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Ultrasound of the shoulder

Changed by Derek Smith, 11 Mar 2016

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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:

long head of biceps tendon is imaged in the intertubercular groove, as it runs under the transverse humeral ligament, in both transvers and longitudinal sections.
it is traced superiorly through the rotator cuff interval towards its insertion on the superior labrum and glenoid.

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: thesubscapularis tendon should be traced both longitudinally and transversely:

longitudinal images: probe is placed in transverse position (mediolaterally) over the humeral head ~~with~~ with the marker of the probe away from the patients torso. Then, the ~~transducer moved~~ transducer moved from top to bottom to to access three portions of the tendon; i.e, superior, middle, and inferior fibers, then:
- dynamic study: by internal and external rotation of the arm while the probe is hold still, possible impingement of the tendoncan ~~be assessed~~ be assessed; as ~~demonstrated~~ demonstrated by bunching of the tendonduring internal rotationwhile it passes under the coracoid process
transverse images: by turning the ~~probe~~ probe 90 degrees (now in craniocuadal direction) with the marker towards the patient's head, 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~~ which keeps it out of the joint. Indeed long head of biceps tendon dislocation is commonly associated with subscapilaris tears, as is with a history of previous anterior shoulder dislocation

Visualised pathology:

supraspinatus tendinopathy
long head of biceps tendon dislocation or subluxation

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:

infraspinatus tendinopathy including tears (note: it is rare for infraspinatus to be torn without supraspinatus tears also)

Glenoid labrum

Patient position: Same as for infraspinatus and inferior to this for more inferior part of the posterior labrum. For 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:

Hill-Sachs lesion
labral tear: > 2mm hypoechoic zone; vacuum phenomenon between labrum and glenoid; absent labrum; movement of the labrum during dynamic examination
sublabral foramen (unknown sensitivity/specificity)
Buford complex (unknown sensitivity/specificity)

Suprascapular notch

Patient position: as for infraspinatus

Normal findings: small notch in the scapular spine

Visualised pathology:

paralabral cyst associated with SLAP lesions
suprascapular notch ganglion

Acromioclavicular joint

Patient position: either position is fine

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

Visualised pathology:

degenerative change of the joint: osteophytes; subchondral cyst formation
Os acromiale
joint instability²

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 hyperechoid subacromial-subdeltoid bursa should be seen sliding effortlessly between the ACJ and the tendon of supraspinatus.

Visualised pathology:

