step by step presentation on ultrasound evaluation of shoulder and knee joints with illustrations of probe positioning.multiple examples of pathologies also added.

1. ULTRASOUND EVALUATION OF
SHOULDER AND KNEE JOINTS
Dr.Sahil Chaudhry
Dr.Ganesh K.
AJIMS Mangalore

2. SHOULDER
• INDICATIONS
• LIMITATIONS
• TECHNIQUE
• PATHOLOGY

11. Sonographic Anatomy

12. 1.POSITIONING
Best method to examine the patient is while
seated on a revolving stool.
This position allows the examiner to reach
the anterior, lateral and posterior aspects of
the shoulder with the probe by simply asking
the patient to rotate on the chair

13. STEP 2: BICEPS BRACHIITENDON, LONG HEAD.
The patient is asked to place his or
her hand palm up on the lap i.e.slight
internal rotation (directed towards
the contralateral knee) with the
elbow flexed 90°, palm up.The
transducer is placed in the axial
plane on the body over the anterior
shoulder.
Within the bicipital groove lies the
long head of the biceps brachii
tendon, seen in short axis.

14. Because the biceps tendon is coursing deep away from the skin surface, it is common for the
tendon to appear artifactually hypoechoic from anisotropy.
This artifact is eliminated by making the transducer along the long axis of the tendon so that
the sound beam is angled superiorly.The normal tendon will then appear hyperechoic and
fibrillar.

16. The transducer is then turned 90°
to visualize the biceps tendon in
long axis.
Transducer pressure distally is
usually needed to aim the
ultrasound beam cephalad and
perpendicular to the biceps
tendon, which will appear
hyperechoic and fibrillar.
If the biceps brachii tendon is
oblique to the sound beam, it will
appear hypoechoic from
anisotropy.

18. STEP 3: SUBSCAPULARIS AND BICEPSTENDON SUBLUXATION
/DISLOCATION.
With the patient’s hand remaining palm up on his or
her lap, the transducer is again placed over the
anterior shoulder in the axial plane to visualize the
bicipital groove.
The transducer is then centered over the lesser
tuberosity at the medial aspect of the
bicipital groove.
The patient is then asked to externally
rotate the shoulder. As the lesser
tuberosity rotates laterally, the
subscapularis located inferior to the
coracoid is pulled laterally.

22. The US transducer is then rotated 90°
along the long axis of the
subscapularis and moved laterally
over the bicipital groove to ensure
that the long head of the biceps
brachii tendon is normally located in
the bicipital groove.
Partial displacement of the biceps
tendon from the bicipital groove is
termed subluxation, while complete
medial displacement
is termed dislocation.
Such abnormal position of the
biceps tendon may only
occur transiently during
external shoulder rotation.

26. Biceps brachii tendon tear. Longitudinal scan of the bicipital groove
shows proximal retraction of the biceps muscle (long arrow). A fluid-filled
gap with echogenic clots (small arrow) at the myotendinous junction.

27. Biceps brachii tendon synovitis. Axial scan of the biceps tendon shows fluid
and synovial thickening (arrow) surrounding the biceps tendon sheath.

29. STEP 4: SUPRASPINATUS AND ROTATOR INTERVAL

30. The bony prominences formed by the clavicle (a), acromion (b), and
coracoid process (c) . Other visible contours represent the greater
tuberosity (d) and spine of the scapula (e),which ends at the medial flat
surface (f ), over which slides the aponeurosis of the trapezius muscle

32. Corresponding US image over humeral head shows hyperechoic and fibrillar
supraspinatus tendon (SS). Note biceps brachii tendon (B) in the rotator interval with
superficial coracohumeral ligament (arrowhead) and medial superior glenohumeral
ligament (arrow). SC = subscapularis tendon, curved arrow = hyaline articular cartilage,
wavy arrow = subacromial-subdeltoid bursa, H = humeral head. Right side of image is
anterior.

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

34. SST Midsubstance full thickness tear

35. Trans Midsubstance tear

37. CompleteTear

38. SUPPORTING SIGNALS
• CLINICAL ASSESSMENT
• SUBACROMIAL-SUBDELTOID EFFUSION
• CORTICAL IRREGULARITY OFTHE GREATER
TROCHANTER

39. POST REPAIR ASSESSMENT
• THINNED OUTTENDON
• HUMERALTROUGH
• JOINT EFFUSION
• SUTURE MATERIAL
• RESECTION OF SUBDELTOID BURSA

41. Corresponding US image shows
acromioclavicular joint (arrow) with
characteristic hyperechoic bone
contours of the distal clavicle (C) and
acromion (A).
Note echogenic fibrocartilage disc
(arrowhead).
To locate the acromioclavicular joint, one may
simply palpate the clavicle and move laterally
toward the acromion, with the transducer in
the coronal plane on the body.
STEP 5:
ACROMIOCLAVICULARJOINT, SUBACROMIAL-SUBDELTOID
BURSA, AND DYNAMIC EVALUATION FOR
SUBACROMIAL IMPINGEMENT.

