post-graduate certifcate musculoskeletal ultrasound - the shoulder

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  1. 1. Diagnostic Ultrasound of the Shoulder Dr. Peter Resteghini Consultant Physiotherapist Musculoskeletal Medicine Musculoskeletal Sonographer peter.resteghini@homerton.nhs.uk Course Director Postgraduate Certificate Musculoskeletal Ultrasound http://www.uel.ac.uk/study/courses/Musculoskeletal.htm
  2. 2. Why Ultrasound? A lack of ionising radiation (Grassi 2004). High spatial resolution, has multiplanar imaging capability and is considered patient friendly due to its ease of tolerance and non- invasiveness (Wakefield 1999, Backhaus 2001, Tan 2003, Grassi 2004). Scanning time is short (5-15 minutes for an experienced sonographer compared to approximately 40 minutes for an MRI Swen 2001) It provides not only anatomical information, but also informs on the physiological state of the joint, being particularly sensitive to inflammatory changes (Grassi 2003). Ultrasound is also unique in that scanning occurs in real-time making it possible to discuss reproduction of symptoms with the patient, and to view dynamic images of the structures under examination. ((Tan 2003, Grassi 2000, Ellis 2002, Shirtley 1999).
  3. 3. Guided Injection Ultrasound guided shoulder girdle injections are more accurate and more effective than landmark guided injections: a systematic review and meta-analysis (Aly, Rajasekaran, Ashworth 2014 ) Lack of aspirate from smaller joints such as the CMCJ of the thumb makes accurate needle placement in these joints also extremely difficult For this reason injections performed under imaging are becoming more popular (Balint 1997, Ghozlan and Vacher 2000, Koski 2000, Weidner et al 2004). Eustace (1997) demonstrated that even in the hands of musculoskeletal specialists only a minority of injections for shoulder pain are performed accurately (29% of subacromial and 42% of intra-articular injections), not surprisingly outcome significantly correlated with accuracy of injection. Similar results were found in patients with De Quervains tenosynovitis (Zhingis 1998). Leopold (2001) assessed the accuracy of needle placement with intra-articular injection using only anatomic landmarks as a guide. Using this blind approach the needle pierced or contacted the femoral nerve in 27% of anterior injections and was within 5mm of the femoral nerve in 60% of all anterior attempts. Using a lateral approach the needle was never within 25mm of any neurovascular structure in any injection however only 80% of injections managed to reach the joint cavity.
  4. 4. Ultrasound of the Shoulder Long head of biceps Rotator cuff Bursa ACJ GHJ Impingement
  5. 5. Long Head Biceps - Transverse
  6. 6. Longitudinal LHB
  7. 7. LHB - Proximal
  8. 8. LHB - Distal
  9. 9. LHB Tenosynovitis
  10. 10. Subluxed LHB
  11. 11. LHB - Injection
  12. 12. Subscapularis - Longitudinal
  13. 13. Medial COR SHB SUBSCAP
  14. 14. Subscapularis - Transverse
  15. 15. Sh thickened subcoracoid bursa with fluid and impingement.wmv
  16. 16. Supraspinatus Transverse at Rotator interval
  17. 17. Supraspinatus - Longitudinal
  18. 18. Ultrasound SST tears Full thickness tears: sensitivity 96-100% specificity 85% Partial thickness tears: sensitivity 93% specificity 94%
  19. 19. Ultrasound and MRI are comparable in both sensitivity and specificity (Joseph 2009) 98.6% sensitivity & 99.3% specificity full thickness tears 97.9% sensitivity & 94.4% specificity partial thickness tears (Al Shawi, Bunker 2005)
  20. 20. Supraspinatus complete rupture
  21. 21. Ruptures IST with associated posterior GHJ Effusion.wmv
  22. 22. SST Midsubstance full thickness tear
  23. 23. Trans Midsubstance tear
  24. 24. Impingement - Calcific SST & Subacromial bursa
  25. 25. Impingement SAB
  26. 26. Ultrasound guided shoulder girdle injections are more accurate and more effective than landmark guided injections: a systematic review and meta-analysis (Aly, Rajasekaran, Ashworth 2014 BJSM)
  27. 27. SAB - Injection
  28. 28. Coracoacromial Ligament
  29. 29. Infraspinatus
  30. 30. Infraspinatus - Longitudinal
  31. 31. Infraspinatus complete rupture
  32. 32. SCJ - Injection
  33. 33. Acromioclavicular joint
  34. 34. GH Joint - Injection
  35. 35. SN - Injection
  36. 36. Homerton University Hospital Department of Physiotherapy & Sports Medicine Dr. Peter Resteghini Consultant Physiotherapist Musculoskeletal Medicine Musculoskeletal Sonographer peter.resteghini@homerton.nhs.uk Course Director Postgraduate Certificate Musculoskeletal Ultrasound http://www.uel.ac.uk/study/courses/Musculoskeletal.htm

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