Comprehensive Shoulder US Examination.pptx

Comprehensive shoulder ultrasound examination

1. Comprehensive Shoulder US Examination: A Standardized Approach with Multimodality Correlation for Common Shoulder Disease Journal report by Kevin Eric R. Santos, MD, DPBR

2. SOURCE Lee MH, Sheehan SE, Orwin JF, Lee KS. Comprehensive Shoulder US Examination: A Standardized Approach with Multimodality Correlation for Common Shoulder Disease. Radiographics . 2016 Oct;36(6):1606-1627. doi : 10.1148/rg.2016160030. PMID: 27726738; PMCID: PMC5084996.

3. Introduction Shoulder pain - 3rd most common reason for MSK consultation in primary care Affects up to 1/3 of the general population

4. Imaging diagnostics for shoulder pathology Radiography Ultrasound MRI MR Arthography

5. Advantages of Ultrasound for Shoulder Imaging Comparable diagnostic accuracy for diseases involving: Rotator cuff Subacromial subdeltoid bursa long head of the biceps tendon Low cost, accessible Realtime imaging and patient feedback No contraindication for px w/ pacemaker No artifact from surgical hardware

6. Disadvantages of Ultrasound for Shoulder Imaging Steep learning curve May be time consuming Lack of experienced sonographers

7. Ultrasound of the Shoulder

8. Anisotropy Ultrasound artifact notably in muscles, tendons, ligaments When the ultrasound beam is not perpendicular, the fibrillar structure of the tendons reflect sound away from the transducer Produces hypoechoic structure May be mistaken for tears, tendinosis

9. Scanning Protocol

10. Scanning Protocol

11. Anterior region Relevant anatomy Subscapularis tendon Long head of the biceps tendon Scanning protocol Common pathologies Biceps tendinosis and tenosynovitis Biceps tendon rupture Biceps tendon subluxation and dislocation

12. Anterior > Relevant anatomy > Subscapularis tendon Most anterior tendon of the rotator cuff Origin: Subscapular fossa Insertion: Lesser tuberosity

13. Anterior > Relevant anatomy > Long head of the biceps tendon Course in the shoulder: superior glenoid labrum  rotator interval  bicipital groove (covered by the transverse humeral ligament) Insertion: Radial tuberosity

14. Anterior Region Scanning Protocol Patient seated in upright position Shoulder In neutral and adducted Elbow flexed 90 degrees, forearm and hand supinated and resting on the ipsilateral thigh Scan LHBT transverse and longitudinally Internally and externally rotate the arm to assess for possible biceps tendon subluxation Subscapularis tendon best viewed with the shoulder in external rotation

15. Long head biceps tendon

16. Dynamic study for long head of the biceps tendon

17. Anterior > Pathology > Biceps Tendinosis and Tenosynovitis Tendinosis Inflammatory and degenerative causes related to chronic repetitive overuse Appearance: Tendon thickening Hypoechoic Loss of fibrillar pattern

18. Anterior > Pathology > Biceps tendinosis and Tenosynovitis Tendinosis Inflammatory and degenerative causes related to chronic repetitive overuse Appearance: Tendon thickening Hypoechoic Loss of fibrillar pattern

19. Anterior > Pathology > Biceps tendinosis and Tenosynovitis Tenosynovitis Inflammation of the LHBT is rare Inflammation of the surrounding synovial sheath is more common

20. Anterior > Pathology > Biceps tendon rupture and tearing Occurs in the setting of tendinosis Can occur spontaneously in patients > 50 w/o trauma Signs “Empty” bicipital groove Pop-eye sign

21. Anterior > Pathology > Biceps tendon rupture and tearing Occurs in the setting of tendinosis Can occur spontaneously in patients > 50 w/o trauma Signs “Empty” bicipital groove Pop-eye sign

22. Popeye sign

23. Anterior > Pathology > Biceps tendon subluxation/dislocation MC site is proximal to or within the bicipital groove Commonly associated with other injuries (rotator cuff tears) Real-time dynamic study is advantageous in confirming the diagnosis

24. Scanning Protocol

25. Superior region Relevant anatomy Acromioclavicular joint Scanning protocol Common pathologies Capsular hypertrophy and distension AC joint dislocation