42. The acromioclavicular joint is evaluated for bone irregularity,
narrowing, widening, or offset.
If the acromioclavicular joint is widened or if there is clinical suspicion
for acromioclavicular joint disruption, dynamic evaluation should be
used to assess for changes in alignment.
While assessing the acromioclavicular joint in long axis relative to the
clavicle, the patient is asked to move his or her ipsilateral hand to the
opposite shoulder.
With this maneuver, the acromioclavicular joint may abnormally
widen or offset or may cause a bone-on-bone contact between the
acromion and clavicle, which can be associated with symptoms.

43. With the bone landmarks of the greater tuberosity and the lateral acromion in view, the
patient is asked to actively elevate the arm to his or her side.

44. Dynamic evaluation is then used to assess for subacromial
impingement.
The transducer is moved laterally from the acromioclavicular joint and is positioned
over the lateral edge of the acromion.
Corresponding US image shows acromion (A) and greater tuberosity (GT) with
supraspinatus tendon (S) and collapsed subacromial-subdeltoid bursa (arrow).

45. US image shows acromion (A), greater tuberosity (GT), and normal collapsed
subacromial-subdeltoid bursa (arrow).
During active arm elevation, the supraspinatus tendon and overlying subacromial-subdeltoid
bursa should slide smoothly under the acromion and out of view.

46. Pooling of bursal fluid at the lateral acromion edge or
snapping of bursal tissue indicates subacromial
impingement.
Other findings of impingement include interposition
of the supraspinatus tendon between the greater
tuberosity and the acromion, as well as direct contact
between the greater tuberosity and the acromion.
Dynamic evaluation for subacromial impingement
can also be completed with the patients raising their
arm anterolateral in front of their body, with their
hand in pronation.

48. STEP 5: INFRASPINATUS,TERES MINOR, AND
POSTERIOR LABRUM
To evaluate the infraspinatus tendon,
the hand is returned to the patient’s
lap, palm up.
In this neutral position, the transducer
is placed just below the scapular spine
over the posterior shoulder in a
slightly oblique axial plane that
parallels the orientation of the
scapular spine.

49. This position will produce a long-axis view of the infraspinatus tendon, which is
assessed at its insertion on the posterior aspect of the greater tuberosity.

50. Moving the transducer medial toward the scapula, other structures to be evaluated include
the posterior labrum (for labral tear), the spinoglenoid notch (for paralabral cyst), and the
posterior glenohumeral joint recess (for joint fluid or synovitis)
US image medial to b shows spinoglenoid notch (arrowheads) of scapula with adjacent
suprascapular vessels. Note infraspinatus musculotendinous junction (straight arrows) and
central tendon (curved arrows). H = humeral head, L = labrum.

51. The transducer is then rotated 90° to assess
the infraspinatus tendon in short axis.
Corresponding US image shows infraspinatus (straight arrows) and central tendon (curved
arrow). S = scapular spine. Left side of image is superior.

52. In addition to evaluating the infraspinatus tendon for tear, it is
important to evaluate for fatty degeneration and atrophy of the
infraspinatus muscle in the setting of a rotator cuff tear as this
finding indicates higher likelihood of failure after rotator cuff
repair.
The transducer is moved medially
over the musculotendinous
junction of the infraspinatus in
short axis.

54. MISCELLANEOUS

55. FRACTURE GREATERTUBEROSITY

57. Cortical depression in posterior superior
aspect of head of humerus.

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

63. Acromioclavicular joint cyst.

64. THREE DIMENSIONAL USG

65. • Multiplanar and 3D representation of biceps tendinitis in a patient
suffering from shoulder pain and weakness. Note the focal
calcifications at the level of the insertion, enlarged and irregular biceps
tendon, and effusion.

66. Ultrasound examination of
the knee joint.

68. ULTRASOUND OFTHE KNEE –
Normal.
Transverse scan plane
for the quadriceps
Transverse suprapatella region:
•RF: Rectus Femoris •VI:Vastus
intermedius
•VL:Vastus Lateralis •VM:Vastus Medialis

69. Suprapatellar scan plane.
Longitudinal suprapatella region showing the
suprapatella bursa and quadriceps tendon.

70. Prepatellar scan plane.

71. Infrapatellar scan plane. The infrapatellar tendon.
Also called the patella ligament.

72. The insertion of the infrapatellar tendon
onto the tibial tuberosity. Note:The
normal physiological amount of fluid
along the underside of the tendon.
Transverse Infrapatellar tendon. Note how
wide it is, to then have an understanding of
the area you need to examine in longitudinal.

73. Pes anserine scan plane.
The Pes Anserine bursa and tendon insertion
are medial to the Infrapatellar tendon on the
tibia, adjacent to the MCL insertion.
Remember the Pes Anserine tendons
as (sargent) SGT: Sartorius, Gracilis
and semi-Tendinosis.

