Ultrasound of the Shoulder - Technique - SD

Introduction to Shoulder Ultrasound

The ultrasound of the shoulder involves trying
to recall it as a modular approach
so the shoulder joint can have a sub folder known
as the anatomy and the technique.
From there, it's not uncommon for us to show you part three,
which would be a live demonstration on how
to exactly perform the routine exploration of the shoulder.
And last but not least, of course we'd like
to show some pathology.
My part for today is to show you the part two of
the ultra sonography of the shoulder
by showing you the techniques that we employ.

Routine Protocols and Topographical Landmarks

Shoulder ultrasound has its routine protocols
and we already started by telling you that
after you become familiar we're to plant your transducer
on the topographical landmark of the patient.
You begin to archive some gray scale images
here in a long axis view you see the parrot beak appearance
of the supraspinatus inserting on the greater tuberosity.
The ultra sonography of the shoulder is all important
after you appreciate the topographical landmarks over the
patient's shoulder, identifying at least in that area
where you expect to see the four rotator cuff tendons,
which is going to be the subs, capillaries,
the supraspinatus, the infraspinatus, and the terce minor.
In order to do that, most of us have familiarized our cells
with the origins
or insertions of these rotator cuff tendons.
Insertion of the subs capillaries involves the
lesser tuberosity.
Insertion of the supraspinatus involves the footprint
of the anterior portion of the greater tuberosity,
and then behind it comes the
infraspinatus inserting again on the posterior portion
of the greater tuberosity
and inferior most, you have the terrace minor in between
the greater tuberosity and the luer tuberosity.
You'll now note that there is a cuff interval,
a rotator cuff interval where you have the longhead
of the bicep tendon
and the longhead of the bicep tendon courses
through this groove, which is known as the intertubular
sulcus or the bpal groove for the shoulder technique.
Here you could see that the explorer puts the transducers in
a sagittal wise type of position, but
because ultrasound is a focus type of examination,
we're actually looking at a single structure
with a transducer in disposition over the
patient's right shoulder.
You'll notice that we're looking at the long axis
of the supraspinatus,
and of course once you have the long axis,
you're actually looking at a single slice.
Frank Netter himself, the great anatomist, realized
that from 2D type of representation of anatomy,
cross-sectional imaging was essential
to get to know anatomy.

