This document provides an overview of ultrasound scanning of the shoulder joint, including sonoanatomy, diagnostic evaluation of pathology, and ultrasound-guided interventions. It details scanning protocols for muscles like the rotator cuff, joints like the glenohumeral joint, and nerves like the suprascapular nerve. Pathologies that can be identified include tears of the rotator cuff tendons, labral tears, joint effusions, adhesive capsulitis, and nerve entrapments. Ultrasound is useful for evaluating both static and dynamic shoulder function and can guide injections to structures like the subacromial-subdeltoid bursa.

1. MSK-USG of
Shoulder:Diagnostic Scanning
Ravi shankar sharma
Moderator-Dr. Praveen Talawar
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

2. Aim:-
• Detailed understanding of:
1. Sonoanatomy of shoulder joint.
2. Diagnosis of MSK-shoulder related pain
generators.
3. Brief knowledge about USG guided shoulder
interventions.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

3. Contents:
• Introduction & general considerations.
• Protocol for shoulder USG
• Diagnostic USG of shoulder joint pathology:
Muscular pathology
Joint Related pathology
Nerves (Suprascapular & Axillary)Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

4. Introduction:
• Common MSK disorder, prevalence of 6.7%–66.7%
• Chronic shoulder pain  rotator cuff pathology to
peripheral nerve entrapment.
• U.S. allows static and dynamic evaluation
• Offers real-time, radiation-free guidance for
therapeutic interventions.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

5. General Comments
• Scan facing the front of the patient
• Patient & Sonologist  sitting on stool
• Sonographer  shoulder is above the patient’s.
• ExposureAdequate (Examine both shoulders)
• Probe- High frequency & linear
• HistoryExaminationUSG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

6. Protocol for Shoulder USG
Shoulder US: Anatomy, Technique, and Scanning Pitfalls.
Radiology: Volume 260: Number 1—July 2011
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

7. Muscles and
associated
structures
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

8. Muscles
• Long head of biceps
• Subscapularis
• Supraspinatus
• Infraspinatus & Teres minor
• Deltoid
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

9. Anatomy-Anterior & posterior
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

10. Long head of the biceps tendon
• Originates from the S.G. tubercle of the scapula,
TRANSVERSE
HUMERAL
LIGAMENT
CORACOHUMERAL
LIGAMENT
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

11. Short Axis view
Shoulder US: Anatomy, Technique, and Scanning
Pitfalls. Radiology: Volume 260: Number 1—July 2011
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

12. Long axis
The normal tendon will then appear hyperechoic and fibrillar.Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

13. Biceps tendon subluxation
Park J, Chai JW, Kim DH, Cha SW. Dynamic ultrasonography of the
shoulder. Ultrasonography. 2018 Jul;37(3):190-199.Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

14. Tear
A. S. Axis Torn LHB with an EMPTY BICIPITAL GROOVE .
B. L.Axis convex superior margin of the retracted muscle belly (POPEYE SIGN).
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

15. Tendinopathy
Effusion
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

16. Injection: Short &Long Axis
Ultrasound-guided interventions for painful shoulder: from anatomy to
evidence Journal of Pain Research 2018:11 2311–2322Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

17. Rotator Cuff Muscles
• Subscapularis
• Supraspinatus
• Infraspinatus & Teres minor
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

18. Subscapularis tendon
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

19. Scanning
• Transducer over anterior shoulder (axial plane)
Bicipital groove.
• Transducer over the lesser tuberosity Hypoechoic
• External rotation L.T. rotates laterally 
subscapularis (inferior to the coracoid) is pulled
laterally Hyperechoic and fibrillar
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

20. Subscapularis tendon (long axis)
Shoulder US: Anatomy, Technique, and Scanning Pitfalls.
Radiology: Volume 260: Number 1—July 2011
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

21. Subscapularis-short axis
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

22. Tear
subscapularis tendon with a partial-thickness articular surface tear in
its superior part (arrow).Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

23. Laffose classification of subscapularis
tear
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

24. Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

25. Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

26. Supraspinatus Muscle
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

27. Scanning
• Modified Crass position
• Elbow should point posterior
• long-axis viewS.axis view
Normal supraspinatus  fibrillar
and hyperechoic with a convex
superior surface.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

28. Supraspinatus tendon (long axis)
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

29. Supraspinatus tendon (short axis)
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

30. Patterns of supraspinatus Tear
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

31. Full thickness vs Partial tear
Full-thickness tear of the tendon reaches from the bursal to
the articular margin with sagging of the overlying bursa
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

32. a. Full-thickness tear (arrow) in anterior free edge of
supraspinatus tendon
b. full-thickness tear in the mid-portion of the tendon
(between the markers) with sagging of the overlying bursa
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

33. Massive SSP tear
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

34. SSP-Partial tear
A.PARTIAL-THICKNESS ARTICULAR SURFACE TEAR IN THE MID-SUBSTANCE OF THE TENDON
(B) PARTIAL-THICKNESS BURSAL SURFACE TEAR
(C) INTRA-SUBSTANCE TEAR (ARROW).
(D) RIM RENT OF SUPRASPINATUS TENDON AT G.T.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

35. A.Supraspinatus tendinosis
B & C. calcification (arrow) without posterior shadowing..Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