-</ul><p>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.</p><h4>Suggested technique</h4><p>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.</p><h5>Biceps tendon</h5><p>Patient position: arm in neutral position, elbow flexed 90 degrees, forearm supinated (palm up).</p><p>Imaging planes: </p><ul>
+</ul><p>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.</p><h4>Suggested technique</h4><p>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.</p><h5>Biceps tendon</h5><p>Patient position: arm in neutral position, elbow flexed 90 degrees, forearm supinated (palm up).</p><p>Imaging planes:</p><ul>
-<a href="/articles/long-head-of-biceps-tendon">long head of biceps tendon</a> is imaged in the <a href="/articles/intertubercular-groove">intertubercular groove</a>, as it runs under the <a href="/articles/transverse-humeral-ligament">transverse humeral ligament</a>, in both transvers and longitudinal sections. </li>
+<a href="/articles/long-head-of-biceps-tendon">long head of biceps tendon</a> is imaged in the <a href="/articles/intertubercular-groove">intertubercular groove</a>, as it runs under the <a href="/articles/transverse-humeral-ligament">transverse humeral ligament</a>, in both transvers and longitudinal sections.</li>
~~-</ul><p>Normal findings: </p><ul>~~
~~-<li>tendon should be located in the <a href="/articles/intertubercular-groove">intertubercular groove</a>, with minimal fluid around it (tendon sheath communicates with the shoulder joint). </li>~~
~~-<li>the tendon fibres should be seen without tears, heterogeneity or thickening (beware of anisotropy). </li>~~
+</ul><p>Normal findings:</p><ul>
+<li>tendon should be located in the <a href="/articles/intertubercular-groove">intertubercular groove</a>, with minimal fluid around it (tendon sheath communicates with the shoulder joint).</li>
+<li>the tendon fibres should be seen without tears, heterogeneity or thickening (beware of anisotropy).</li>
-</ul><h5>Subscapularis</h5><p>Patient position: the arm is kept in the same position as above and is externally rotated, pulling the insertion of subscapularis tendon with it.</p><p>Imaging planes: the <a href="/articles/subscapularis-1">subscapularis</a> tendon should be traced both longitudinally and transversely:</p><ul>
+</ul><h5>Subscapularis</h5><p>Patient position: the arm is kept in the same position as above and is externally rotated, pulling the insertion of subscapularis tendon with it.</p><p>Imaging planes: the <a href="/articles/subscapularis-1">subscapularis</a> tendon should be traced both longitudinally and transversely:</p><ul>
-<strong>longitudinal images</strong>: probe is placed in transverse position (mediolaterally) over the humeral head with the marker of the probe away from the patients torso. Then, the transducer moved from top to bottom to access three portions of the tendon; i.e, superior, middle, and inferior fibers, then:<ul><li>dynamic study: by internal and external rotation of the arm while the probe is hold still, possible impingement of the tendon <span style="line-height:13.8666658401489px">can be assessed; as</span> demonstrated by bunching of the tendon <span style="line-height:13.8666658401489px">during internal rotation </span>while it passes under the coracoid process</li></ul>
+<strong>longitudinal images</strong>: probe is placed in transverse position (mediolaterally) over the humeral head with the marker of the probe away from the patients torso. Then, the transducer moved from top to bottom to access three portions of the tendon; i.e, superior, middle, and inferior fibers, then:<ul><li>dynamic study: by internal and external rotation of the arm while the probe is hold 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</li></ul>
-<strong>transverse images</strong>: by turning the probe 90 degrees (now in craniocuadal direction) with the marker towards the patient's head, 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 </li>
~~-</ul><p>Normal findings: </p><ul>~~
+<strong>transverse images</strong>: by turning the probe 90 degrees (now in craniocuadal direction) with the marker towards the patient's head, 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</li>
+</ul><p>Normal findings:</p><ul>
-<li>if the biceps tendon is dislocated then it will lie anterior to the subscapularis tendon which keeps it out of the joint. Indeed <a href="/articles/long-head-of-biceps-tendon-dislocation">long head of biceps tendon dislocation</a> is commonly associated with subscapilaris tears, as is with a history of previous <a href="/articles/anterior-shoulder-dislocation">anterior shoulder dislocation</a>
+<li>if the biceps tendon is dislocated then it will lie anterior to the subscapularis tendon which keeps it out of the joint. Indeed <a href="/articles/long-head-of-biceps-tendon-dislocation">long head of biceps tendon dislocation</a> is commonly associated with subscapilaris tears, as is with a history of previous <a href="/articles/anterior-shoulder-dislocation">anterior shoulder dislocation</a>
-</ul><h5>Supraspinatus</h5><p>Patient position: Shoulder internally rotated and extended (reaching to get wallet from back pocket, or scratching between shoulder blade positions).</p><p>Imaging planes: </p><ul>
~~-<li>the <a href="/articles/supraspinatus-muscle-and-tendon">supraspinatus</a> tendon should be traced both longitudinally and transversely. </li>~~
+</ul><h5>Supraspinatus</h5><p>Patient position: Shoulder internally rotated and extended (reaching to get wallet from back pocket, or scratching between shoulder blade positions).</p><p>Imaging planes:</p><ul>
+<li>the <a href="/articles/supraspinatus-muscle-and-tendon">supraspinatus</a> tendon should be traced both longitudinally and transversely.</li>
~~-</ul><p>Normal findings: </p><ul>~~
+</ul><p>Normal findings:</p><ul>
-</ul><h5>Infraspinatus</h5><p>Patient position: Patient reaches across and holds the contralateral shoulder with their hand, across their chest.</p><p>Imaging planes: the <a href="/articles/infraspinatus">infraspinatus</a> tendon should be traced both longitudinally and transversely.</p><p>Normal findings: </p><ul>
-<li>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 <a href="/articles/rotator-cuff">rotator cuff</a> is designated to be the supraspinatus, and the next 1.5 cm the tendon of infraspinatus. </li>
+</ul><h5>Infraspinatus</h5><p>Patient position: Patient reaches across and holds the contralateral shoulder with their hand, across their chest.</p><p>Imaging planes: the <a href="/articles/infraspinatus">infraspinatus</a> tendon should be traced both longitudinally and transversely.</p><p>Normal findings:</p><ul>
+<li>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 <a href="/articles/rotator-cuff">rotator cuff</a> is designated to be the supraspinatus, and the next 1.5 cm the tendon of infraspinatus.</li>
~~-<li>joint instability <sup>2</sup>~~
+<li>joint instability <sup>2</sup>

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