74. Medial knee joint scan plane. The medial collateral ligament (green) directly
overlying the medial meniscus (purple).

75. Lateral knee joint scan plane.
Assess the Lateral collateral ligament, Ilio-Tibial
band insertion and peripheral margins of the lateral
meniscus. Unlike the medial side, the LCL is
separated from the meniscus by a thin issue plane.

76. Ilio-Tibial Band.
Rotate the probe off the LCL with the toe
of the probe angled slightly posteriorly.

77. Popliteal fossa scan plane. Medial aspect of the popliteal fossa showing
the semimembranosis/gastrocnemius plane.

78. Ultrasound of the Popliteal vein and
artery in transverse.Without and
with compression to exclude DVT.
Confirm both arterial and venous flow
and exclude a popliteal artery aneurysm

79. Posterior knee: Semimembranosogastrocnemia bursa
region transverse

80. Posterior knee: Peroneal nerve transverse

81. Posterior knee: Peroneal nerve longitudinal

82. Posterior knee: Posterior horn of the medial meniscus

83. Posterior knee: Posterior horn of the lateral meniscus

84. Posterior knee: Posterior cruciate ligament insertion
longitudinal

89. Posterior knee: Intercondylar fossa transverse

90. Quad tear??? No!!! - ANISOTROPY

94. Prepatellar Bursitis

95. Prepatellar Bursitis

96. PatellarTendinosis
Normal Swollen

97. Partial PatellarTendonTear

98. PatellarTendon Rupture

99. PatellarTendon Rupture
Top Images: Tendon Rupture
Bottom Images: Post operative

100. Medial Collateral LigamentTear

101. Medial Collateral LigamentTear

102. Medial MeniscusTear

103. Jumpers Knee

104. Osgood Schlatter on both sides with cartilage swelling and
fragmentation of the apophysis.

105. Osgood schlatter disease with cartilage swelling and irregular apophysis
and thickened hypervascularized inhomogeneous patellar tendon.

106. Popliteal Artery Aneurysm

107. Horizontal lateral meniscus rupture and meniscal cyst.

108. Baker's cyst. Longitudinal scan of the medial aspect of the popliteal fossa
shows a well-defined cystic lesion with a narrow neck. It contains echogenic
debris and thick septa, which are characteristics of a complicated Baker cyst.

109. Baker's cyst.

110. Rheumatoid arthritis: US shows synovial thickening and effusion.
The synovial thickening appears hypoechoic or heterogenous
proliferation of the synovial membrane with poorly defined
contour.
Doppler study show increased vascularity within the
hypertrophied synovium.
Degenerative arthritis: Sonography show extent of cartilage
damage and US also show thinning or disappearance of the
cartilage.
Osteochondral defect of the femoral condyle appears as thinning
of the hyaline cartilage or as irregularities or defect of the
hyperechoic bone cortex.
Bone lesion:The cortex is an intensely hyperechoic interface with
distal acoustic shadowing. Fracture appears as breaks or steps in
the hyperechoic cortex, often accompanied by a hypoechoic
subperiosteal hematoma. Sonography has been used to measure
the thickness of the cartilaginous cap of an osteochondroma.

111. Rheumatoid arthritis. Longitudinal ultrasound scan shows a small
effusion in the suprapatellar bursa with mild irregular thickening
of the synovial membrane, which is indicative of inactive disease.

112. Degenerative arthritis.Transverse ultrasound scan of the flexed knee shows loss of
the normal hypoechoic pattern of the articular cartilage, marked irregularity of the
cartilage–soft-tissue interface, and blurring of the bone–cartilage interface.

113. Osteochondral defect. Defect and displacement are seen in the
hypoechoic articular cartilage and hyperechoic bony cortex.

114. Osteochondroma. Ultrasound scan of the knee joint shows bony
outgrowth from the upper end of the tibia. Ultrasound can be used
to measure the thickness of the hypoechoic cartilaginous cap.

115. Loose bodies. Ultrasound scan of the popliteal fossa shows two large
loose bodies within a popliteal cyst with posterior acoustic shadowing.

116. Soft-tissue masses. (A) Intramuscular ganglion: longitudinal scan along the
popliteal fossa shows a well-defined, thick-walled, multiloculated intramuscular
cyst with mild flow within the septa with color Duplex examination. (B) Soft-
tissue sarcoma: Sonogram shows a large mass in the popliteal fossa with mixed
echogenicity and increased vascularity on the color Duplex examination.

117. Pigmented Villonodular Synovitis with a vascularized hypoechoic mass
on the medial aspect of the knee extending behind the patellar tendon.

118. Dermatofibroma on the medial side of the knee.

119. Gastrocnemius muscle injury. Sonogram of the medial aspect of the
popliteal fossa shows disruption of the gastrocnemius muscle with
a hyperechogenic intramuscular hematoma denoting acute injury.