ULTRASOUND OF THE SHOULDER - Normal

Move your mouse over the image to see highlighted anatomy

Transverse Biceps tendon scan plane	Transverse Long Head Biceps
Longitudinal Biceps tendon scan plane	BT LS normal
SSC scan plane	Normal subscapularis
Axial view of shoulder anatomy	CAL
Patient begins with arm by their side and abducts sideways to 90degrees. Look for bunching of bursa or tendon against the acromion or coraco-acromial ligament	Normal supraspinatus LS
SSP scan plane 2: Patient's hand behind their back.	Normal supraspinatus TS
ACJ scan plane	AC joint normal
Infraspinatus scan plane: Patient's hand towards unaffected shoulder.	Infraspinatus
Infraspinatus scan plane: Patient's hand towards unaffected shoulder.	Abduction: Hover mouse over to see supraspinatus pre and post abduction at the acromion.
Click to open a pdf showing a broad classification of tendon tears.

U/S OF THE SHOULDER PROTOCOL

ROLE OF ULTRASOUND

Ultrasound is essentially used for the rotator cuff complex of the shoulder. Ultrasound is a valuable diagnostic tool in assessing the following indications;

• Muscular, tendonous and some ligamentous damage (chronic and acute)
• Bursitis
• Joint effusion
• Vascular pathology
• Haematomas
• Soft tissue masses such as ganglia, lipomas
• Classification of a mass eg solid, cystic, mixed
• Post surgical complications eg abscess, oedema
• Guidance of injection, aspiration or biopsy
• Some bony pathology.

LIMITATIONS

It is recognised that ultrasound offers little or no diagnostic information for internal structures such as the gleno-humeral ligaments. Ultrasound is complimentary with other modalities, including plain X-ray, CT, MRI and arthroscopy.

EQUIPMENT SELECTION AND TECHNIQUE

Use of a high resolution probe (7-15MHZ) is essential when assessing the superficial structures of the shoulder. Careful scanning technique to avoid anisotropy (and possible misdiagnosis) Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

SCANNING TECHNIQUE

PATIENT POSITION

Patient seated on chair in front of ultrasound machine. Have the patient's chair at an appropriate height to be ergonomically comfortable for you to scan.

LONG HEAD BICEPS (BT)

For example images of pathology, click here to goto the shoulder pathology page.

• Patient rests hand palm up on thigh.
• Scan transversely over the anterior humeral head.
• Visualize the bicipital groove. Identify the biceps tendon in the groove (if not identified it may be either torn or subluxed medially out of the groove). Follow down to the muscle belly.
• Rotate into longitudinal and re-examine.
• The tendon should be a uniform fibrillar structure, generally less than 5mm thick.
• Examine dynamically in a transverse plane during internal/external rotation to ensure it doesn't sublux medially.

SUBSCAPULARIS (SSC)

For example images of pathology, click here to goto the shoulder pathology page

• Again in a transverse plane at the bicipital groove, externally rotate the patient's arm.
• The SSC tendon will be visible inserting medial to the groove.
• It will be seen as an elongated slightly convex tendon

SUPRASPINATUS (SSP)

For example images of pathology, click here to goto the shoulder pathology page

• Position the patient palm up with their elbow flexed and pulled back passed their side so their hand is near their hip.

Identify the SSP tendon supero-lateral to the bicipital groove. In a coronal plane, the tendon emerges from beneath the acromion to insert on the greater tuberosity of the humerus.

It should be uniform, fibrillar & 'beak shaped' (convex superiorly).

INFRASPINATUS (ISP)

For example images of pathology, click here to goto the shoulder pathology page

• Ask the patient to place their affected hand across their chest towards the contralateral shoulder.

The ISP can be seen by placing the probe immediately inferior to the spine of the scapula and following the tendon to it's insertion postero-laterally on the humeral head.

It will have a similar appearance to subscapularis.

DYNAMIC ASSESSMENT

• Biceps: assess it's stability within the bicipital groove during external rotation.
• Subscapularis: assess for any overlying subdeltoid bursal bunching against coracoid during internal rotation
• Supraspinatus: assess for bunching of the tendon &/or overlying subacromial bursa against the acromion or coraco-acromial ligament during abduction.
• Ensure the patient does NOT hunch their shoulder or lean towards the contralateral side during abduction.
• Posterior joint recess: during internal/external rotation, assess for a gleno-humeral joint effusion. This will be most evident during external rotation
• Acromio-clavicular joint: During forward flexion with internal rotation look for boney contact or ganglia of the ACJ.

BASIC HARD COPY IMAGING

Document the normal anatomy and any pathology found, including measurements and vascularity if indicated.

A shoulder series should include the following minimum images:

• Long head biceps tendon - long, trans
• Subscapularis tendon
• Coraco-acromial ligament
• Supraspinatus tendon
• Infraspinatus tendon
• Acromio-clavicular joint
• Posterior joint recess
• Pre & post abduction views
• Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity. Detail any limitation to range of movement and degree that pain or symptoms begin.