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Patrick R Meyers, BS, RDMS, RVT, RDCS Musculoskeletal Ultrasound of SE Wisconsin, LLC the shoulder what’s included • palpable landmarks • anterior, anteriolateral, superior & posterior views • anatomic relationships • dynamic maneuvers • patient positions • bone landmarks • ipsilateral to contralateral comparisons • manual techniques to adjust for anisotropy anatomic structures • Biceps Tendon (BT) and muscle • Subscapularis Tendon (SCT) and muscle • Supraspinatus Tendon (SST) and muscle • Acromio-Clavciular Joint (AC Joint) • Infraspinatus Tendon (IST) and muscle • Posterior Labrum (Lab) • Spinoglenoid groove or notch • Superior Labrum (optional) anatomic structures – insonation angles anterior anatomic structures Biceps Tendon • attached to the supraglenoid tubercle • lies between the greater and lesser tuberosity of the humeral head • covered by transverse humeral ligament at tuberosities Sonography • tendon is evaluate in SAX & LAX • follow biceps tendon from the intracapsular segment through the insertion of the pectoralis on humerus • clip in SAX from intracapsular segment through pectoralis insertion • clip from medial to lesser tuberosity through bicipital groove through greater tuberosity sonography – biceps tendon Technique • elbow bent 900 arm rests on thigh • palm up • may use some internal or external rotation depending on patient • stills of LAX with clip • stills in SAX with clip • LAX sweep from groove to M/T junction • use power Doppler hypoechoic areas sonography – biceps tendon Technique • elbow bent 900 arm rests on thigh • palm up • LAX sweep from medial to lesser tuberosity to lateral to the greater tuberosity • LAX sweep from intracapsular segment to MT junction • SAX sweep from intracapsular segment to insertion of the pectoralis muscle anatomic structures - subscapularis tendon Subscapularis Tendon/Muscle • tendon insertion on lesser tuberosity of humerus and anterior scapula proximally • bone landmarks lesser tuberosity and coracoid process of scapula Sonography • tendon is evaluate in SAX & LAX • dynamic maneuver with elbow tucked and arm externally rotated • evaluate tendon, bursa and lesser tuberosity slip • SAX of tendon from coracoid to tendon insertion on lesser tuberosity • LAX superior to inferior sonography – subscapularis tendon Subscapularis tendon and muscle • tendon insertion on lesser tuberosity of humerus and anterior scapula proximally • bone landmarks lesser tuberosity and coracoid process of scapula Technique • tendon is evaluate in LAX • superior, middle and inferior segment • note any loss of mass between segments sonography – subscapularis tendon Technique • tendon is evaluate in SAX with arm externally rotated • stills from coracoid process to tendon insertion on the lesser tuberosity • make note of fluid collections or loss tendon segment bulk sonography - subscapularis Technique • externally rotate arm with elbow tucked • stills evaluating superior, mid and inferior sections • capture clip of arm in FULL internal and external rotations anatomic structures – Acromio-Clavciular joint Anatomy • lateral end of the clavicle and acromion process of scapula • cart ligneous intra articular disk • joint is wider anteriorly then posteriorly sonography – Acromio-Clavciular (AC) joint Sonography • LAX only • evaluated in neutral and internal rotation • if instability is suspected dynamic maneuver bilaterally • ipsilateral to contralateral comparison in neutral position is routine Sonography – internal rotation AC joint Sonography • AC joint space closes • slight superior bulging of capsule • no fluid “fountain” should appear • minimal caudal/cephalid translation Sonography – internal rotation AC joint Sonography • AC joint space closes • slight superior bulging of capsule • no fluid “fountain” should appear • minimal caudal/cephalid translation Sonography – internal rotation AC joint Sonography • AC joint space closes • slight superior bulging of capsule • no fluid “fountain” should appear • minimal caudal/cephalid translation anatomic structures -supraspinatus Supraspinatus Tendon/Muscle • muscle arises from the supraspinatus fossa of the scapula • passes beneath the acromion and attaches to the greater tuberosity of the humerus • slides beneath the subdeltoid subacromial bursa (SDSA) • responsible for abduction of the arm Crass Sonography Crass Modified Crass Middleton • tendon is evaluate in SAX & LAX • two positions Crass and modified Crass or Middleton •SAX & LAX of tendon and muscle sweeps from M/T junction through insertion point in both Crass and Middleton position • superior margin is the coracoacromial ligament sonography – supraspinatus SAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! sonography – supraspinatus LAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! modifications to Crass position Technique • patients with rotator cuff disease have trouble with Crass position • minimal position is to get arm with dorsal hand resting on lower back sonography – supraspinatus LAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! sonography – supraspinatus LAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! modified Crass SAX - advantage Technique • SAX rotator cuff interval • occasionally helps visualize cuff more completely • routinely completed in adjunct with Crass • MUST FOR PATHOLOGY DETERMINATION! supraspinatus – tendon insertion Tendon fiber insert perpendicular to bone • enthesis – insertion of tendon into bone • do not mistake for articular cartilage or tear • surface is smooth and non-articular supraspinatus – deltoid shelf common area for fluid to collect in the subdeltoid (yellows arrows) • MUST be included in any LAX view of supraspinatus • • supraspinatus – deltoid shelf supraspinatus insertion ends at the greater tuberosity (yellows arrows) • any anatomy beyond this point is likely the subdeltoid-subacromial bursa (SDSA) • • sonography – supraspinatus LAX Humeral head Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! Anatomic neck Greater tuberosity SONOGRAPHY – SUBACROMIAL IMPINGEMENT SUPRASPINATUS Sonography • transducer LAX over acromion • arm abducted 30 degrees with thumb down • arm raised and lowered – assist if necessary anatomic structures - infraspinatus infraspinatus Tendon/Muscle • muscle arises from the infraspinatus fossa of the scapula • attaches to the greater tuberosity of the humerus laterally • slides beneath the subdeltoid subacromial bursa (SDSA) • primary external rotator of shoulder. Sonography • tendon is evaluate in LAX unless directed • LAX sweep • Note is made of atrophy in cases of suspected neurologic deficit sonography – infraspinatus LAX Technique • LAX only • patient is asked to put their arm in a “sling” • external rotation until tendon covers glenohumeral joint posteriorly • cine clips only if normal sonography – posterior glenoid labrum Technique • transducer slides slightly inferior and medial to the infraspinatus tendon. • palm up and the arm is moved from full adduction in 90degree external rotation • clip of humeral head slip over labrum • observe humeral head slip and relationship to glenoid labrum anatomic structures – posterior glenoid labrum Posterior glenoid labrum • fibrous attachment of the glenohumeral ligaments and capsule to the glenoid rim • majority of labrum not readily accessible by ultrasound (primary MRI) • posterior labrum imaged with shoulder • primary external rotator of shoulder. Sonography • tendon is evaluate in LAX unless directed • LAX sweep • Note is made of atrophy in cases of suspected neurologic deficit anatomic structures – spinoglenoid groove Posterior spinoglenoid groove/notch • contains suprascapular nerve, artery and vein • common site for fluid collection or paralabral cyst following posterior labrum tear Sonography • groove is evaluated in LAX unless directed • suprascapular vein may dilate with internal rotation sonography – spinoglenoid notch/groove Technique • transducer slides slightly medial and is turned clockwise 15 degrees from posterior labrum view • palm up and the arm is moved in slight external rotation • observe dilation of vein • observe humeral head slip and relationship to glenoid labrum MAJOR CRITERIA Absent cuff Cuff atrophy Hypoechoic defect Focal hyperechoic defect MINOR CRITERIA Abnormal fluid Naked tuberosity Cartilage interface Deltoid herniation ROTATOR CUFF PATHOLOGY MAJOR CRITERIA LAX SUPRASPINATUS – ATROPHY LAX LAX SAX SUPRASPINATUS – CUFF ABSENCE LAX SAX SUPRASPINATUS – HYPOECHOIC DEFECT LAX SAX SUPRASPINATUS – HYPERECHOIC DEFECT MINOR CRITERIA ABNORMAL FLUID COLLECTION SASD fluid collection ABNORMAL FLUID COLLECTION SASD fluid collection ABNORMAL FLUID COLLECTION SAX LAX Fluid around the long biceps tendon ABNORMAL FLUID COLLECTION – POSTERIOR LAX LAX Normal Abnormal Glenohumeral joint effusion DELTOID “HERNIATION” SIGN LAX Deltoid “herniates” fills void left by torn tendon SAX HYALINE CARTILAGE INTERFACE SIGN LAX SAX Highlighting of cartilage due sound transmission through fluid MAJOR CRITERIA 99% sensitive & accurate Easiest to observe NOT majority of studies MINOR CRITERIA 1 finding ~ 50% 2 > 90% Needs careful evaluation Majority of studies ROTATOR CUFF PATHOLOGY - CONCLUSION YOU MAKE THE CALL Seriously hope you were paying attention…………………………audience participation CASE#1 CASE#2 Biceps tendon biceps tendon SDSA bursa Thank you….! Recognized for their contributions: J. Anthony Bouffard , MD Marnix T. van Holsbeeck, MD Anders Elvin, MD Questions?
