ROTATOR CUFF ULTRASOUND;A CASE AND TECHNICAL CONSIDERATIONS(RADIOLOGIC SOCIETY OF PAKISTAN)

Adnan Rashid, MDDepartment of Diagnostic Radiology,SIMS & SERVICES HOSPITAL, LAHORE

Case!

34 years old male was referred to our Ultrasound service for evaluation of “Left” shoulder pain and abduction weakness.

Pain started 3 months back after shoulder trauma (falling from bike on to his “Left” shoulder).

Radiographs acquired after trauma were normal.

D/D:

Joint disease (post traumatic)

Rotator cuff injury Supra-spinatous injury

(most common)

Methods/options to evaluate:Ultrasound of the shoulder: High-

resolution linear transducer (5 to 13 MHz)MRI: Coronal plane T1, T2, Fatsuppressed

(STIR or PDFS) Axial - T1, fatsuppressed Sagittal - T2 and fat suppressed.

MR- Arthrography:

Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: A Meta-Analysis(65 articles..2009)

MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears.

Ultrasound and MRI are comparable in both sensitivity and specificity.

Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean Leblond2, François Desmeules3,4,Clermont E Dionne1,5, Joy C MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a meta-analysis(82 articles…2015)

Centre interdisciplinaire de recherche en réadaptation et en intégration sociale (CIRRIS), 525, boulevard Wilfrid-Hamel, local H-1710, Quebec, Canada G1M 2S8

Diagnostic accuracy of imaging modalities for

Full-thickness RC tears

Similar performance of the three imaging modalities for overall estimates of

Sn (0.90 to 0.91) Sp (0.93 to 0.95)

Diagnostic accuracy of imaging modalities for

Partial thickness RC tearSensitivity: US and MRI were similar (0.68 and 0.67

respec) MRA has higher (Sn 0.83).

Specificity: the three imaging modalities

performed equivalently (0.93–0.94).

Why shoulder Ultrasound?? Sensitivities and specificities in excess of

90%. Easily available & Cost effective Focused use in clinics, operating room, &

at point of injury………Quicker diagnosis No radiation Useful in pts with Metallic prosthesis Dynamic &Interactive evaluation Allows therapeutic interventions as well

Pit-fall; Highly operator dependant; Requires

skill to ellucidate and identify a specific tendon.

Due to Parallelism of collagen fibers within the cuff; the echogenicity of the tendon depends on the angle of the transducer. Tendon may appear hypo-echoic (torn/absent) when the angle of the beam is not perpendicular (Anisotropy)

Technique of Shoulder Sonography

The rotator cuff anatomy Supraspinatus Fails first >40 Years Most commonly injured

Subscapularis

Infraspinatus

Teres minor (rarely affected)

Sonographic Anatomy

Steps in Shoulder Sonography

Step 1 - Biceps brachii tendon, long head Step 2 - Subscapularis and biceps brachii

tendon Step 3 - Acromioclavicular joint Step 4 - Supraspinatus and rotator interval, Subacromial-subdeltoid bursa, Step 5 - Infraspinatus, teres minor & post-

labrum

Biceps brachiiStep 1

Arm and forearm on the patient’s thigh

Step 1a – Transverse Biceps brachii(long head)

Step 1 - Biceps brachii(long head)

SubscapularisStep 2

Step 2a – Subscapularis Long axis)

Step 2 - Subscapularis

Step 2b – Short axis/ Transverse

Acromioclavicular jointStep 3

SupraspinatusStep 4

extension &internal rotation

Step 4a:Supraspinatus(Transverse)

Transducer is placed between the anterior acromion and the coracoid & swept from the edge of the acromion down to the level of the lateral greater tuberosity.

Step 4 b – Supraspinatus(Long axis)

transducer is placed perpendicular to the curvature of the acromial process ; Translate the probe anterior to posterior 2.5 cm lateral to long Biceps tendon.

Infraspinatus, posterior labrum and Teres Minor

Step 5

Step 5 – Infraspinatus, and posterior labrumLong axis

Moving the transducer posteriorly and in the plane parallel to the scapular spine. Optimal image contrast for detection of intra-articular fluid will be obtained by bringing the arm in external rotation(B).

Transverse;

Teres minor insertion(Long-axis view )

The probe placed parallel to the spine of the scapula and just proximal to the prominence of the teres major …The insertion appears hypoechoic, due to more muscle fibers

Dynamic evaluation(for subacromial impingement)

Comparing patient positions

After learning the shoulder ultrasound techniques!

Back to case….

Ultrasound Diagnosis??

Diagnosis??

Supra-spinatus tendon rupture!

Diagnosis supported with MRI

Coronal MRI, image in the middle third

Patient

Normal

References:1) Accuracy of MRI, MR Arthrography, and Ultrasound in the

Diagnosis of Rotator Cuff Tears: A Meta-Analysis: O. de Jesus1, Laurence Parker, Andrea J. Frangos and Levon N. June 2009, Volume 192, Number 6 http://www.ajronline.org/doi/abs/10.2214/AJR.08.1241Joseph )

2)Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a meta-analysis;Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean Leblond2, François Desmeules3

,4,Clermont E Dionne1,5,Joy C MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5

3)) The Rotator Cuff; Marnix T. van Holsbeeck, Dzung Vu, and J. Antonio Bouffard… Chapter 22 ■ The Rotator Cuff 879, Rumack Ultrasound.

4) RSNA, US of the shoulder, January 2006

Thank you!