Ultrasound of Shoulder Pathology and Intervention 서울대학교병원재활의학과 김기원
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1 Ultrasound of Shoulder Pathology and Intervention 서울대학교병원재활의학과 김기원
2 Ultrasound for Shoulder Disorder Advantage Dynamic evaluation Immediate clinical correlation + Intervention Weakness Diagnostic accuracy? Retrospective review Articular cartilage of labrum
3 Subacromial impingement syndrome
4 Ultrasound for Shoulder Disorder Advantage Dynamic evaluation Immediate clinical correlation + Intervention Weakness Diagnostic accuracy? Retrospective review Articular cartilage of labrum
5 Contents Common Pathology of Shoulder Rotator cuff tear Useful Interventions of Shoulder Intra-articular injection Calcific tendinitis SASD bursal injection Adhesive capsulitis AC joint injection Instability Barbotage
6 Rotator cuff tear Prevalence Increases with age Clinical implication Symptomatic asymptomatic Etiology Multi-factorial Intrinsic factors Critical zone Extrinsic factors Subacromial impingement
7 Rotator cuff tear Diagnostic accuracy Ultrasound ~ MRI
8 Full thickness tear Rotator cuff tear
9 Rotator cuff tear Full thickness tear Inadequate compression
10 Rotator cuff tear Full thickness tear sagging
11 Rotator cuff tear Full thickness tear Joint fluid accumulation in SASD bursa High specificity (95%)
12 Rotator cuff tear Full thickness tear Cartilage interface sign High specificity (~100%) Low sensitivity
13 Rotator cuff tear Full thickness tear Geyser sign
14 Rotator cuff tear Partial thickness tear Articular surface Bursal surface Intratendinous
15 Partial thickness tear Rotator cuff tear
16 Rotator cuff tear Partial thickness tear Do not confuse with Musculo-tendinous junction Anisotropy
17 Rotator cuff tear Cortical irregularity Low specificity High sensitivity
18 Rotator cuff tendinosis Swelling, Hypo-echoic +/- tear Bilateral comparison
19 Rotator cuff tear Full-thickness vs. Partial-thickness?
20 [Case] F/78YO, Rt Shoulder Pain (1MA) Slip down, 1MA right shoulder pain developed Motion pain >> resting pain ROM: C7-L2 Neer + Empty can +- Belly press ++ Lift off +
21 Ultrasound Subscap Subscap Subscap Subscap
22 Rotator cuff tear Full-thickness vs. Partial-thickness??
23 Arthro-sonography Subcoracoid bursa Leakage shown to the subcoracoid bursa and through the anterior capsule.
24 Calcific tendinitis
25 Calcific tendinitis
26 Calcific tendinitis Composition Hydorxyapatite Frequently at Critical zone of the supraspinatus Lower third of the infraspinatus Preinsertion fibers of the subscapularis
27 Calcific tendinitis Stages Precalcific calcific resorptive postcalcific 3 types in ultrasound Type I Type II Type III
28 Calcific tendinitis Type I Well defined Highly echoic Formative phase
29 Calcific tendinitis Type II More blurred calcification Hyperechoic foci with a faint acoustic shadow
30 Calcific tendinitis Type III mild echogenicity no acoustic shadows Resorptive phase
31 Calcific tendinitis Hyperemic on color Doppler? Twinkle artifact
32 Adhesive capsulitis Limited range of motion at glenohumeral joint Etiology Idiopathic Secondary to various conditions MR arthrography Restricted joint capacity Thickening of axillary pouch or rotator interval Ultrasound Exclusion of other pathologies Increased joint fluid (at LBTB)
33 Adhesive capsulitis Rotator interval, short-axis view +/- Thickening with hyperemia Not pathognomic
34 Adhesive capsulitis Exclusion of other possible pathologies LBTB LBTB Subscap Suprasp
35 Instability Shoulder instability in ultrasound Biceps tendon instability Glenohumeral joint instability Acromioclavicular joint instability
36 Biceps tendon instability Coracohumeral ligament tear + +/- Shallow bicipital groove Subscapularis tendon tear
37 Glenohumeral joint instability Limited role of ultrasound Hill-Sachs lesion can be seen in ultrasound
38 Acromioclavicular joint instability High Sensitivity of US in low grade lesion Ligamentous and capsular complex thickened, hypoechoic inserting more medial clavicle Joint space widening
39 Acromioclavicular joint instability Hematoma in high grade lesion between the clavicle and coracoid d/t coracoclavicular ligament tear Irregular cortical erosion at distal end of the clavicle
40 Acromioclavicular joint degeneration Cortical erosion Capsule thickening
41 Intervention General consideration Long axis is more favored than short-axis Finding a best view is important Maintain the target, while not missing the needle
42 Intra-articular Injection Indications Capsular lesions Adhesive Capsulitis Articular side RCT Arthro-sonography to differentiate full vs Partial RCT Hydraulic distension Points Avoid hitting painful structures central tendon, labrum Make sure to pierce the capsule
43 Shoulder Intra-articular Injection Position to view both the injection site and monitor Put the probe just below and parallel to the scapular spine
44 Shoulder Intra-articular Injection Move away from the central tendon of IST
45 Shoulder Intra-articular Injection Make the target at left 1/3 Starting point
46 Shoulder Intra-articular Injection Make the capsular line (target) flat
47 Shoulder Intra-articular Injection Make the capsular line (target) brighter
48 Shoulder Intra-articular Injection Hold a needle facing the bevel toward myself. Stick the needle 5mm-15mm from the margin of the probe.
49 Shoulder Intra-articular Injection Aim at the joint space Starting point
50 Shoulder Intra-articular Long Axis Must see this: the needle penetrates the capsule!!!
51 Signs of Successful Placement
52 Bursa Injection Indications Bursitis, Bursa swelling Inflammatory Traumatic Impingement syndrome: SASD/subcoracoid bursa Bursography for articular side tear Reactive bursa swelling: less effective Points Identify the potential space of bursae Advance a needle within the space Check out filling patterns
53 Identification of Bursa Space
54 SASD Bursa Injection
55 SASD Bursa: good filling penetraion
56 AC Joint Injection Indications ACJ origin shoulder pain Not for simple degeneration or swelling Should be confirmed by Hx and provocative tests Points Longitudinal is better Outlining the whole joint capsule Remember beam width artifact when the needle tip is blocked by bone even you don t see one. nudge it slightly
57 AC joint injection 14
58 Calcium Barbotage Indications Symptomatic calcium Calcium nodule at resolving phase Points Patient selection!! Plan the best USG view/positioning/needle projection to yield the most calcium material Large needle: need to anesthetize the bursa Care not to disrupt the nodule leaking of calcium with no return
59 Calcium Barbotage
60 Summary Ultrasound for shoulder Diagnosis of clinically relevant conditions Immediate intervention
61 Thank you
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