26. Superior > Relevant anatomy > Acromioclavicular joint Synovial joint articulating the acromion with the clavicle

27. Superior scanning protocol Transducer along long axis of the clavicle, move laterally until to profile the joint space Overlying hypoechoic joint capsule Fibrocartilagenous disc seen as linear hyperechoic structure in the center of the joint

28. Superior scanning protocol Dynamic scan Have the patient move the hand to the contralateral shoulder Look for: Separation Irregularity in bony margins Osteoarthritis “Geyser phenomenon” Bursal fluid moving upwards

29. Dynamic scan of the AC joint

30. Superior > Pathology > Capsular hypertrophy and distension May have varied causes (degenerative, infectious, inflammatory Capsule to bone distance < 3 mm rules out capsular hypertrophy

31. Superior > Pathology > Acromioclavicular joint dislocation Ultrasound is best for grade I AC joint dislocation Rockwood classification for acromioclavicular dislocation

32. Superior > Pathology > Acromioclavicular joint dislocation Ultrasound is best for grade I AC joint dislocation

33. Scanning Protocol

34. Anterolateral region Relevant anatomy Supraspinatus tendon Subacromial subdeltoid bursa Scanning protocol Common pathologies Rotator cuff tear Subacromial impingement Bursitis

35. Anterolateral > Relevant anatomy > Supraspinatus tendon Primarily implicated in symptomatic rotator cuff disease. Origin – supraspinatus fossa of the scapula Insertion – superior facet of greater tubercle of humerus Abducts the arm

36. Anterolateral > Relevant anatomy > Subacromial-subdeltoid bursa Synovial lined potential space Composed of synovial tissue, connective tissue and fat Largest bursa in the body Located between the rotator cuff, coraco -acromial arch, and deltoid muscle Facilitates RC motion, dissipates friction from complex shoulder movement

37. Anterolateral scanning protocol Positions that optimize viewing the supraspinatus tendon Crass position Arm hyperextended, elbow flexed, and dorsum placed along the low midline of the back Modified Crass position Elbow flexed and volar aspect of the hand on the ipsilateral iliac wing

38. Anterolateral scanning protocol Crass and modified Crass expose more of the supraspinatus tendon

39. Dynamic scan of the anterolateral region Start with patient in neutral shoulder position, adducted with elbow flexed Probe in long axis of supraspinatus tendon, cephalad end of the probe over the acromion Have the patient abduct the arm

40. Dynamic scan of the anterolateral region

41. Anterolateral > Pathology > Rotator Cuff Tear Multifactorial Intrinsic (genetic, tendon thinning), extrinsic (trauma, impingement syndrome), environmental Risk factors include increased age, hand dominance, history of trauma

42. Anterolateral > Pathology > Full Thickness Rotator Cuff Tear Extend through the entire thickness of the tendon substance Articular to bursal surface Most RC tears involve the SST and occur 13-17mm post to the LHBT Hypoechoic or anechoic tendon defect Describe: location and dimensions in short and long axis, shape (crescent-shaped, L-shaped), presence of retraction 63/M w/ right shoulder pain Full thickness supraspinatus tendon tear

43. Anterolateral > Pathology > Full Thickness Rotator Cuff Tear Acute tear Involve the middle substance + bursal effusion

44. Anterolateral > Pathology > Full Thickness Rotator Cuff Tear Chronic tear Non-visualization, retraction (-) bursal effusion Pitfall – mistaking the deltoid sitting on top of the humeral head/granulation tissue for an intact tendon

45. Anterolateral > Pathology > Full Thickness Rotator Cuff Tear

46. Anterolateral > Pathology > Partial Thickness Rotator Cuff Tear Articular surface tear Bursal surface tear

47. Anterolateral > Pathology > Subacromial impingement Assessed on dynamic study Signs Impaired gliding Soft tissue compression Bursal fluid pooling Bursal thickening Upward migration of the humeral head that impedes movement

48. Anterolateral > Pathology > Subacromial subdeltoid bursa pathology Conditions that may be seen: Bursal reaction secondary to rotator cuff disease Infectious or inflammatory bursitis 90% of patients with tears present with bursal distension Bursitis may be communicating or noncommunicating the glenohumeral joint Communicating – Presence of full thickness tear allowing the bursa to communicate with the glenohumeral joint underneath 35/F with bacteremia, and left shoulder pain and swelling Case of infectious bursitis

