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Ultrasound of the ShoulderPatrick Battaglia, DC, DACBR
Logan University, Department of Radiology
© 2018 Logan University, Department of Radiology
Outline
• Review ultrasound appearance of NMSK tissues
• Present indications for ultrasound of the shoulder.
• Present an introductory shoulder protocol.
© 2018 Logan University, Department of Radiology
Ultrasound appearance of neuromusculoskeletal tissues
ANATOMY
• Muscle
• Tendon
• Ligament
• Nerve
• Bone
© 2018 Logan University, Department of Radiology
SKELETAL MUSCLE
SHORT-AXIS
LONG-AXIS
Radiographics. 2018 Jan-Feb;38(1):124-148
© 2018 Logan University, Department of Radiology
SKELETAL MUSCLE – FULL THICKNESS TEAR
SKELETAL MUSCLE – NORMAL MUSCLE
© 2018 Logan University, Department of Radiology
TENDON/LIGAMENT
SHORT-AXIS
LONG-AXIS
Acta Biomater. 2017 Nov;63:18-36.
© 2018 Logan University, Department of Radiology
TENDON/LIGAMENT – FULL THICKNESS TEAR
© 2018 Logan University, Department of Radiology
TENDON/LIGAMENT – TENDINOSIS
© 2018 Logan University, Department of Radiology
PERIPHERAL NERVE
SHORT-AXIS
LONG-AXIS
June 2016 Expert Review of Medical Devices 13(8)
© 2018 Logan University, Department of Radiology
PERIPHERAL NERVE – ENTRAPMENT NEUROPATHY
© 2018 Logan University, Department of Radiology
BONE
SHORT-AXIS
LONG-AXIS
By SEER - U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program (http://training.seer.cancer.gov/index.html)Exact adress, Public Domain, https://commons.wikimedia.org/w/index.php?curid=378948
© 2018 Logan University, Department of Radiology
BONE – ACUTE FRACTURE
© 2018 Logan University, Department of Radiology
BONE – HEALING FRACTURE WITH CALLUS
© 2018 Logan University, Department of Radiology
Ultrasound of the shoulder
Indications for shoulder ultrasound
• Bursitis
• Rotator cuff and long head of the biceps tendinopathy and tear
• Postoperative cuff failure
• Pectoral muscle tears
• Acromioclavicular joint osteoarthritis, trauma, and instability
• Suprascapular nerve entrapment
Sconfienza et al. Eur Radiol. 2018 Jun 6. [Epub ahead of print] © 2018 Logan University, Department of Radiology
Limitations of shoulder ultrasound
• Bone evaluation (including cartilage and marrow)
• Glenoid labrum evaluation*
• Adhesive capsulitis*
• Thoracic outlet syndrome*
* Limited evidence – emerging applications
Sconfienza et al. Eur Radiol. 2018 Jun 6. [Epub ahead of print] © 2018 Logan University, Department of Radiology
Introductory shoulder protocol
*All anatomy plates, unless otherwise noted, are attributed to:
e-Anatomy, Micheau A, Hoa D, imaios.com
© 2018 Logan University, Department of Radiology
Introductory shoulder protocol
• Biceps tendon short and long axis
• Subscapularis tendon long and short axis
• Subacromial space and bursa
• Rotator interval
• Posterior rotator cuff (supra- and infraspinatus, teres minor tendons) – long and short axis
• Posterior glenohumeral joint
• Supraspinatus muscle
• Infraspinatus muscle
© 2018 Logan University, Department of Radiology
CROSS-SECTIONAL ANATOMY
http://www.freitasrad.net/pages/atlas/Shoulder/Shoulder.html
© 2018 Logan University, Department of Radiology
© 2018 Logan University, Department of Radiology
BICEPS TENDON SHORT AXIS AT INTERTUBERCULAR GROOVE
© 2018 Logan University, Department of Radiology
BICEPS TENDON SHORT AXIS AT INTERTUBERCULAR GROOVE
© 2018 Logan University, Department of Radiology
BICEPS TENDON LONG AXIS AT INTERTUBERCULAR GROOVE
Long head biceps tendon pathology
• LHBT tendinosis/ tenosynovitis
• LHBT rupture
• LHBT subluxation/dislocation
• Fluid in the tendon sheath
© 2018 Logan University, Department of Radiology
Long head biceps tendinosis
http://ultrasoundcases.info
© 2018 Logan University, Department of Radiology
Normal
Long head biceps tendon rupture
© 2018 Logan University, Department of Radiology
Long head biceps tendon pathology• Fluid in the tendon sheath of the LHBT
• Fluid in the LHBT tendon sheath on ultrasound is highly predictive of rotator cuff tears or LHBT pathology• Hanusch et al. Biceps sheath fluid on shoulder ultrasound as a predictor of rotator cuff
tear: analysis of a consecutive cohort. J Shoulder Elbow Surg. 2016 Oct;25(10):1661-7.
