Ultrasound assessment of most frequent shoulder disorders

Ultrasound assessment of most frequent shoulder disorders Poster No.: C-2026 Congress: ECR 2014 Type: Educational Exhibit Authors: S. P. Ivanoski; Ohrid/MK Keywords: Trauma, Athletic injuries, Arthritides, Education, Diagnostic procedure, Ultrasound, Musculoskeletal soft tissue, Musculoskeletal joint DOI: 10.1594/ecr2014/C-2026 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 36

Learning objectives To demonstrate the normal anatomy of shoulder joint, and visualization of the structures with ultrasound. To show the most frequent disorders, traumatic, inflammatory and degenerative, involving the joint structures. To explain the importance of the method for accurate diagnosis of the common shoulder pathology To illustrate the advantages and limitations of the method Background According to some statistics, shoulder problems occur in about 20% of population during their live. Many of these conditions affect joint soft tissue structures. Rotator cuff muscles and tendons, tendon of long head of biceps brachii, deltoid muscle, ligaments, bursas, some osseous and cartilage parts of the shoulder are all structures that can be easily evaluated by ultrasound. Dynamic investigation for shoulder functions, such as establishing diagnosis of impingement syndrome can also be conducted. Interventional procedures of the shoulder are easily performed by experienced radiologists. That's why ultrasound examination, together with radiography should be the first choice for imaging of shoulder disorders. It can lead to correct diagnosis in great part of the cases and help avoiding more complicated investigations: MRI, CT arthrography. Findings and procedure details Ultrasound examination can be very useful in diagnosing both rotator cuff and non-rotator cuff disorders of the shoulder. The rotator cuff consists of the tendons of four muscles: Subscapularis muscle that originates from the subscapular fossa and inserts into the humeral lesser tuberosity. Supraspinatus muscle is localized in supraspinous fossa, and laterally inserts into the greater tuberosity of the humerus. Infraspinatus muscle takes origin from the infraspinous Page 2 of 36

fossa, and teres minor muscle originates just inferiorly. They both insert into the greater tuberosity. Normal ultrasound anatomy of supraspinatus tendon and surrounding shoulder structures is shown and explained on figures 1, 2 and 3. Fig. 1: Normal supraspinatus tendon, longitudinal view References: Radiology, St. Erasmo Hospital - Ohrid/MK Page 3 of 36

Fig. 2: Supraspinatus tendon, normal anatomy, longitudinal view References: Radiology, St. Erasmo Hospital - Ohrid/MK Fig. 3: Supraspinatus tendon, transverse view Page 4 of 36

References: Radiology, St. Erasmo Hospital - Ohrid/MK Ultrasound evaluation has similar accuracy as MRI in detecting rotator cuff tears. The tears of the rotator cuff can be total, or subtotal affecting articular or bursal side of the tendon. Direct ultrasound signs of rotator cuff tear are hypoechoic or anechoic defects of the bursal or articular side of the tendon for partial thickness tears. Absence of a part of the tendon, replaced by fluid is characteristic for full thickness tendon tear. Various degree of tendon retraction can also be observed. There are also indirect signs such as greater tuberosity irregularity, or increased amount of fluid in subacromion subdeltoid bursa. On fig. 4 a bursal-side partial thickness tear of supraspinatus tendon, with increased amount of subacromion subdeltoid bursal fluid is shown. Tendon of supraspinatus is thickened with irregularity of great portion of the fibres. Page 5 of 36

Fig. 4: Supraspinatus tendon-bursal side partial thickness tear References: Radiology, St. Erasmo Hospital - Ohrid/MK Full thickness tear with retraction of the supraspinatus tendon (chronic) is observed of fig. 5. There is also an irregularity of the greater tuberosity. Fig. 5: Supraspinatus tendon-full thickness chronic tear References: Radiology, St. Erasmo Hospital - Ohrid/MK Other conditions affecting the supraspinatus tendon can be also adequately proven using ultrasound. The most common disorders are degenerative tendinosis, calcifying tendonitis, bursitis, shoulder impingement syndrome. Degenerative changes-tendinosis of supraspinatus tendon are shown on fig. 6. The tendon is thickened, irregular, heteroechoic, but there are no signs of tendon tear. Page 6 of 36

