Role of Ultrasound in shoulder pathologies. In this presentation we will discuss the rotator cuff pathologies.

1. Role of Ultrasound in Clinical Evaluation
of Shoulder Pain
DR. MUHAMMAD BIN ZULFIQAR
SIMS & SERVICES HOSPITAL LAHORE

2. INTRODUCTION
• Shoulder Is one of the most sophisticated and
complicated joint of the body with great range of
movements.
• A series of complex ligaments and muscles help in
stability.
• Different pathologies especially related to rotator
cuff are encountered in patients presenting with
shoulder pain.

3. INTRODUCTION
• By assessing shoulder pain we ascertain integrity of
rotator cuff and extent of tear ,if any, in order to give
a plan to orthopedic surgeon for appropriate
treatment and further management.
• Shoulder ultrasound gives diagnostic sensitivities and
specificities in excess of 90%.

4. Learning Objectives
• Implications of the morphologic features and extent
of rotator cuff tears for glenohumeral joint
mechanics, treatment, and prognosis.
• Identify injuries to adjacent structures that may
accompany rotator cuff tears and discuss their
implications for treatment and prognosis.
• Describe the value of imaging and evaluating the
rotator cuff muscles.

5. Learning Objectives
• Distinguish between the potential contributing factors to
impingement syndrome.
• Determine if surgery is contraindicated.
• Radiologist must:
(a) identify and evaluate cuff lesions that may compromise
glenohumeral joint function, taking into account functional
anatomy.
(b) recognize imaging findings that decrease
the likelihood of favorable functional anatomic outcome after
cuff repair.
(c) identify and describe imaging findings that will assist in selecting
a repair technique.

6. Learning Objectives
• Tear dimensions, tear depth or thickness,
tendon retraction, and tear shape.
• Tear extension to adjacent structures, muscle
atrophy, size of muscle cross-sectional area,
and fatty degeneration.
• Information about the coracoacromial arch
and impingement.

7. ANATOMY

8. ANATOMY

9. Joints (shoulder complex)

10. Glenoid labrum
• Fibrocartilage similar to knee menisci
• Deepens the glenoid fossa

11. Bursae

12. Sonographic Anatomy of Shoulder
 Step 1 - Biceps brachii tendon, long head
 Step 2 - Subscapularis and biceps brachii tendon
 Step 3 - Supraspinatus and rotator interval
 Step 4 - Acromioclavicular joint, subacromial-
subdeltoid bursa,
 Step 5 - Infraspinatus, teres minor, and posterior
labrum

13. Step 1 - Biceps brachii tendon, long head
Sonographic Anatomy

14. Sonographic Anatomy
• Step 2 - Subscapularis
Step 2 - Subscapularis

15. Sonographic Anatomy
• Step 3 - Supraspinatus
Step 3 - Supraspinatus

16. Step 4 - Acromioclavicular joint
Dynamic evaluation for subacromial impingement

17. • Step 5 - Infraspinatus, teres
minor, and posterior labrum

18. Sonographic Anatomy

19. Pathologies
• Rotator Cuff
• Biceps tendon
• Labrum and capsule
• Osseous structures
• Arthritis
• Neural impingement
• Tumors

20. Rotator Cuff
• Tendinopathy
• Partial tears
• Full thickness tears
• Calcific tendinitis

21. Rotator cuff tendinopathy
Also known as -
• Rotator cuff tendinosis
• Definition – collagenous degeneration of
rotator cuff tendons, most commonly
supraspinatus (SST)

22. Tendinopathy
Mucinousdegeneration (Microscopic tears in
critical zone area)
• Intra substance in location delamination
• Begins at early 30 years
• Often asymptomatic
• At 60 tendon ruptures 60%

23. Rotator cuff tendinopathy
• Thickened hypoechoic
• Tears directly visible
• Less sensitive for partial thickness tears
• Advantage – allows dynamic evaluation with
pain correlation

24. Rotator cuff tendinopathy
• Supraspinatus “tendinitis”.
There is focal hypoechoic
swelling of the more
superficial fibers of
supraspinatus insertion

25. Rotator cuff tendinopathy
• Static imaging of the
supraspinatus tendon show
features of “tendinitis”
which included tenderness,
hypoechoic thickening of
the insertional fibers
(arrowheads)

