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Arizona Osteopathic Medical Association
Annual Convention, April 2016
Enhancing Osteopathic Palpatory Diagnosis and Treatment of Shoulder Pain
through the Use of Ultrasound Imaging
Deborah M. Heath, DO, CSPOMM and Inder Raj S. Makin, MD, PhD, RDMS
Musculoskeletal Ultrasound Imaging of the Shoulder
ANTERIOR SHOULDER
Structures to identify:
•
•
•
Long head of biceps brachii tendon, transverse and sagittal views
Subscapularis tendon, transverse and sagittal views
Subscapular tendon / Coracohumeral interval, transverse view
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Arizona Osteopathic Medical Association
Annual Convention, April 2016
Patient positioning for identifying anterior structures: Seated, elbow is flexed ~90-degrees, forearm
is supinated (palm up) resting on the thigh or table with shoulder slightly internally rotated.
Long Head of Biceps Tendon, transverse (short-axis) view
Probe placement: Place probe transversely across anterior shoulder at the level of the greater and lesser
tuberosities; move probe superior and inferior to see length of tendon.
LH Biceps
GT
GT: greater tuberosity
Medial
Lateral
Superficial
LT: lesser tuberosity
LH Biceps: long head of biceps brachii
tendon
LT
Right shoulder
Depth: 2.7 cm
Long Head of Biceps Tendon, longitudinal (long-axis) view
Probe placement: Once the transverse view is visualized, while maintaining contact with the patient’s skin, rotate
the transducer 90-degrees (to vertical position). Locate the humerus and then identify the long head of the biceps
tendon.
Del
LH Biceps
Del: deltoid
Inferior
Superior
Superficial
HH: humeral head
LH Biceps: long head of biceps
brachii tendon
HH
Right shoulder
Depth: 2.7 cm
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Arizona Osteopathic Medical Association
Annual Convention, April 2016
Subscapularis tendon, transverse (long-axis) view
Probe placement: Place probe so the greater and lesser tuberosities are visible. Ask patient to actively move into
external rotation. Statically and dynamically visualize the subscapularis tendon and its attachment onto the lesser
tuberosity.
LH Biceps
Subs
GT: greater tuberosity
Medial
Lateral
Superficial
LT: lesser tuberosity
LH Biceps: long head of biceps brachii
tendon
Subs: subscapularis tendon
GT
LT
Right shoulder
Depth: 2.7 cm
Subscapularis tendon, sagittal (short-axis) view
Probe placement: From the position used above, turn the transducer probe 90-degrees so it is vertical. Ask patient
to maintain slight external rotation. Visualize subscapularis muscle.
HH: humeral head
Inferior
Superior
Superficial
Subs
Subs: subscapularis tendon
HH
Right shoulder
Depth: 2.7 cm
Subscapularis tendon / Coracohumeral interval, transverse (long-axis) view
Probe placement: Place probe so the greater and lesser tuberosities are visible. Move probe medially to visualize
coracoid process. Ask patient to actively externally and internally rotate back to neutral. Dynamically and statically
visualize the subscapularis tendon as it passes under the coracoid process.
Medial
Lateral
Superficial
Subs
LT: lesser tuberosity
Subs: subscapularis tendon
Co: coracoid process
CorHum: coracohumeral interval
Co
LT
Co
um
rH
Right shoulder
Depth: 2.7 cm
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Arizona Osteopathic Medical Association
Annual Convention, April 2016
ANTERIOLATERAL SHOULDER
Structures to identify:
• Supraspinatus tendon, transverse and sagittal views
Patient positioning for identifying anteriolateral structures: Seated, hand is placed on the hip with
the elbow facing posterior.
Supraspinatus tendon, transverse (long-axis) view
Probe placement: Place probe on anterior supraspinatus, parallel to supraspinatus tendon fibers (slightly tilted from
vertical). Sweep probe superior and inferior to visualize anterior and posterior tendon fibers and their attachment
onto the superior aspect of the greater tuberosity.