Cross-Sectional Anatomy of the Shoulder

Here you see a cross action view off the shoulder.
Let us begin by identifying from the bottom part all the way
up to the superior part, the different structures
that we have to become familiar with.
First you have the subc chondral plate of the convexity
of the humal head.
Then you have the ledge
or footprint of the greater tuberosity.
Beyond that, you have the down sloping part of the deltoid.
If you look at this here, you could have the deltoid shelf
from the subclonal plate of the pro proximal humeral head.
You see the highline cartilage of the articulating surface,
and as we go superiorly, you begin
to see again the fibrile pattern
of the supraspinatus superior.
To that you have a virtual space
of the subacromial deltoid bursa.
Note that the subacromial deltoid bursa is line by synovium,
which will be hyper coic and ultrasound.
So you'll have a hyper coic line representing the
deltoid level of the subacromial deltoid bursa.
Then as you go down to the tendon,
you'll have the hyper coic line of the synovium at the
tendon level or supraspinatus level of the bursa.
And in between this two synovial lining,
you'll see a near imperceptible line
or potential space of the subacromial beal sac.
Continuing upwards, you'll identify the cortex
of the acromion and finally the penate structure of the
deltoid muscle as it originates from the lateral aspect.
At these, in this cross-section image of the acromion
from the color images that you are looking at,
let's now proceed to what it would look like on ultrasound.
Of course over here you have more
or less a whole region we're into appreciate the
cross-sectional anatomy in ultrasound.
It is a more focused field of view
or a smaller field of view,
which gives you exquisite resolution.
So let's get accost to the point
that we're not only only going to leave the color portion
of anatomy and going into gray scale imaging,
but we'll now also look at a smaller field of view.
Here in gray scale imaging you could see the corresponding
ultrasound representation of the same anatomy
that we showed that Dr.
Netter presented to us.
Let us again begin by identifying the convexity
of the humerus and then the footprint
of the greater tuberosity
and then the lateral deltoid shelf.
This is the convexity of the proximal humerus footprint
of the greater tuberosity and the lateral deltoid shelf.
Above the subc chondral plate of the proximal humerus,
you see a dark line,
which is the highline cartilage over
the articulating surface.
Similarly, you also see a hypo coic, which is an artifact
of the insertion of the supraspinatus,
which represents the enthesis or insertion of the tendon.
As we go further superior up, now you begin
to appreciate the filar pattern of the supraspinatus.
Note that as imagers, we'd like
to have certain colloquialisms.
In this case, for example, we think that the
long axis view of the supraspinatus appears to be a parrot
or a beak of a parrot or a parrot's beak appearance.
From here now we can identify a bit of the virtual space
of the subacromial deltoid bursa as a black line in
between two hyper coic lines representing the synovial
lining of the subacromial deltoid bursa proceeding.
Further superiorly, you meet the penate structure
or multi penetrate structure of the deltoid
as it originates from the bony acoustic landmark
of the lateral chromium.
Na shown in Dr. Netter's anatomy is
the subcutaneous fat.
And finally, the skin of the patient.
While we were looking at a long axis, try to remember
that ultra sonography
of the shoulders actually a tomographic type of modality.
Therefore, you have to turn your transducer around
and approach it in the 90 degree partner
of the long axis view, which is now the short axis
in the short axis view.
You also can have a cross-sectional anatomy
here dis articulating the head
of the humerus from the shoulder.
We look at Dr. Netter's tro
and for the first time you're going to note that one
of the first images to approach it would be the long
of the bis tendon in a short axis view posterior to it,
you appreciate the bristle pattern of the anterior
and posterior supraspinatus going into the in infraspinatus.
As we proceed further up,
we'll see one more time the virtual space
of the subacromial deltoid bursa With its synovial
lining, Dr.
Netter dispense with the drawing of the deltoid muscle,
which we'll be seeing shortly on ultrasound.
So like we told you that ultrasound is a tomographic type
of modality but also
has high resolution smaller field of view.
So let's focus into an area
and one more time leave what we've gotten accustomed to
as color and go to gray scale imaging,
but also leave a large region going to a smaller field
of view representing what we begin
to appreciate on ultrasound.
Starting from the bottom of the image,
you'll see the convexity of the subc chondral plate
of the proximal humerus.
Above that, a black line representing the highline cartilage
As we go a little bit more superior.
Now you see the bristle pattern
that is the 90 degree representation of the fibrile pattern
that you noted on long access view, the bristle pattern
of the supraspinatus
and all the way to the infraspinatus further superior.
Now we begin to see one more time the virtual space
of the subacromial deltoid versa
with its subacromial deltoid lining of nuvia.
Above that, like I warned you not shown by netter, Dr.
Netter was the ide appearance of the deltoid muscle.
And one more time, we're gonna end up
by looking at the subcutaneous fat or panus.
And finally, the skin note that I told you about the long
of the biceps tendon
and clearly you could see its relation to the supraspinatus.
When you look back to the ultrasound image, you'll notice
that this more hyper echoic bristle pattern
represents short axis view of the long head
of the biceps tendon.
Remember that all images on ultrasound have
to be approached in orthogonal planes.
So after looking at something on short axis view,
one more time, the bone acoustic landmark of the humerus,
the bristle pattern of the supraspinatus
as you go from anterior to posterior portion
for the infraspinatus,
separated from another bristle oval pattern of the longhand
of the bis tendon and short axis
approaching the virtual space
of the sub acromial delta bursa
and into the styro night appearance in the short axis view
of muscle ending up with the subcutaneous fat and skin.
When you do a slice across this for long axis view,
you now end up with the paired beak appearance
of the supraspinatus with its filar pattern
inserting on the footprint of the greater tuberosity,
the greater tuberosity itself separated from the convexity
of the humerus by the anatomic neck.
The near imperceptible space
of the subacromial delta bursa can be appreciated here
and of course superior to that the multipennate structure
of muscle multipennate meaning like the
veins of a leaf or feather.
And one more time, just like the shorten axis you ending up
with the subcutaneous fat
and skin for normal shoulder exploration
or routine protocol, we begin
by taking a look at the anterior region.
The four regions will be approached systematically in order
to more or less cover as much of the region as we can.

