Ultrasound of the Shoulder
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1 Ultrasound of the Shoulder Patrick Battaglia, DC, DACBR Logan University, Department of Radiology
2 Outline Review ultrasound appearance of NMSK tissues Present indications for ultrasound of the shoulder. Present an introductory shoulder protocol.
3 Ultrasound appearance of neuromusculoskeletal tissues
4 ANATOMY Muscle Tendon Ligament Nerve Bone
5 SKELETAL MUSCLE SHORT-AXIS LONG-AXIS Radiographics Jan-Feb;38(1):
6 SKELETAL MUSCLE FULL THICKNESS TEAR SKELETAL MUSCLE NORMAL MUSCLE
7 TENDON/LIGAMENT SHORT-AXIS LONG-AXIS Acta Biomater Nov;63:18-36.
8 TENDON/LIGAMENT FULL THICKNESS TEAR
9 TENDON/LIGAMENT TENDINOSIS
10 PERIPHERAL NERVE SHORT-AXIS LONG-AXIS June 2016 Expert Review of Medical Devices 13(8)
11 PERIPHERAL NERVE ENTRAPMENT NEUROPATHY
12 BONE SHORT-AXIS LONG-AXIS By SEER - U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program ( adress, Public Domain,
13 BONE ACUTE FRACTURE
14 BONE HEALING FRACTURE WITH CALLUS
15 Ultrasound of the shoulder
16 Indications for shoulder ultrasound Bursitis Rotator cuff and long head of the biceps tendinopathy and tear Postoperative cuff failure Pectoral muscle tears Acromioclavicular joint osteoarthritis, trauma, and instability Suprascapular nerve entrapment Sconfienza et al. Eur Radiol Jun 6. [Epub ahead of print]
17 Limitations of shoulder ultrasound Bone evaluation (including cartilage and marrow) Glenoid labrum evaluation* Adhesive capsulitis* Thoracic outlet syndrome* * Limited evidence emerging applications Sconfienza et al. Eur Radiol Jun 6. [Epub ahead of print]
18 Introductory shoulder protocol
19 *All anatomy plates, unless otherwise noted, are attributed to: e-anatomy, Micheau A, Hoa D, imaios.com
20 Introductory shoulder protocol Biceps tendon short and long axis Subscapularis tendon long and short axis Subacromial space and bursa Rotator interval Posterior rotator cuff (supra- and infraspinatus, teres minor tendons) long and short axis Posterior glenohumeral joint Supraspinatus muscle Infraspinatus muscle
21 CROSS-SECTIONAL ANATOMY
22 BICEPS TENDON SHORT AXIS AT INTERTUBERCULAR GROOVE
23 BICEPS TENDON SHORT AXIS AT INTERTUBERCULAR GROOVE
24 BICEPS TENDON LONG AXIS AT INTERTUBERCULAR GROOVE
25 Long head biceps tendon pathology LHBT tendinosis/ tenosynovitis LHBT rupture LHBT subluxation/dislocation Fluid in the tendon sheath
26 Long head biceps tendinosis Normal
27 Long head biceps tendon rupture
28 Long head biceps tendon pathology Fluid in the tendon sheath of the LHBT Fluid in the LHBT tendon sheath on ultrasound is highly predictive of rotator cuff tears or LHBT pathology Hanusch et al. Biceps sheath fluid on shoulder ultrasound as a predictor of rotator cuff tear: analysis of a consecutive cohort. J Shoulder Elbow Surg Oct;25(10):
29 SUBSCAPULARIS TENDON LONG AXIS
30 SUBSCAPULARIS TENDON LONG AXIS
31 SUBSCAPULARIS TENDON SHORT AXIS
32 SUBSCAPULARIS TENDON SHORT AXIS
33 Subscapularis Tendon Pathology Tendinosis Tear Allows LHBT subluxation/dislocation)
34 Subscapularis tendinosis Normal
35 Subscapularis tear
36 Subscapularis tear
37 SUBACROMIAL SPACE AND BURSA
38 SUBACROMIAL SPACE AND BURSA Bursal complex: Peribursal fat (yellow) Fluid (purple) ROTATOR CUFF ACROMION HUMERUS
39 Subacromial impingement At ultrasound, failure of humeral depression may be seen, but is subjective Ultrasound signs of impingement: Rotator cuff thickening Bursal sided tearing Subacromial/subdeltoid bursitis or thickening (normal bursa 2 mm) Accumulation of bursal fluid with abduction or flexion more reliable ultrasound signs
40 SUBACROMIAL IMPINGEMENT
41 SUBACROMIAL IMPINGEMENT
42 SUBACROMIAL IMPINGEMENT
43 DIFFERENTIAL DIAGNOSIS ADHESIVE CAPSULITIS Correlate (passive external rotation) Look for a normal rotator cuff See: Ryu et al. J Ultrasound Med Aug;12(8):445-9.