© 2018 Logan University, Department of Radiology
© 2018 Logan University, Department of Radiology
SUBSCAPULARIS TENDON LONG AXIS
© 2018 Logan University, Department of Radiology
SUBSCAPULARIS TENDON LONG AXIS
© 2018 Logan University, Department of Radiology
SUBSCAPULARIS TENDON SHORT AXIS
© 2018 Logan University, Department of Radiology
SUBSCAPULARIS TENDON SHORT AXIS
Subscapularis Tendon Pathology
• Tendinosis
• Tear• Allows LHBT subluxation/dislocation)
© 2018 Logan University, Department of Radiology
Subscapularis tendinosis
© 2018 Logan University, Department of Radiology
Normalhttp://ultrasoundcases.info
Subscapularis tear
© 2018 Logan University, Department of Radiology
Subscapularis tear
© 2018 Logan University, Department of Radiology
SUBACROMIAL SPACE AND BURSA
SUBACROMIAL SPACE AND BURSA
HUMERUS
ACROMION
ROTATOR CUFF
Bursal complex:• Peribursal fat (yellow)• Fluid (purple)
Subacromial impingement
• At ultrasound, failure of humeral depression may be seen, but is subjective
• Ultrasound signs of impingement:• Rotator cuff thickening
• Bursal sided tearing
• Subacromial/subdeltoid bursitis or thickening (normal bursa ≤ 2 mm)
• Accumulation of bursal fluid with abduction or flexion more reliable ultrasound signs
© 2018 Logan University, Department of Radiology
SUBACROMIAL IMPINGEMENT
© 2018 Logan University, Department of Radiology
SUBACROMIAL IMPINGEMENT
SUBACROMIAL IMPINGEMENT
• Correlate (passive external rotation)
• Look for a normal rotator cuff
• See: Ryu et al. J Ultrasound Med. 1993 Aug;12(8):445-9.
DIFFERENTIAL DIAGNOSIS – ADHESIVE CAPSULITIS
ROTATOR INTERVAL
Ultrasound Int Open. 2017 Jun;3(3):E107-E116.
ROTATOR INTERVAL
HUMERUS
SSTSCT
BT
Rotator interval - pathology
• Long head of the biceps tendon pathology• Tear
• Dislocation
• Supraspinatus and subscapularis pathology
• Joint capsule and related pathology• Effusion
• Capsulitis
© 2018 Logan University, Department of RadiologyUltrasound Int Open. 2017 Jun;3(3):E107-E116.