Anterior Region: Biceps Tendon

The joint is first explored by asking the patient to assume
a position wherein he rests his hand on his
thigh with his palm up.
This affords us the chance
that the shoulder will be slightly externally rotated
and will give us a better exposure of the bicipital groove.
And here in yellow you could see the long head
of the bicep tendon.
We'll put the probe across the patient transversely,
but we're going to be looking at the short axis view
of the long head of the biceps tendon.
First, identify the bone acoustic landmarks
and from left to right you see the greater tuberosity,
the canyon of the bicipital groove
and another peak which represents the lesser tuberosity.
In between those two peaks, you see the bristle pattern
of the hyper coic long under the biceps tendon in its short
axis plane medial
or internal to the lesser tuberosity.
You'll appreciate some anisotropic effect
of the subs capillaries.
The subcap failures inserts on the peak
of the lesser tuberosity,
but also sends out some packed fibrile pattern
of the transverse humal ligament that we shown earlier
with Dr vs anatomic slides above that,
because we're in short axis view, you now appreciate
that the deltoid muscles going
to have a styro night appearance
underneath the hyper coic fat.
And of course finally the skin Recall
that these are tomographic cuts, so you have
to make a sweep across the entire structure here in yellow
with the the patient.
Again, in a neutral position, you appreciate
that the probe has to be moved from the superior portion
to more distal portion.
When you do that, now you are into the shallower part of the
bicipital groove, readily appreciated as the distal portion.
Here you could see the bristle pattern
of the oval along the biceps stand,
and in short axis lying in the bici groove
between the greater tuberosity and lesser tuberosity.
Above it you have the sty appearance of the deltoid muscle
underneath the fat and skin.
This is why we were telling you that as imagers,
we could tell what level we're at.
That's because remember that we told you
that the proximal portion of the bici groove is deep.
So as the red colored longhand device tendon runs
through it on short axis, clearly we can identify
that when it is a deep bici groove,
we're in the proximal portion
and when it's a shallower bici groove,
we're in the distal portion of the biceps tendon,
but we're not finished with that
because we did warn you
that ultrasound is a tomographic modality
and we have to look at it on long axis.
Turn the probe around 90 degrees
and follow the longer axis of the longhand.
The bicep tendon patient's still in neutral position
and once doing that, you begin to appreciate
that From the short axis bristle pattern,
we now have a fibrillar pattern of the longhead,
the biceps tendon.
I'm showing you only the proximal portion of the longhead,
the biceps tendon, but it's going to be your job
to run all the way to the musculo tendonous
junction above it.
Now because we're on long ax of view,
you see the deltoid muscle.
Its multipennate structure underneath skin
and subcutaneous fat.
One of the things you'll encounter when you explore the
shoulder is the artifact known as anisotropy.
When the transducer is not perfectly 90 degrees
or perpendicular 90 degrees
to the structure you're looking at in this case the long
of the bias of tendon.
You will create what is usually a hypo coic structure.
You will now force it to be a hypo coic structure.
So you have to be ready to do a heel to maneuver
here in a video clip.
You can appreciate that when the transducer is perfectly 90
degrees, you see the fibrile pattern off the long
head of the biceps tendon.
But when you're not 90 degrees,
you have a relatively hypoechoic tendon which could be
misinterpreted as tendinosis
or some edema within the tendon.
So aside from shoulder positioning, try to remember
that you also have to do some transducer maneuvers,
in this case, a heel to toe maneuver.
Continuing now from the long handed divisive tendon.
Here we'd like to see one, some of the advantages
that the newer ultrasound machines have.
This is called the panoramic view
or an extended field of view.
Let's identify the bone acoustic landmarks.
We are going to look at the convexity of the humeral head
and then on the floor
of the long hood of the bice of tendon.
From there we can identify the soft tissue structures
of the intracapsular portion
of the longhead devices tendon going
to the extracapsular portion.
As you proceed further down, now you begin to catch
the multipennate structure of the biceps muscle
with the fibrile pattern of the longhead
of the biceps tendon, giving you a clear picture
of the musculo tendonous junction of the biceps tendon.
Above that, you see the penate structure
of the deltoid muscle.
As you finish identifying the long
of bis tendon in its two axis,
you move the probe a little bit more medial
and you begin to look at the subs capillaries.
Try to remember that because the subs capillaries was in a
neutral position by asking the patient to rotate his arm out
as shown in this small picture or the insert.
Now you begin to appreciate the bird's beak appearance
of the subs capillaries with its filar pattern
as it inserts in into the footprint
of the lesser tuberosity.
Likewise, you also begin to see the medial portion
of the convexity of the humerus in this patient.
Above it you see the multipage structure
of the deltoid muscle
and under over
that you'll see the subcutaneous fat and skin.
You'll have to rotate the probe 90 degrees
to look at the subs, capillaries
and short axis view with a patient.
Still, as you can see on the photo insert in external
rotation, you'll appreciate the short axis view
of the musculus junction,
but at this level we're going
to show you predominantly the musculus junction.
The muscular tendus junction of course will have muscle
and tendon interdigitating
or interpolating alternatively with each other.
So you'll have hyper coic, tendon hypo coic muscle,
hyper coic tendon,
hypo coic muscle over the head of the humerus.
If you wanna see only tendon, you have
to move the probe exactly over the footprint
of the lesser tuberosity above it.
Now you see this tite pattern of the deltoid muscle
or the at least the anterior third bundle
of the deltoid muscle.