44 ROTATOR INTERVAL Ultrasound Int Open Jun;3(3):E107-E116.
45 ROTATOR INTERVAL SST BT SCT HUMERUS
46 Rotator interval - pathology Long head of the biceps tendon pathology Tear Dislocation Supraspinatus and subscapularis pathology Joint capsule and related pathology Effusion Capsulitis Ultrasound Int Open Jun;3(3):E107-E116.
47 ACUTE BICEPS LONG HEAD TENDON TEAR
48 NORMAL ADHESIVE CAPSULITIS
49 POSTERIOR ROTATOR CUFF
50 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) CRASS POSITION
51 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) MODIFIED CRASS POSITION
52 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) CRASS V. MODIFIED CRASS POSITIONS
53 CRASS V. MODIFIED CRASS POSITIONS Ferri M 2005: Modified Crass position may over-estimate size of rotator cuff tear in long-axis No difference in short-axis Shah NP 2012: No difference between Crass, modified Crass, and neutral positions for diagnosing posterior rotator cuff pathology
54 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) DELTOID MUSCLE HUMERUS
55 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) DELTOID MUSCLE HUMERUS
56 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S) FOOTPRINT APPEARANCE
57 POSTERIOR ROTATOR CUFF LONG AXIS IMAGE(S)
58 POSTERIOR ROTATOR CUFF SHORT AXIS IMAGE(S) DELTOID MUSCLE BT HUMERUS
59 Posterior rotator cuff - pathology Continuum: tendinosis (± enthesopathy, calcific tendinitis), partial tear, fullthickness tear, massive tear Tendinosis (Bretzke CA 1985, Crass JR 1988) : Consider when > 6 mm Measured 1 cm proximal to insertion May be larger in athletes Contralateral comparison very helpful
60 Posterior rotator cuff - pathology Partial tear: Articular sided Bursal sided Intrasubstance Ultrasound features (van Holsbeeck) Hypoechoic or anechoic region, heterogeneous Irregular margin Focal thinning (i.e. loss of convex bursal contour) Bony irregularity Bursal fluid or fluid around biceps tendon
61 Posterior rotator cuff - pathology Ultrasound has 93% sensitivity and 94% specificity to diagnosis a full thickness rotator cuff tear (de Jesus JO, AJR Am J Roentgenol Jun;192(6): ) Primary signs of full thickness tear: tendon absence (naked tuberosity), anechoic defect spanning bursal to articular surface, marked contour abnormality of the bursa/deltoid (van Holsbeeck) Secondary signs of full thickness tear: greater tubercle irregularity, effusion around biceps tendon, subdeltoid bursal fluid, cartilage interface sign
62 Full thickness v. massive tear NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)
63 Full thickness v. massive tear NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)
64 POSTERIOR ROTATOR CUFF TENDINOSIS
65 POSTERIOR ROTATOR CUFF CALCIFIC TENDINITIS
66 POSTERIOR ROTATOR CUFF CALCIFIC TENDINITIS
67 POSTERIOR ROTATOR CUFF ENTHESOPATHY
68 POSTERIOR ROTATOR CUFF PARTIAL THICKNESS TEAR
69 POSTERIOR ROTATOR CUFF PARTIAL THICKNESS TEAR
70 POSTERIOR ROTATOR CUFF FULL THICKNESS TEAR
71 POSTERIOR ROTATOR CUFF FULL THICKNESS TEAR
72 POSTERIOR ROTATOR CUFF MASSIVE TEAR
73 POSTERIOR ROTATOR CUFF MASSIVE TEAR
74 POSTERIOR GLENOHUMERAL JOINT
75 POSTERIOR GLENOHUMERAL JOINT DYNAMIC EVALUATION
76 POSTERIOR GLENOHUMERAL JOINT POSTERIOR LABRAL TEAR AND PARALABRAL CYST NORMAL
77 POSTERIOR LABRAL TEAR WITH PARALABRAL CYST
78 SUPRASPINATUS MUSCLE SHORT AXIS Supraspinatus Body of scapula
79 SUPRASPINATUS MUSCLE LONG AXIS Trapezius Supraspinatus Scapula
80 INFRASPINATUS MUSCLE SHORT AXIS
81 INFRASPINATUS MUSCLE LONG AXIS
82 MUSCLE ATROPHY NORMAL
83 References and recommended reading Jacobson JA. Fundamentals of Musculoskeletal Ultrasound, 3 rd ed. Chapter 3 Shoulder Ultrasound.
84 Thank you! Questions, comments, concerns:
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