Role of Ultrasound in Clinical Evaluation of Shoulder Pain

DR. MUHAMMAD BIN ZULFIQARSIMS & SERVICES HOSPITAL LAHORE

INTRODUCTION

• Shoulder Is one of the most sophisticated and complicated joint of the body with great range of movements.

• A series of complex ligaments and muscles help in stability.

• Different pathologies especially related to rotator cuff are encountered in patients presenting with shoulder pain.

INTRODUCTION

• By assessing shoulder pain we ascertain integrity of

rotator cuff and extent of tear ,if any, in order to give

a plan to orthopedic surgeon for appropriate

treatment and further management.

• Shoulder ultrasound gives diagnostic sensitivities and

specificities in excess of 90%.

Learning Objectives

• Implications of the morphologic features and extent of rotator cuff tears for glenohumeral joint mechanics, treatment, and prognosis.

• Identify injuries to adjacent structures that may accompany rotator cuff tears and discuss their implications for treatment and prognosis.

• Describe the value of imaging and evaluating the rotator cuff muscles.

Learning Objectives

• Distinguish between the potential contributing factors to impingement syndrome.

• Determine if surgery is contraindicated.

• Radiologist must:(a) identify and evaluate cuff lesions that may compromise

glenohumeral joint function, taking into account functional anatomy.

(b) recognize imaging findings that decrease

the likelihood of favorable functional anatomic outcome after cuff repair.

(c) identify and describe imaging findings that will assist in selecting a repair technique.

Learning Objectives

• Tear dimensions, tear depth or thickness, tendon retraction, and tear shape.

• Tear extension to adjacent structures, muscle atrophy, size of muscle cross-sectional area, and fatty degeneration.

• Information about the coracoacromial arch and impingement.

ANATOMY

ANATOMY

Joints (shoulder complex)

Glenoid labrum• Fibrocartilage similar to knee menisci

• Deepens the glenoid fossa

Bursae

Sonographic Anatomy of Shoulder

Step 1 - Biceps brachii tendon, long head

Step 2 - Subscapularis and biceps brachii tendon

Step 3 - Supraspinatus and rotator interval

Step 4 - Acromioclavicular joint, subacromial-

subdeltoid bursa,

Step 5 - Infraspinatus, teres minor, and posterior

labrum

Step 1 - Biceps brachii tendon, long head

Sonographic Anatomy

Sonographic Anatomy

• Step 2 - Subscapularis

Step 2 - Subscapularis

Sonographic Anatomy

• Step 3 - Supraspinatus

Step 3 - Supraspinatus

Step 4 - Acromioclavicular joint

Dynamic evaluation for subacromial impingement

• Step 5 - Infraspinatus, teres minor, and posterior labrum

Sonographic Anatomy

Pathologies

• Rotator Cuff

• Biceps tendon

• Labrum and capsule

• Osseous structures

• Arthritis

• Neural impingement

• Tumors

Rotator Cuff

• Tendinopathy

• Partial tears

• Full thickness tears

• Calcific tendinitis

Rotator cuff tendinopathy

Also known as -

• Rotator cuff tendinosis

• Definition – collagenous degeneration of rotator cuff tendons, most commonly supraspinatus (SST)

Tendinopathy

Mucinousdegeneration (Microscopic tears in critical zone area)

• Intra substance in location delamination

• Begins at early 30 years

• Often asymptomatic

• At 60 tendon ruptures 60%

Rotator cuff tendinopathy

• Thickened hypoechoic

• Tears directly visible

• Less sensitive for partial thickness tears

• Advantage – allows dynamic evaluation with pain correlation

Rotator cuff tendinopathy

• Supraspinatus “tendinitis”. There is focal hypoechoic swelling of the more superficial fibers of supraspinatus insertion

Rotator cuff tendinopathy

• Static imaging of the supraspinatus tendon show features of “tendinitis” which included tenderness, hypoechoic thickening of the insertional fibers (arrowheads)

Rotator cuff tears• Clinical –

– Trauma (acute / chronic micro-trauma)

– Adults > 4o with impingement

– Collagen vascular diseases

– Partial more painful than complete tears !!!!

