Ultrasound of Shoulder Pathology and Intervention 서울대학교병원재활의학과 김기원

Ultrasound of Shoulder Pathology and Intervention 서울대학교병원재활의학과 김기원

Ultrasound for Shoulder Disorder Advantage Dynamic evaluation Immediate clinical correlation + Intervention Weakness Diagnostic accuracy? Retrospective review Articular cartilage of labrum

Subacromial impingement syndrome

Ultrasound for Shoulder Disorder Advantage Dynamic evaluation Immediate clinical correlation + Intervention Weakness Diagnostic accuracy? Retrospective review Articular cartilage of labrum

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

Rotator cuff tear Prevalence Increases with age Clinical implication Symptomatic asymptomatic Etiology Multi-factorial Intrinsic factors Critical zone Extrinsic factors Subacromial impingement

Rotator cuff tear Diagnostic accuracy Ultrasound ~ MRI

Full thickness tear Rotator cuff tear

Rotator cuff tear Full thickness tear Inadequate compression

Rotator cuff tear Full thickness tear sagging

Rotator cuff tear Full thickness tear Joint fluid accumulation in SASD bursa High specificity (95%)

Rotator cuff tear Full thickness tear Cartilage interface sign High specificity (~100%) Low sensitivity

Rotator cuff tear Full thickness tear Geyser sign

Rotator cuff tear Partial thickness tear Articular surface Bursal surface Intratendinous

Partial thickness tear Rotator cuff tear

Rotator cuff tear Partial thickness tear Do not confuse with Musculo-tendinous junction Anisotropy

Rotator cuff tear Cortical irregularity Low specificity High sensitivity

Rotator cuff tendinosis Swelling, Hypo-echoic +/- tear Bilateral comparison

Rotator cuff tear Full-thickness vs. Partial-thickness?

[Case] F/78YO, Rt Shoulder Pain (1MA) Slip down, 1MA right shoulder pain developed Motion pain >> resting pain ROM: 58-135-60-C7-L2 Neer + Empty can +- Belly press ++ Lift off +

Ultrasound Subscap Subscap Subscap Subscap

Rotator cuff tear Full-thickness vs. Partial-thickness??

Arthro-sonography Subcoracoid bursa Leakage shown to the subcoracoid bursa and through the anterior capsule.

Calcific tendinitis

Calcific tendinitis

Calcific tendinitis Composition Hydorxyapatite Frequently at Critical zone of the supraspinatus Lower third of the infraspinatus Preinsertion fibers of the subscapularis

Calcific tendinitis Stages Precalcific calcific resorptive postcalcific 3 types in ultrasound Type I Type II Type III

Calcific tendinitis Type I Well defined Highly echoic Formative phase

Calcific tendinitis Type II More blurred calcification Hyperechoic foci with a faint acoustic shadow

Calcific tendinitis Type III mild echogenicity no acoustic shadows Resorptive phase

Calcific tendinitis Hyperemic on color Doppler? Twinkle artifact

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)

Adhesive capsulitis Rotator interval, short-axis view +/- Thickening with hyperemia Not pathognomic

Adhesive capsulitis Exclusion of other possible pathologies LBTB LBTB Subscap Suprasp

Instability Shoulder instability in ultrasound Biceps tendon instability Glenohumeral joint instability Acromioclavicular joint instability

Biceps tendon instability Coracohumeral ligament tear + +/- Shallow bicipital groove Subscapularis tendon tear

Glenohumeral joint instability Limited role of ultrasound Hill-Sachs lesion can be seen in ultrasound

Acromioclavicular joint instability High Sensitivity of US in low grade lesion Ligamentous and capsular complex thickened, hypoechoic inserting more medial clavicle Joint space widening

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

Acromioclavicular joint degeneration Cortical erosion Capsule thickening

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

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

Shoulder Intra-articular Injection Position to view both the injection site and monitor Put the probe just below and parallel to the scapular spine

Shoulder Intra-articular Injection Move away from the central tendon of IST

Shoulder Intra-articular Injection Make the target at left 1/3 Starting point

Shoulder Intra-articular Injection Make the capsular line (target) flat

Shoulder Intra-articular Injection Make the capsular line (target) brighter

Shoulder Intra-articular Injection Hold a needle facing the bevel toward myself. Stick the needle 5mm-15mm from the margin of the probe.

Shoulder Intra-articular Injection Aim at the joint space Starting point

Shoulder Intra-articular Long Axis Must see this: the needle penetrates the capsule!!!

Signs of Successful Placement

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

Identification of Bursa Space 3 2 1 4

SASD Bursa Injection

SASD Bursa: good filling penetraion

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

AC joint injection 14

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

Calcium Barbotage

Summary Ultrasound for shoulder Diagnosis of clinically relevant conditions Immediate intervention

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