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Ultrasound of the ShoulderEric W. Lee, MDEric W. Lee, MD

Advanced Concepts in Sports Medicine Advanced Concepts in Sports Medicine November 2015November 2015

DisclosuresDisclosures

Speaker: Sonosite, Arthrex

Royalties: None

Stock Options: None Stock Options: None

I do not intend to discuss any off‐label use/ unapproved use of drugs or devices

Objectives

Uses of ultrasoundUses of ultrasoundShoulder anatomyShoulder anatomyShoulder Shoulder sonosono--Shoulder Shoulder sonosono--

anatomyanatomyUltrasound shoulder Ultrasound shoulder

examexam

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Diagnostic Uses

Soft tissue disordersSoft tissue disorders Tears

Muscle, tendon, ligament

Inflammation

Joint disordersJoint disorders Erosions on bones Loose bodies Pannus Inflammation

Tenosynovitis

Masses Hematoma, cyst, solid

tumors, calcifictendonitis

Nerve disorders Morton’s neuroma,

neuropathies, trauma

Foreign bodies Infections

Inflammation Effusion

Bone disordersBone disorders Fractures

Therapeutic Uses

InjectionsInjections Marcaine/Lidocaine

Cortisone

Hyaluronic acid

Surgical adjunct to Surgical adjunct to arthroscopyarthroscopy

BiopsyBiopsy

Removal of foreign Removal of foreign Hyaluronic acid

PRP

Stem Cells

AspirationAspiration Drain joints, cysts,

hematomas

ggbodiesbodies

Shoulder Anatomy

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Muscular Anatomy -Anterior

Muscular Anatomy -Posterior

The Labrum

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Shoulder Bony Anatomy

Shoulder Sono-Anatomy

Shoulder U/S Tissue Types

BoneBoneFatFat TendonTendonMuscleMuscle LabrumLabrumBursaBursa

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Shoulder U/S Tissue Types

BoneBoneFatFat TendonTendonMuscleMuscle LabrumLabrumBursaBursa

Other Signals

Synovial fluidSynovial fluid Synovial fluidSynovial fluid

Foreign BodyForeign Body

AirAir

Ultrasound Shoulder Exam

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Shoulder Ultrasound: Terminology

Long Axis (Longitudinal) viewLong Axis (Longitudinal) view Transducer parallel to the long axis of the Transducer parallel to the long axis of the

structure of intereststructure of interest

Short Axis (Transverse) viewShort Axis (Transverse) view Transducer perpendicular to the structure of Transducer perpendicular to the structure of

interestinterest

Shoulder Ultrasound: Approaches

AnteriorAnteriorAnterolateralAnterolateral PosteriorPosterior

Shoulder Shoulder osteology creates osteology creates challengeschallenges

Shoulder Ultrasound: Anterior exam

Biceps tendonBiceps tendon Long & Short Axis

Superior & Inferior

SubscapularisSubscapularis Long & Short Axis

Anterior LabrumAnterior Labrum

CoracoidCoracoid Subcoracoid

impingement

AC JointAC Joint

ClavicleClavicle

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Biceps Tendon – Short Axis

Arm position: Neutral

Tip: Find bicipital groove

MRI equivalent: Axial plane

Biceps Tendon – Short / Sup vs Inf

Superior: Deep bicipital groove

Inferior: Flattened bone with transition to muscle

Biceps Subluxed & SubscapTorn

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Biceps Subluxing

Biceps Tendon – Long Axis

Arm position: Neutral

Tip: Find transverse view, keep groove centered then turn probe 90o

MRI equivalent: Sagittal plane

Biceps Tenosynovitis

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Subscapularis – Long Axis

Arm position: External rotation

Tip: Find bicipital groove @ neutral then ER

MRI equivalent: Axial plane

Subscapularis – Short Axis

Arm position: External rotation

Tip: Find longitudinal view, then turn probe 90o

MRI equivalent: Sagittal plane

Partial Subscapularis Tear

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Coracoid-Subscapularis

Arm position: ER <-> IR, with Flex/Add/IR

Tip: Move medial once found Longitudinal Subscap

MRI equivalent: Axial plane

Coracoid-Subscapularis

Subscapularis Cyst

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AC Joint

Arm position: Neutral

MRI equivalent: Coronal plane

Tip: Palpate the joint for easy localization

AC Separation

Normal AC Separation, Grade II

Clavicle Fracture

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Shoulder Ultrasound: Anterolateral exam

SupraspinatousSupraspinatous Long & Short Axis

Anterior & Posterior

SubacromialSubacromial BursaBursa SubacromialSubacromial BursaBursa

Supraspinatous – Long Axis

Arm position: Extended

Tip: Probe parallel plane [Contralateral shoulder : Ipsilateral hip]

MRI equivalent: Coronal plane

Supraspinatous

BursaBursa Greater TuberosityHumeral Head

PeribursalPeribursal FatFat

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Supraspin. – Long / Ant vsPost

Anterior: Step off pronounced on tuberosity Posterior: Flatter transition of head to tuberosity

Subacromial Bursitis

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Partial-thickness RC Tears

FT RC Tears

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Calcific Tendonitis

Long Axis Short Axis

Chronic RCT w/ Cystic Changes

Shoulder Ultrasound: Posterior exam InfraspinatousInfraspinatousGlenohumeralGlenohumeral

JJoint & Posterior oint & Posterior JJoint & Posterior oint & Posterior LabrumLabrum

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Infraspinatous – Long Axis

Arm position: Neutral

Tip: Stay more lateral and find edge of humeral head

MRI equivalent: Axial plane

Infraspinatous – Short Axis

Arm position: Neutral to flexed

Tip: Find longitudinal view, then turn probe 90o

MRI equivalent: Sagittal plane

Infraspinatous - Tear

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Posterior GlenohumeralJoint

Arm position: Neutral

Tip: Find longitudinal view infraspinatous, then move medial, rotating arm

MRI equivalent: Axial plane

Posterior Instability

Posterior Labral TearUSA: Ultrasound Arthrogram

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Biceps Tendon: Biceps Split

RCT - Full Thickness?

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Biceps Tendon: Medial Subluxation

Biceps Tenosynovitis

Subcoracoid Loose Body

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Posterior Labral Tear

Severe DJD of Humeral Head

Normal Severe DJD

Bones

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5th Metatarsal

Finger Middle Phalange

Epiphyseal Plate

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Fibula: Cortical Thickening

Os Acromiale

Scanning the Cortex

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Supraspinatous

Shoulder Fracture

Courtesy of Daniel Shelton

FT RC Tears

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Ca Tendonitis

Acromioclavicular (AC) Joint

AcromionAcromionClavicleClavicle

ACROMIOCLAVICULAR LIGAMENTACROMIOCLAVICULAR LIGAMENT

Courtesy of Daniel She