From NBA Team Physicians Society MSK Ultrasound Course, Chicago IL, June 2012

1. Ultrasound of the Shoulder
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. Objectives
• Uses of ultrasound
• Shoulder anatomy
• Sono-anatomy
• Ultrasound shoulder exam

3. Diagnostic Uses
• Soft tissue disorders • Joint disorders
– Tears – Erosions on bones
• Muscle, tendon, ligament – Loose bodies
– Inflammation – Pannus
• Plantar fasciitis, tenosynovitis – Inflammation
– Masses – Effusion
• Hematoma, cyst, solid tumors, calcific
tendonitis
– Nerve disorders • Bone disorders
• Morton’s neuroma, neuropathies, – Fractures
trauma
– Stress fractures
– Foreign bodies
– Infections

4. Therapeutic Uses
• Injections • Biopsy
– Marcaine/Lidocaine • Removal of foreign bodies
– Cortisone
– Hyaluronic acid
– PRP
• Aspiration
– Drain joints
– Drain hematomas
• Surgical adjunct to arthroscopy

5. SHOULDER ANATOMY

6. SHOULDER SONO-ANATOMY

7. Shoulder U/S Tissue Types
• Bone
• Fat
• Tendon
• Muscle
• Cartilage
• Bursa

8. Other Signals
• Synovial fluid
• Foreign Body
• Air

9. ULTRASOUND SHOULDER EXAM

10. Ultrasound Technique: Shoulder
• Biceps tendon
– Longitudinal & Transverse
– Superior & Inferior
• Subscapularis
• Infraspinatous
– Longitudinal & Transverse
– Longitudinal & Transverse
• Coracoid - Subscapularis
• Glenohumeral jt & Labrum
– Subcoracoid impingement
• AC joint
• Supraspinatous
– Longitudinal & Transverse
– Anterior & Posterior
– Subacromial bursa

11. Biceps Tendon - Transverse
• Arm position: Neutral
• Tip: Find bicipital groove
• MRI equivalent: Axial plane

12. Biceps Tendon – Trans / Sup vs Inf
• Superior: Deep bicipital groove
• Inferior: Flattened bone with transition to muscle

13. Biceps Subluxed & Subscap Torn

14. Biceps Subluxing

15. Biceps Tendon: Biceps Split

16. Biceps Tendon - Longitudinal
• Arm position: Neutral
• Tip: Find transverse view, keep groove centered then turn probe 90o
• MRI equivalent: Sagittal plane

17. Biceps Tenosynovitis

18. Subscapularis - Longitudinal
• Arm position: External rotation
• Tip: Find bicipital groove @ neutral then ER
• MRI equivalent: Axial plane

19. Subscapularis - Transverse
• Arm position: External rotation
• Tip: Find longitudinal view, then turn probe 90o
• MRI equivalent: Sagittal plane

20. Partial Subscapularis Tear

21. Coracoid-Subscapularis
• Arm position: ER <-> IR, with Flex/Add/IR
• Tip: Move medial once found Longitudinal Subscap
• MRI equivalent: Axial plane

22. Coracoid-Subscapularis

23. Subscapularis Cyst

24. Subcoracoid Loose Body

25. Supraspinatous - Longitudinal
• Arm position: Extended
• Tip: Probe parallel plane [Contralateral shoulder : Ipsilateral hip]
• MRI equivalent: Coronal plane

26. Supraspin. – Long / Ant vs Post
• Anterior: Step off pronounced on tuberosity
• Posterior: Flatter transition of head to tuberosity

27. Subacromial Bursitis

28. Supraspinatous - Transverse
• Arm position: Extended
• Tip: Probe parallel plane [Ipsilateral shoulder : Contralateral hip]
• MRI equivalent: Sagittal plane

29. Supraspin. – Trans / Ant vs Post
• Anterior: Note biceps tendon
• Posterior: See black cartilage layer over bone

30. Partial-thickness RC Tears

31. FT RC Tears

32. RCT - Full Thickness?

33. Calcific Tendonitis

34. Ca Tendonitis

35. Chronic RCT w/ Cystic Changes

36. Infraspinatous - Longitudinal
• Arm position: Neutral
• Tip: Stay more lateral and find edge of humeral head
• MRI equivalent: Axial plane

37. Infraspinatous - Transverse
• Arm position: Neutral to flexed
• Tip: Find longitudinal view, then turn probe 90o
• MRI equivalent: Sagittal plane

38. Infraspinatous - Tear

39. Glenohumeral Joint
• Arm position: Neutral
• Tip: Find longitudinal view infraspinatous, then move medial, rotating arm
• MRI equivalent: Axial plane

40. Posterior Labral Tear
USA: Ultrasound Arthrogram

41. Posterior Instability

42. AC Joint
• Arm position: Neutral
• MRI equivalent: Coronal plane
• Tip: Palpate the joint for easy localization