GT: greater tuberosity
Superomedial
Inferolateral
Superficial
Supra
GT
Supra: supraspinatus tendon
Right shoulder
Depth: 2.7 cm
Supraspinatus tendon, sagittal (short-axis) view
Superficial
Delt
Supra
Inferomedial
Superolateral
Probe placement: Place probe vertical on anterior shoulder; rotate probe so that superior end is slightly more lateral
than the inferior end
HH: humeral head
Delt: deltoid
Supra: supraspinatus tendon
HH
Right shoulder
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Depth: 2.7 cm
Arizona Osteopathic Medical Association
Annual Convention, April 2016
POSTERIOR SHOULDER
Structures to identify:
• Infraspinatus tendon, transverse and sagittal views
• Posterior glenohumeral joint – humeral head, glenoid fossa, labrum, transverse view
Patient positioning for identifying posterior structures: Seated, elbow is flexed ~90-degrees,
forearm is supinated (palm up) resting on the thigh or table with shoulder slightly internally rotated.
Infraspinatus, transverse (long-axis) view
Probe placement: Place probe on posterior shoulder, just below scapular spine and lateral to view humeral head
and infraspinatus tendon. Statically and dynamically view infraspinatus tendon as patient performs internal and
external rotation.
Delt
Infra T
GT: greater tuberosity
Medial
Lateral
Superficial
Infra M
Delt: deltoid
InfraT: infraspinatus tendon
InfraM: infraspinatus muscle
GT
Right shoulder
Depth: 4.0 cm
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Arizona Osteopathic Medical Association
Annual Convention, April 2016
Infraspinatus, sagittal (short-axis) view
Probe placement: Place probe on posterior shoulder in vertical position, just below scapular spine and lateral to
view humeral head and infrapinatus tendon.
Inferior
Superior
Superficial
Delt
HH: humeral head
Delt: deltoid
InfraT: infraspinatus tendon
Infra T
HH
Right shoulder
Depth: 4.0 cm
Posterior glenohumeral joint / Glenoid labrum, sagittal (long-axis) view
Probe placement: Place probe on posterior shoulder in vertical position, just below scapular spine and lateral to
view humeral head and infrapinatus tendon. From this position, move the probe inferior and slightly medial to
visualize the humeral head (laterally) and glenoid fossa/labrum (medially).
HH: humeral head
Medial
Lateral
Superficial
Delt
Delt: deltoid
Infra: infraspinatus tendon
Labr: glenoid labrum
Infra
GL: glenoid of scapula
Labr
Right shoulder
HH
GL
Depth: 3.3 cm
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Arizona Osteopathic Medical Association
Annual Convention, April 2016
SUPERIOR SHOLDER
Structures to identify:
• Acromioclavicular joint, sagittal (long-axis) view
Patient positioning for identifying superior structures: Seated, elbow is flexed ~90-degrees, forearm
is supinated (palm up) resting on the thigh or table with shoulder slightly internally rotated.
Acromioclavicular joint, sagittal (long-axis) view
Probe placement: Place probe on superior shoulder parallel to the clavicle; move probe laterally to visualize distal
clavicle and acromion process. Statically and dynamically examine acromioclavicular joint by applying downward
pressing to the arm and/or clavicle.
Superficial
AC: acromion process
Medial
Lateral
ACJ
AC
ACJ: acromioclavicular joint
CL: clavicle
CL
Right shoulder
Depth: 2.7 cm
References
European Society of Musculoskeletal Radiology (ESSR). Musculoskeletal ultrasound: Technical guidelines. Insights
Imaging. 2010;1:99-141. DOI: 10.1007/s13244-010-0032-9.
Buford D. (2011, August 3). Dr. Don Buford Live 13 Point Shoulder Ultrasound Exam [video file]. Retrieved from:
https://www.youtube.com/watch?v=eglplbWaqxA
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