26. Rotator cuff tears
• Clinical –
– Trauma (acute / chronic micro-trauma)
– Adults > 4o with impingement
– Collagen vascular diseases
– Partial more painful than complete tears !!!!
TYPES -
• Partial –
– supraspinatus most common
– Types – bursal surface
interstitial (not seen on arthroscopy)
articular surface
• Complete –
– supraspinatus most common
– Extends from bursal to articular surface

27. Dimensions of a Full-Thickness Tear
• small (1 cm),
• medium (1–3 cm),
• large (3–5 cm),
• massive (5 cm)
The dimensions of rotator cuff tears may have
implications for selection of treatment and surgical
approach, postoperative prognosis, and tear
recurrence

28. Partial tear
• Decreased echogenicity and thinning in
affected region
• Loss of convexity of tendon / bursae interface
in bursal surface tears
• Calcific foci in tendons

29. Partial tear
• Rt. image shows bursal surface tear
• Lt. image shows full thickness partial tear

30. Partial tear
Supraspinatus: Full thickness partial tear Supraspinatus: intrasubstance and
bursal surface tearing

31. Partial tear
Supraspinatus: Partial thickness tear, transverse
is posterior tear
Supraspinatus: Partial thickness tear,
transverse is anterior tear

32. Partial undersurface tear of the rotator cuff

33. Partial Tear
Supraspinatus tear with associated bursal fluid

34. Complete Tear
• Focal tendon interruption
• Fluid filed gap (hypoechoic)
• Loss of convexity of tendon / bursa interface
• Tendon retraction
• Uncovered cartilage sign

35. Complete Tear

36. Complete Tear

37. • Full thickness tear of the distal aspect of the Supraspinatus
tendon ( ) with retraction and effusion of the
subacromial bursae ( ). The humeral head cartilage is laid
bare ( ). There is also fluid in the Long Biceps sheath ().

38. Subscapularis tendon rupture

39. Rotator interval tears
• What is rotator interval ??
– Tunnel through which long head of biceps travels
from its origin at the supraglenoid tubercle
• Rotator interval tears – tears in the capsule
between the supraspinatus and subscapularis
tendons
• Can be classified as subtype of RTC tears

40. Normal rotator interval

41. Internal impingement
• Definition - Degeneration and tearing of posterior SST
and anterior infraspinatus tendons (undersurface /
articular surface) due to impingement by postero-
superior labrum and humeral head
• Postero-superior glenoid impingement (PSGI)
• Overhead throwing activities – athletes (throwers)
• Dynamic compression – occurs during abduction (> 120
degrees), retropulsion and extreme external rotation
(ABER)

42. Rotator cuff calcific tendinitis

43. Rotator cuff calcific tendinitis
• Calcium Hydroxyapatite deposition disease (HADD)
• Calcifying bursitis
• Not typical Ca++ of degenerative disease of tendons, but crystalline
Ca++
• Pathology – deposition of Calcium Hydroxyapatite in RTC tendons
• Etiology – Avascular change, trauma, abnormal Ca++ metabolism
• Housewives and clerical workers more affected
• Location – SST > IST > TM > SSC
• Peri-articular soft tissues like capsule, bursae may be involved

44. Rotator cuff calcific tendinitis
Longitudinal image

45. Rotator cuff calcific tendinitis
Transverse Image

46. Rotator cuff calcific tendinitis
Calcific tendinitis penetration of the cortex of the
greater tubercle

47. Tendon Tear Vs. Tendinosis
Tear
• Anechoic
• Well defined
• Homogeneous
• Thin
• Bone Irregularity
Tendinosis
• Hypoechoic
• Ill defined
• Heterogenous
• Swollen
• Smooth Cortex

48. Biceps tendon pathologies

49. Tendinosis

50. Tendinosis
• Degeneration of long head of biceps
• Long head of biceps –
– LHBT originates at supra glenoid tubercle
– Passes through the antero-superior joint
– Enters the humeral bicipital groove
• Chronic micro-trauma
• Acute trauma (rare cause)
• Accompanies RTC disease (especially impingement)
• Common with subacromial impingement (30-60%
association)
• Biceps tenosynovitis may accompany

51. USG
– Thickened hypoechoic tendon
– Tears often directly visible
– Allows dynamic evaluation

52. Biceps tendon tear

53. Biceps tendon tear
• Tendinosis predisposes
• Associated with SST tear
• Distal tendon edge may retract into upper
arm(popaye sign)

54. Biceps tendon tear

55. Biceps tendon tear

56. Popeye Sign

59. Subacromial-Subdeltoid Bursa

68. THANK YOU