ACUTE BICEPS LONG HEAD TENDON TEAR
ADHESIVE CAPSULITIS
http://ultrasoundcases.info/Slide-View.aspx?cat=331&case=4110
NORMAL
POSTERIOR ROTATOR CUFF
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S) – CRASS POSITION
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S) – MODIFIED CRASS POSITION
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S) – CRASS V. MODIFIED CRASS POSITIONS
CRASS V. MODIFIED CRASS POSITIONS
• Ferri M 2005:• Modified Crass position may over-estimate size of rotator cuff tear in long-axis
• No difference in short-axis
• Shah NP 2012:• No difference between Crass, modified Crass, and neutral positions for
diagnosing posterior rotator cuff pathology
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S)
DELTOID MUSCLE
HUMERUS
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S)
DELTOID MUSCLE
HUMERUS
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S) – FOOTPRINT APPEARANCE
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S)
POSTERIOR ROTATOR CUFF – SHORT AXIS IMAGE(S)
DELTOID MUSCLE
BT
HUMERUS
Posterior rotator cuff - pathology
• Continuum: tendinosis (± enthesopathy, calcific tendinitis), partial tear, full-thickness tear, massive tear
• Tendinosis (Bretzke CA 1985, Crass JR 1988) :• Consider when > 6 mm
• Measured 1 cm proximal to insertion
• May be larger in athletes
• Contralateral comparison very helpful
© 2018 Logan University, Department of Radiology
Posterior rotator cuff - pathology
• Partial tear:• Articular sided
• Bursal sided
• Intrasubstance
• Ultrasound features (van Holsbeeck)• Hypoechoic or anechoic region, heterogeneous
• Irregular margin
• Focal thinning (i.e. loss of convex bursal contour)
• Bony irregularity
• Bursal fluid or fluid around biceps tendon
© 2018 Logan University, Department of Radiology
Posterior rotator cuff - pathology
• Ultrasound has 93% sensitivity and 94% specificity to diagnosis a full thickness rotator cuff tear (de Jesus JO, AJR Am J Roentgenol. 2009 Jun;192(6):1701-7.)
• Primary signs of full thickness tear: tendon absence (naked tuberosity), anechoic defect spanning bursal to articular surface, marked contour abnormality of the bursa/deltoid (van Holsbeeck)
• Secondary signs of full thickness tear: greater tubercle irregularity, effusion around biceps tendon, subdeltoid bursal fluid, cartilage interface sign
© 2018 Logan University, Department of Radiology
Full thickness v. massive tear
© 2018 Logan University, Department of Radiology
NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)
Full thickness v. massive tear
© 2018 Logan University, Department of Radiology
NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)
POSTERIOR ROTATOR CUFF – TENDINOSIS
POSTERIOR ROTATOR CUFF – CALCIFIC TENDINITIS
POSTERIOR ROTATOR CUFF – CALCIFIC TENDINITIS
POSTERIOR ROTATOR CUFF – ENTHESOPATHY
POSTERIOR ROTATOR CUFF – PARTIAL THICKNESS TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – PARTIAL THICKNESS TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – FULL THICKNESS TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – FULL THICKNESS TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – MASSIVE TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR ROTATOR CUFF – MASSIVE TEAR
© 2018 Logan University, Department of Radiology
POSTERIOR GLENOHUMERAL JOINT
© 2018 Logan University, Department of Radiology
POSTERIOR GLENOHUMERAL JOINT – DYNAMIC EVALUATION
© 2018 Logan University, Department of Radiology
POSTERIOR GLENOHUMERAL JOINT – POSTERIOR LABRAL TEAR AND PARALABRAL CYST
NORMAL
POSTERIOR LABRAL TEAR WITH PARALABRAL CYST
© 2018 Logan University, Department of Radiology
© 2018 Logan University, Department of Radiology
SUPRASPINATUS MUSCLE – SHORT AXIS
Supraspinatus
Body of scapula
© 2018 Logan University, Department of Radiology
SUPRASPINATUS MUSCLE – LONG AXIS
Scapula
Supraspinatus
Trapezius
© 2018 Logan University, Department of Radiology
INFRASPINATUS MUSCLE – SHORT AXIS
© 2018 Logan University, Department of Radiology
INFRASPINATUS MUSCLE – LONG AXIS
© 2018 Logan University, Department of Radiology
MUSCLE ATROPHY
NORMAL
References and recommended reading
• Jacobson JA. Fundamentals of Musculoskeletal Ultrasound, 3rd ed. Chapter 3 “Shoulder Ultrasound”.
© 2018 Logan University, Department of Radiology