Ultrasound of the Shoulder · 2019-01-25 · •Hanusch et al. Biceps sheath fluid on shoulder...

Ultrasound of the ShoulderPatrick Battaglia, DC, DACBR

Logan University, Department of Radiology

Outline

• Review ultrasound appearance of NMSK tissues

• Present indications for ultrasound of the shoulder.

• Present an introductory shoulder protocol.

Ultrasound appearance of neuromusculoskeletal tissues

ANATOMY

• Muscle

• Tendon

• Ligament

• Nerve

• Bone

SKELETAL MUSCLE

SHORT-AXIS

LONG-AXIS

Radiographics. 2018 Jan-Feb;38(1):124-148

SKELETAL MUSCLE – FULL THICKNESS TEAR

SKELETAL MUSCLE – NORMAL MUSCLE

TENDON/LIGAMENT

SHORT-AXIS

LONG-AXIS

Acta Biomater. 2017 Nov;63:18-36.

TENDON/LIGAMENT – FULL THICKNESS TEAR

TENDON/LIGAMENT – TENDINOSIS

PERIPHERAL NERVE

SHORT-AXIS

LONG-AXIS

June 2016 Expert Review of Medical Devices 13(8)

PERIPHERAL NERVE – ENTRAPMENT NEUROPATHY

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

BONE – ACUTE FRACTURE

BONE – HEALING FRACTURE WITH CALLUS

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

Limitations of shoulder ultrasound

• Bone evaluation (including cartilage and marrow)

• Glenoid labrum evaluation*

• Adhesive capsulitis*

• Thoracic outlet syndrome*

* Limited evidence – emerging applications

Introductory shoulder protocol

*All anatomy plates, unless otherwise noted, are attributed to:

e-Anatomy, Micheau A, Hoa D, imaios.com

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

CROSS-SECTIONAL ANATOMY

http://www.freitasrad.net/pages/atlas/Shoulder/Shoulder.html

BICEPS TENDON SHORT AXIS AT INTERTUBERCULAR GROOVE

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

Long head biceps tendinosis

http://ultrasoundcases.info

Normal

Long head biceps tendon rupture

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.

SUBSCAPULARIS TENDON LONG AXIS

SUBSCAPULARIS TENDON SHORT AXIS

Subscapularis Tendon Pathology

• Tendinosis

• Tear• Allows LHBT subluxation/dislocation)

Subscapularis tendinosis

Normalhttp://ultrasoundcases.info

Subscapularis tear

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

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

Rotator interval - pathology

• Long head of the biceps tendon pathology• Tear

• Dislocation

• Supraspinatus and subscapularis pathology

• Joint capsule and related pathology• Effusion

• Capsulitis

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

DELTOID MUSCLE

HUMERUS

POSTERIOR ROTATOR CUFF – LONG AXIS IMAGE(S) – FOOTPRINT APPEARANCE

POSTERIOR ROTATOR CUFF – SHORT AXIS IMAGE(S)

DELTOID MUSCLE

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

• 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

• 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

Full thickness v. massive tear

NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)

Full thickness v. massive tear

NORMAL FULL THICKNESS MASSIVE (THICKNESS + WIDTH)

POSTERIOR ROTATOR CUFF – TENDINOSIS

POSTERIOR ROTATOR CUFF – CALCIFIC TENDINITIS

POSTERIOR ROTATOR CUFF – ENTHESOPATHY

POSTERIOR ROTATOR CUFF – PARTIAL THICKNESS TEAR

POSTERIOR ROTATOR CUFF – FULL THICKNESS TEAR

POSTERIOR ROTATOR CUFF – MASSIVE TEAR

POSTERIOR GLENOHUMERAL JOINT

POSTERIOR GLENOHUMERAL JOINT – DYNAMIC EVALUATION

POSTERIOR GLENOHUMERAL JOINT – POSTERIOR LABRAL TEAR AND PARALABRAL CYST

NORMAL

POSTERIOR LABRAL TEAR WITH PARALABRAL CYST

SUPRASPINATUS MUSCLE – SHORT AXIS

Supraspinatus

Body of scapula

SUPRASPINATUS MUSCLE – LONG AXIS

Scapula

Supraspinatus

Trapezius

INFRASPINATUS MUSCLE – SHORT AXIS

INFRASPINATUS MUSCLE – LONG AXIS

MUSCLE ATROPHY

NORMAL

References and recommended reading

• Jacobson JA. Fundamentals of Musculoskeletal Ultrasound, 3rd ed. Chapter 3 “Shoulder Ultrasound”.

Thank you!

Questions, comments, concerns:

patrick.battaglia@logan.edu

Ultrasound of the Shoulder · 2019-01-25 · •Hanusch et al. Biceps sheath fluid on shoulder...

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