49. Anterolateral > Pathology > Subacromial subdeltoid bursa pathology Conditions that may be seen: Bursal reaction secondary to rotator cuff disease Infectious or inflammatory bursitis 90% of patients with tears present with bursal distension Bursitis may be communicating or noncommunicating the glenohumeral joint Communicating – Presence of full thickness tear allowing the bursa to communicate with the glenohumeral joint underneath 35/F with bacteremia, and left shoulder pain and swelling Case of infectious bursitis

50. Scanning Protocol

51. Posterior region Relevant anatomy Supraspinatus muscle Infraspinatus tendon Teres minor Glenohumeral joint and spinoglenoid notch Scanning protocol Common pathologies Rotator cuff tear and muscle atrophy Spinoglenoid notch and posterior labrum cyst Glenohumeral joint disease

52. Posterior > Relevant anatomy > Infraspinatus tendon Origin: Infraspinatus fossa Insertion: Middle facet of the greater tuberosity

53. Posterior > Relevant anatomy > Teres minor Origin: Superolateral border of the scapula Insertion: Inferior facet of the greater tuberosity

54. Posterior > Relevant anatomy > Glenohumeral joint and Spinoglenoid notch Spinoglenoid notch – connects the supra and infraspinatus fossae Suprascapular nerve and artery pass through this notch under the inferior scapular ligament

55. Posterior Scanning Protocol Patient arm in neutral resting adduction, palm supinated on the lap Orient transducer axial to view the posterior glenohumeral joint and posterior labrum Assess supraspinatus muscle (above the scapular spine) Assess infraspinatus and teres minor muscles (below the scapular spine) Follow course to its insertion into the greater tuberosity Examine both muscles in long and short axes to determine difference in muscle bulk, or find fatty atrophy. Compare right and left – to determine atrophy

56. Posterior Scanning Protocol

57. Posterior > Pathology > Rotator cuff tear and muscle atrophy Rotator cuff muscle atrophy Negative prognostic factor for repair US and MR have comparable diagnostic performance in detecting RC atrophy Atrophy can be non-tear related (i.e. shoulder denervation) Smaller, hyperechoic muscle Appearance: Increased echogenicity relative to muscle Loss of normal architecture 54/F with long-standing right anterior shoulder pain. Fatty atrophy of the supraspinatus muscle.

58. Posterior > Pathology > Spinoglenoid /posterior labrum cyst Paralabral or ganglion cyst Request for MR Cysts are associated with labral tears Large cysts may cause entrapment neuropathy Appearance: Anechoic or hypoechoic masses 28/M with left shoulder pain. Lobulated cyst seen the posterior region.

59. Posterior > Pathology > Spinoglenoid / posterior labrum cyst Paralabral or ganglion cyst Request for MR Cysts are associated with labral tears Large cysts may cause entrapment neuropathy Appearance: Anechoic or hypoechoic masses 28/M with left shoulder pain. Lobulated cyst seen the posterior region.

60. Summary Region Structures evaluated Special Position or Dynamic maneuver Anterior Long head biceps tendon Subscapularis tendon Internal and external rotation Superior AC joint Cross hand to the opposite shoulder Anterolateral Supraspinatus tendon Subacromial subdeltoid bursa Crass/Modified Crass position Abduction Posterior Infraspinatus tendon Teres minor tendon Rotator cuff muscle bulk Spinoglenoid notch Glenohumeral joint None

61. Anterior

62. Superior

63. Anterolateral

64. Posterior

65. Conclusion US is an important and complementary imaging tool for the evaluation of the superficial soft-tissue structures of the shoulder. To facilitate these objectives, the study used a standardized shoulder US examination framework (ASAP [ a nterior, s uperior, a nterolateral, and p osterior]) Using a standardized approach to shoulder US will aid radiologists, sonographers, and technologists in overcoming the barriers to implementing shoulder US in clinical practice and help to promote high-quality diagnostic imaging.

66. Other sources: Radiology Nation. Ultrasound Tutorial: MSK Series: Shoulder/Rotator Cuff. https://www.youtube.com/watch?v=BwSJCkTBN0c&t=141s Fujifilm Sonosite . How To: Acromioclavicular Joint Ultrasound Exam. https://www.youtube.com/watch?v=KqwfHguKZlI Musculoskeletal US. Subacromial impingement on dynamic real-time shoulder ultrasound (case 6). https://www.youtube.com/watch?v=GjSVvyowZq0