Ultrasound of the shoulder

A.Prof Frank Gaillard et al.

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.

Suggested technique

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.

Biceps tendon

Patient position: arm in neutral position, elbow flexed 90 degrees, forearm supinated (palm up).

Imaging planes:

Normal findings:

  • 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).

Visualised pathology:

Subscapularis

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

Normal findings:

  • 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

Visualised pathology:

Supraspinatus

Patient position: Shoulder internally rotated and extended (reaching to get wallet from back pocket, or scratching between shoulder blade positions).

Imaging planes:

  • 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.

Normal findings:

  • 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

Visualised pathology:

Infraspinatus

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.

Normal findings:

  • 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.

Visualised pathology:

Glenoid labrum

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.

Visualised pathology:

Suprascapular notch

Patient position: as for infraspinatus

Normal findings: small notch in the scapular spine

Visualised pathology:

Acromioclavicular joint

Patient position: either position is fine

Normal findings: the problematic under surface of the AC joint is, unfortunately, not visible.

Visualised pathology:

Dynamic examination

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.

Visualised pathology:

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Article information

rID: 2238
Synonyms or Alternate Spellings:
  • Shoulder ultrasound
  • Ultrasound of shoulder
  • Ultrasound of the shoulders
  • Ultrasound of shoulders

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Cases and figures

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    Shoulder USG supr...
    Case 1: supraspinatous tear
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    Case 2: paralabral cyst of shoulder
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    Shoulder usg bice...
    Case 3: biceps dislocation
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    Shoulder USG Cuff...
    Case 4: rotator cuff tear with biceps dislocation
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    Greater Tuberosit...
    Case 5: greater tuberosity fracture
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    Comparison view
    Case 6: rupture of long head of biceps
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    Comparision Of Bi...
    Case 7: multiple tendon tears
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    Supraspinatous te...
    Case 8: supraspinatous tendon tear
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    Shoulder usg mass...
    Case 9: massive cuff tear with biceps dislocation
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    Infraspinatous ca...
    Case 10: infraspinatous calcific tendinosis
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    Case 11: cartilage interface sign - supraspinatus tear
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    Case 12: AC joint synovitis
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    Fluid collection ...
    Case 13: AC joint cyst with chronic cuff tear
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    Case 14: subscapularis tear
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