Fig. 6: Supraspinatus tendon tendinosis References: Radiology, St. Erasmo Hospital - Ohrid/MK Calcifying tendonitis is a frequent generator of shoulder pain. Ultrasound has a high sensitivity in detecting tendon calcifications. They appear as variously hiperechoic structures with different size, sometimes very big, and posterior shadowing. Supraspinatus is the most affected of the rotator cuff tendons. Cases of advanced supraspinatus calcifying tendonitis are shown in fig. 7 and 8. Page 7 of 36

Fig. 7: Supraspinatus tendon calcifying tendonitis References: Radiology, St. Erasmo Hospital - Ohrid/MK Page 8 of 36

Fig. 8: Supraspinatus tendon calcifying tendonitis-transverse view References: Radiology, St. Erasmo Hospital - Ohrid/MK Subacromial subdeltoid bursitis is evident on fig. 9. Supraspinatus tendon is heterogeneous, and increased amount of anechoic fluid in the bursa is visualized. Page 9 of 36

Fig. 9: Subacromial subdeltoid bursitis References: Radiology, St. Erasmo Hospital - Ohrid/MK Normal anatomy of subscapularis tendon is demonstrated on fig 10 and 11. Subscapularis tendon tear is less common and is usually combined with the tear of supraspinatus tendon. Page 10 of 36

Fig. 10: Normal Subscapularis tendon-longitudinal view References: Radiology, St. Erasmo Hospital - Ohrid/MK Page 11 of 36

Fig. 11: Normal subscapularis tendon-transverse view References: Radiology, St. Erasmo Hospital - Ohrid/MK Subdeltoid bursitis with a huge amount of fluid over subscapularis tendon is evident on fig.12. Page 12 of 36

Fig. 12: Subdeltoid bursitis References: Radiology, St. Erasmo Hospital - Ohrid/MK Ultrasound image of normal infraspinatus tendon is demonstrated on fig 13. Page 13 of 36

Fig. 13: Normal Infraspinatus tendon-longitudinal view References: Radiology, St. Erasmo Hospital - Ohrid/MK Non rotator cuff disorders affect the shoulder in many cases, and can be adequately evaluated with ultrasound. Superiorly of the myotendinous junction, the tendon of the long head of biceps brachii enters the bicipital groove. More cranially it passes into the rotator interval (the space between the supraspinatus and subscapularis tendon. Then the tendon extends to the upper pole of the humeral head and inserts on the superior rim of the glenoid. Normal ultrasound appearance of tendon of the long head of biceps in the bicipital groove is exposed on fig. 14 and 15. Page 14 of 36

Fig. 14: Tendon of long head of biceps brachii-longitudinal view References: Radiology, St. Erasmo Hospital - Ohrid/MK Page 15 of 36

Fig. 15: Tendon of long head of biceps brachii in the bicipital groove-transverse view References: Radiology, St. Erasmo Hospital - Ohrid/MK Various traumatic and degenerative conditions can affect the tendon. Among the most common are medial dislocation/subluxation of the tendon and tendon degenerationtendinosis. Acute or chronic tendon tear occurs less often. Tendinosis of the long head of biceps tendon is visualized on image 16. The tendon is hypoechoic, with increased diameter, and hypoechoic fluid around it is visible (in the tendon sheath). Page 16 of 36

Fig. 16: Degeneration of the tendon of long head of biceps brachii-transverse view References: Radiology, St. Erasmo Hospital - Ohrid/MK Abnormalities of other parts of the shoulder: acromioclavicular joint traumatic and degenerative lesions, bony abnormalities (compression fractures, avulsions of the tuberosities), cysts, joint effusion, synovial disorders can also be diagnosed with ultrasound examination. Ultrasound image of normal acromioclavicular joint is shown on fig. 17. Page 17 of 36

