultrasonography for rotator cuff tendons tears. Knee Surg Sports Traumatol Arthrosc. 2013;21 (7): 1593-7. doi:10.1007/s00167-012-2105-4 - Pubmed citation