TYPES -

• Partial –– supraspinatus most common

– Types – bursal surface

interstitial (not seen on arthroscopy)

articular surface

• Complete –– supraspinatus most common

– Extends from bursal to articular surface

Dimensions of a Full-Thickness Tear

• small (1 cm),

• medium (1–3 cm),

• large (3–5 cm),

• massive (5 cm)

The dimensions of rotator cuff tears may have implications for selection of treatment and surgical approach, postoperative prognosis, and tear recurrence

Partial tear

• Decreased echogenicity and thinning in affected region

• Loss of convexity of tendon / bursae interface in bursal surface tears

• Calcific foci in tendons

Partial tear

• Rt. image shows bursal surface tear

• Lt. image shows full thickness partial tear

Partial tear

Supraspinatus: Full thickness partial tear Supraspinatus: intrasubstance and bursal surface tearing

Partial tear

Supraspinatus: Partial thickness tear, transverse is posterior tear

Supraspinatus: Partial thickness tear, transverse is anterior tear

Partial undersurface tear of the rotator cuff

Partial Tear

Supraspinatus tear with associated bursal fluid

Complete Tear

• Focal tendon interruption

• Fluid filed gap (hypoechoic)

• Loss of convexity of tendon / bursa interface

• Tendon retraction

• Uncovered cartilage sign

Complete Tear

Complete Tear

• Full thickness tear of the distal aspect of the Supraspinatus tendon ( ) with retraction and effusion of the subacromial bursae ( ). The humeral head cartilage is laid bare ( ). There is also fluid in the Long Biceps sheath ().

Subscapularis tendon rupture

Rotator interval tears

• What is rotator interval ??

– Tunnel through which long head of biceps travelsfrom its origin at the supraglenoid tubercle

• Rotator interval tears – tears in the capsulebetween the supraspinatus and subscapularistendons

• Can be classified as subtype of RTC tears

Normal rotator interval

Internal impingement

• Definition - Degeneration and tearing of posterior SSTand anterior infraspinatus tendons (undersurface /articular surface) due to impingement by postero-superior labrum and humeral head

• Postero-superior glenoid impingement (PSGI)

• Overhead throwing activities – athletes (throwers)

• Dynamic compression – occurs during abduction (> 120degrees), retropulsion and extreme external rotation(ABER)

Rotator cuff calcific tendinitis

Rotator cuff calcific tendinitis

• Calcium Hydroxyapatite deposition disease (HADD)• Calcifying bursitis

• Not typical Ca++ of degenerative disease of tendons, but crystallineCa++

• Pathology – deposition of Calcium Hydroxyapatite in RTC tendons

• Etiology – Avascular change, trauma, abnormal Ca++ metabolism

• Housewives and clerical workers more affected

• Location – SST > IST > TM > SSC

• Peri-articular soft tissues like capsule, bursae may be involved

Rotator cuff calcific tendinitis

Longitudinal image

Rotator cuff calcific tendinitis

Transverse Image

Rotator cuff calcific tendinitis

Calcific tendinitis penetration of the cortex of the greater tubercle

Tendon Tear Vs. Tendinosis

Tear

• Anechoic

• Well defined

• Homogeneous

• Thin

• Bone Irregularity

Tendinosis

• Hypoechoic

• Ill defined

• Heterogenous

• Swollen

• Smooth Cortex

Biceps tendon pathologies

Tendinosis

Tendinosis• Degeneration of long head of biceps

• Long head of biceps –– LHBT originates at supra glenoid tubercle– Passes through the antero-superior joint– Enters the humeral bicipital groove

• Chronic micro-trauma• Acute trauma (rare cause)• Accompanies RTC disease (especially impingement)• Common with subacromial impingement (30-60%

association)• Biceps tenosynovitis may accompany

USG

– Thickened hypoechoic tendon

– Tears often directly visible

– Allows dynamic evaluation

Biceps tendon tear

Biceps tendon tear

• Tendinosis predisposes

• Associated with SST tear

• Distal tendon edge may retract into upper arm(popaye sign)

Biceps tendon tear

Biceps tendon tear

Popeye Sign

Subacromial-Subdeltoid Bursa

THANK YOU