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M Court-Payen, MD, PhD - Dept of Musculoskeletal Imaging GHP Gildhøj Private Hospital Copenhagen - Denmark US of the Shoulder – Examination Technique • High Frequency Linear Array : 12-10 MHz • Rotating Chair • Very Systematic • Different Specific Patient Positions • Comparison with Contralateral Side • Dynamic • Interactive ++ Longitudinal Long Head of the Biceps Rotator Cuff US of the Shoulder – Examination Technique • High Frequency Linear Array : 12-10 MHz • Rotating Chair • Very Systematic • Different Specific Patient Positions • Comparison with Contralateral Side • Dynamic • Interactive ++ US of the Shoulder – Examination Technique • High Frequency Linear Array : 12-10 MHz • Rotating Chair • Very Systematic • Different Specific Patient Positions • Comparison with Contralateral Side • Dynamic • Interactive ++ US of the Shoulder – Examination Technique • High Frequency Linear Array : 12-10 MHz • Rotating Chair • Very Systematic • Different Specific Patient Positions • Comparison with Contralateral Side • Dynamic • Interactive ++ US of the Shoulder • Anatomy of the Shoulder • Systematic US Examination of the Shoulder • Dynamic Examination of the Shoulder • (US-guided Injection) The Shoulder = 5 “Joints” Acromioclavicular Joint Sternoclavicular Joint Subacromial Space Scapulothoracic Space Glenohumeral Joint Lateral Scapula Supraspinatus Long Head of the Biceps Infraspinatus Teres Minor Subscapularis Superior Shoulder Subscapularis Biceps Supraspinatus CA ligt AC joint Acromion Infraspinatus Teres Minor Anterior Shoulder AC joint Acromion Greater Tuberosity Bicipital Groove Coracoid Process Lesser Tuberosity Anterior Shoulder Subscapularis Biceps Anterior Shoulder Deltoid SDSA Bursa Anterior Shoulder AC Joint + SASD Bursa CA Ligt Subscap LH Biceps Long Head of the Biceps Patient Sitting Supination Rotating Chair Long Head of the Biceps Rotator Cuff Interval Transv Humeral Ligt Pectoralis Tendon Transversal Biceps Muscle Long Head of the Biceps Rotator Cuff Interval Coraco-Humeral Ligt Retropulsion Superior Glenohumeral Ligt Anterior Sling ! Long Head of the Biceps Longitudinal Biceps Muscle Rotator Cuf Interval Subscapularis Tendon External Rotation + Adduction Cor Subscapularis Tendon External Rotation + Adduction - Volume - Structure - Upper Margin Subscapularis Tendon Coracoacromial Ligament Deltoid Acromion Bursa Rotator Cuff Coracoid Acromioclavicular Joint Anatomical Variations Compaire to Contralateral ++ SASD Bursa No Fluid Van Holsbeeck MT, Introcaso JH, Musculoskeletal Ultrasound 2001, p 472 Hypoechoic Layer < 1.5 mm Milgrom C et al. J Bone Joint Surg [Br] 1995, 77-B, 296-298 Van Holsbeeck MT, Introcaso JH, Musculoskeletal Ultrasound 2001, p 476 Unless Steroid Injection within 48 h Major NM, Skel Radiol 1999, 28, 628-631 Lateral Shoulder + SASD Bursa Supraspin Supraspinatus Tendon Neutral Supraspinatus Tendon Internal Rotation + Retropulsion Crass JR, J Clin Ultrasound 1987, 15, 416-420 Neutral Supraspinatus Tendon • Convexe Upper Margin • Progressive Thining Deltoid • Echorich Fibrillar Structure SASD Bursa < 1.5 mm • Regular Bony Surface Cartilage • Thickness : 5 - 7 mm (neck) Head Neck Great Tuberosity Normal Supraspinatus Tendon - 5 Histologic Layers 1 2 3 4 5 Clark JM et al. J Bone Joint Surg Am. 1992 Jun;74(5):713-25 Normal Supraspinatus Tendon - 2 BioMechanical Layers 1 2 3 4 5 Modified from Guérini et al. Actualité en Echographie de l´Appareil Locomoteur, Sauramps Médical 2008:21-33 Normal Supraspinatus Tendon - 2 Layers 1 2 3 4 5 Modified from Guérini et al. Actualité en Echographie de l´Appareil Locomoteur, Sauramps Médical 2008:21-33 Supraspinatus Tendon Homogeneous But Pitfalls ... Supraspinatus Tendon Homogeneous But Pitfalls ... Oblique Scan Supraspinatus Tendon Homogeneous But Pitfalls ... Intratendinous Lesion ? No : Muscle Layer (Young ++) Supraspinatus Tendon Homogeneous But Pitfalls ... Biceps Hiatus Deltoid Septation Supraspinatus Tendon Deltoid SASD Bursa SS 2 cm Biceps Humeral Head Supraspinatus Tendon SS 2 cm Biceps Modified Position Posterior Shoulder Spinoglenoid Notch Greater Tuberosity Post Recess Humeral Head Posterior Shoulder Infraspinatus Teres Minor Posterior Shoulder + SASD Bursa Infraspin Muscles Spinoglenoid Notch Teres Minor Infraspinatus Tendon SASD Bursa Deltoid Cartilage Labrum Neck Head GT Infraspinatus Tendon Head Neck Normal Irregularity Infraspinatus + Teres Minor Muscles Deltoid TM IS Supraspinatus Muscles Trap Sp SS Cl Supraspinatus Muscles Trap Ac SS Spinoglenoid Notch Suprascapular Neurovascular Bundle Infraspinatus Spine Neck Subacromial Impingement Neer CS, J Bone Joint Surg 1972;54-A:41-50 Tendinitis Tendinosis Tendon Tear Bursitis Painful Arc Subacromial Impingement 1 2 Dynamic US Examination Longitudinal Views of the Supraspinatus Tendon Longitudinal Movement Longitudinal US Scanning 1- At the level of the Acromion 2- At the level of the CAL Calcific Tendinopathy Subacromial Impingement Bulging of Bursa and Blocking of Tendon Thank You
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