Fig. 17: Acromioclavicular joint References: Radiology, St. Erasmo Hospital - Ohrid/MK Arthritis of the acromioclavicular joint. Heterogeneous joint space is visible on fig. 18. Page 18 of 36

Fig. 18: Acromioclavicular joint osteoarthritis References: Radiology, St. Erasmo Hospital - Ohrid/MK Images for this section: Page 19 of 36

Fig. 1: Normal supraspinatus tendon, longitudinal view Page 20 of 36

Fig. 2: Supraspinatus tendon, normal anatomy, longitudinal view Fig. 3: Supraspinatus tendon, transverse view Page 21 of 36

Fig. 4: Supraspinatus tendon-bursal side partial thickness tear Page 22 of 36

Fig. 5: Supraspinatus tendon-full thickness chronic tear Page 23 of 36

Fig. 6: Supraspinatus tendon tendinosis Page 24 of 36

Fig. 7: Supraspinatus tendon calcifying tendonitis Page 25 of 36

Fig. 8: Supraspinatus tendon calcifying tendonitis-transverse view Page 26 of 36

Fig. 9: Subacromial subdeltoid bursitis Page 27 of 36

Fig. 10: Normal Subscapularis tendon-longitudinal view Fig. 11: Normal subscapularis tendon-transverse view Page 28 of 36

Fig. 12: Subdeltoid bursitis Page 29 of 36

Fig. 13: Normal Infraspinatus tendon-longitudinal view Page 30 of 36

Fig. 14: Tendon of long head of biceps brachii-longitudinal view Fig. 15: Tendon of long head of biceps brachii in the bicipital groove-transverse view Page 31 of 36

Fig. 16: Degeneration of the tendon of long head of biceps brachii-transverse view Page 32 of 36

Fig. 17: Acromioclavicular joint Page 33 of 36

Fig. 18: Acromioclavicular joint osteoarthritis Page 34 of 36

Conclusion Ultrasound in shoulder disorders has lots of benefits and can help in establishing correct diagnosis in many of the cases. It's inexpensive, widely available method, with advantages, as dynamic examination, comparison with contralateral side. Ultrasound guided application of medications and biopsy of the soft tissue changes make the shoulder ultrasound irreplaceable method among the MSK radiologists. It is also important for the radiologist to understand the weaknesses of the method. The major limitations are the inability to evaluate the osseous structures and structures covered by bones, cartilaginous labrum, joint capsule. Adequate experience of the radiologist is also among the key factors for establishing correct diagnosis. Knowledge of shoulder ultrasound anatomy, most common disorders that could be evaluated with ultrasound, possibilities for US guided therapy, as well as its limitations can be crucial for MSK radiologist in taking the right decision, making early and correct diagnosis, and avoiding more complicate and expensive investigations. Personal information References Hide G. Ultrasonography for Rotator Cuff Injury. Medscape updated Jul 11, 2013 DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Clin Orthop Relat Res.2008;466:543-551 Meyers PR, Craig JG, van Holsbeeck M. Shoulder ultrasound. AJR American Journal of Roentgenology 2009; 193:W174 Jacobson JA. Shoulder US: anatomy, technique, and scanning pitfalls. Radiology 2011;260(1):6-16 Ostlere S. Imaging the shoulder. Imaging 2003; 15:162-173 Martinoli C, Bianchi S, Prato N, et al. US of the shoulder: non-rotator cuff disorders. Radiographics 2003; 23:381-401 Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical, radiographic, and US findings. Radiographics 2005;25:1591-607 Papatheodorou A, Ellinas P, Takis F, Tsanis A, Maris I, Batakis N. US of the shoulder: rotator cuff and non-rotator cuff disorders. Radiographics 2006; 26:e23 Page 35 of 36

Olubaniyi B. O, Bhatnagar G, Vardhanabhuti V, Brown S. E, Gafoor A, and Suresh P S. Comprehensive Musculoskeletal Sonographic Evaluation of the Hand and Wrist. J Ultrasound Med 2013; 32(6):901-914 Brasseur J R. The biceps tendons: From the top and from the bottom. J Ultrasound. 2012; 15(1): 29-38 Page 36 of 36