36. External rotators: ISP & T.min
Tendons lies posteriorly , visualized with arm in a flexed
and adducted palm up/ neutral position.Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

37. Scanning
• Place transducer just below the scapular spine
• longitudinal section “beak-shaped” structure
• Move medial toward the scapula
• Posterior labrum (labral tear), the spinoglenoid
notch (paralabral cyst), and the posterior G.H. joint
recess (for joint fluid or synovitis)
• Scan depth ↑  posterior aspect of the G.H. jointDr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

38. Spinoglenoid notch
connects the infraspinatus fossa with the supraspinatus fossa
passage for the suprascapular nerve and artery
 bounded by the inferior transverse scapular ligament (spinoglenoid ligament).
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

39. Labrum , spinoglenoid notch (arrowheads) of scapula
Shoulder US: Anatomy, Technique, and Scanning Pitfalls.
Radiology: Volume 260: Number 1—July 2011Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

40. Infraspinatus and teres minor (short axis)
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

41. Infraspinatous tendon
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

42. Deltoid
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

43. Anterior visualization
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

44. Long axis -view
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

45. Posterior visualization
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

46. Haematoma
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

47. Joint related pathology
• A-C joint
• Gleno-Humeral joint
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

48. Acromioclavicular joint
• Palpate clavicle and move laterally toward the
acromion, with the transducer in the coronal
plane on the body.
• Evaluated for bone irregularity, narrowing,
widening, or offset.
• Clinical suspicion for acromioclavicular joint
disruption  Dynamic evaluation
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

49. A-C joint
Ultrasound-guided interventions for painful shoulder: from anatomy
to evidence Journal of Pain Research 2018:11 2311–2322Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

50. Acromioclavicular joint-Normal USG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

51. A-C joint effusion
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

52. A-C joint arthritis
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

53. Ultrasound guided injection for the
acromioclavicular joint
Ultrasound-guided interventions for painful shoulder: from
anatomy to evidence Journal of Pain Research 2018:11
2311–2322
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

54. Glenohumeral joint
• a ball-and-socket type diarthrodial structure,
lined by synovium and reinforced by the capsule.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

55. Normal G.H. Joint-USG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

56. G.H. Joint effusion-USG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

57. G.H. arthritis
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

58. USG guided G.H. Joint Injection
Ultrasound-guided interventions for painful shoulder: from anatomy to
evidence Journal of Pain Research 2018:11 2311–2322Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

59. Non-rotator cuff abnormalities
• Subacromial impingement syndrome
• SA-SD bursitis
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

60. Subacromial impingement syndrome
• Chronic irritation of the SST against the
undersurface of the anterior 1/3 of acromion,
the coracoacromial ligament, and the A.C. joint.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

61. • Move transducer laterally from ac joint to position
over the lateral edge of the acromion
• G.T. and the lateral acromion visualization
• Actively elevate the arm
• SSP tendon and overlying SA-SD bursa should slide
smoothly under the acromion.
• Pooling of bursal fluid at the lateral acromion edge
or snapping of bursal tissue indicates subacromial
impingement Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

62. Dynamic assessment for subacromial
impingement.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

63. Dynamic testing for impingment-USG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

64. Ultrasonographic classification of
subacromial impingement
Bureau et al. AJR Am J Roentgenol 2006;187:216-220.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

65. Subacromial subdeltoid bursitis
demonstrated by the presence of increased fluid in the bursa and/or
thickening of the wall of the bursaDr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

66. SA-SD Bursa
Ultrasound-guided interventions for painful shoulder: from anatomy to
evidence Journal of Pain Research 2018:11 2311–2322
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

67. USG picture :SA-SD Bursitis
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

68. SA-SD bursa injection-USG
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

69. Adhesive capsulitis of the shoulder
• Characterised by thickening and contraction of
the shoulder joint capsule and surrounding
synovium.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

70. USG features of A. Capsulitis
• limitation of movement of the supraspinatus
sensitive feature
• thickened coracohumeral ligament (CHL)
• Echogenic material around the long head of
biceps at rotator interval
• Increased vascularity of long head of biceps at
rotator interval Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

71. Nerve
related pathology
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

72. Suprascapular nerve
• Upper trunk of the brachial plexus ,C5 and C6 input
• Suprascapular notch below the superior
transverse suprascapular ligament
• suprascapular artery above the transverse
suprascapular ligament
• sensory supply to the AC and G.H. joints and
innervates the SSP and ISP muscle.Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

73. Suprascapular nerve
Ultrasound-guided interventions for painful shoulder: from anatomy to evidence
Journal of Pain Research 2018:11 2311–2322Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

74. Scanning
• Transducer on the SSP fossa over lateral 1/3 of the
scapular spine.
• Move laterally
• S.S. nerve Bottom of the supraspinatus fossa.
• The suprascapular artery (pulsating dot) positive
Doppler signals
.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

75. USG –suprascaular nerve
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

76. Axillary nerve
• Posterior cord of the brachial plexus i.e. from
ventral rami of C5 and C6
• Quadrilateral space
• Posterior humeral circumflex artery
• Deltoid muscle and teres minor muscles.
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

77. Axillary nerve
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

78. USG- guided Axillary nerve block
Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)

79. Dr Ravi Shankar Sharma, AIIMS,Rishikesh
(DM, pain medicine)