Superior Region: Acromioclavicular Joint and Rotator Cuff

We now leave the an anterior portion of the shoulder
and let's take a look at the superior region.
Because this is relatively a short stop for us.
We are going to almost immediately jump from the superior
region into the antola region, identifying the
supraspinatus and in infraspinatus.
Let's start by looking at the AHR canicular joint,
which is the only structure present in the superior region
of the shoulder, although it's quite important
because its proximity to the rotator cuff
can simulate diseases that may appear just like each other.
So you may have rotator cuff disease
that mimics acrom canicular joint disease
and vice versa, place the probe over the vertex off the
shoulder and just move anterior to posterior.
Sometimes you may have to move just a bit lateral
and you begin to identify the bon acoustic landmark of the
acromial and then the distal portion of the clavicular.
And in between the acromial clavicular
you have the joint space.
The chromal clavicular joint is capped superiorly
by usually a minimally distended capsule.
From there, let's go immediately
to the probably the most important portion
of the exploration of the shoulder.
That includes, as you could see here, the fact that we have
to now identify
and reposition the patient in
what we call the Jeffrey Krass maneuver.
Dr. Jeffrey Krass from Minnesota has his patients
hyperextend the shoulder
and internally rotate the arm trying to ask the patient
to reach for the opposite shoulder blade or scapula.
If your patient's familiar with medical terms,
as you can see on the insert when you do this,
you completely stretch the supraspinatus infraspinatus from
underneath the acromioclavicular junction or joint.
Therefore, that will afford you a complete visualization
of the entire extent of the supraspinatus
and in infraspinatus.
So in the long axis view, everybody has now become familiar
with the parrot beak appearance of the supraspinatus.
One more time. The most important player in this image,
of course, is going to be the fibrillar pattern
of the supraspinatus as it inserts on the footprint
of the greater tuberosity
and the greater tuberosity is separated from the convexity
of the humerus by the anatomic neck.
As you go a little bit more medially, you'll note
that there is some hypo echogenicity
of the musculotendinous junction as the muscle
transforms itself into tendon structures.
Above that, you have the virtual space
of the subacromial deltoid bursa,
which extends just a tad inferior
to the lateral deltoid shelf.
Then you have the multipage structure of the deltoid muscle,
subcutaneous panus.
And finally, the skin. The other bone acoustic landmark
that we see in this single slice is the acromion
or the deltoid originates.
Now turn the probe 90 degrees
to look at the supraspinatus in short axis, we're going
to go from the acromial level down to the
greater tuberosity level, which is the
inferior part of the red line.
As you could see that the yellow structure identifies the
longhead, the bice of tendon in short axis.
So in short axis, the yellow structure
represents the longhead bice of tendon
with its pac fibular pattern on a short axis view behind it,
you have the supraspinatus
and then the infraspinatus arbitrarily separated of course
by the distance from the long B of tendon.
Most of us will say that in the rotator cuff from anterior
to posterior measures about four centimeters.
The first two centimeters is the supraspinatus divided into
the anterior supraspinatus and posterior supraspinatus.
Again arbitrarily
after the two first two centimeters, you go
to the posterior portion,
which is gonna be the infraspinatus
and not shown here would be the terrace minor.
This is all arbitrary
'cause the tendon is a conjoint structure.
Below that you have the convexity
and the alion cartilage of the proximal humeral head.
Above the bristle pattern of the supraspinatus, you have
the potential space of the subacromial deltoid bursa.
In short axis, you see the styre night sky
of the deltoid muscle,
and finally, the subcutaneous fat and skin.
Note that as we move from the acromial level
of the rotator cuff to the greater tuberosity level
or tuberosity level,
that the volume in short axis view changes from what appears
to be a nice thick tendon to a thinner tendon
because we are now again showing a single slice.
So prepare yourselves to move the probe around
and kind of appreciate in real time the entire extent
of the rotator cuff.
We're going to move the probe from the anterior portion
to a more posterior lateral portion,
and here you can see on the insert a position
of the hyperextension internal rotation,
but this time we asked the patient
to relax his arm a bit more by parking his thumb
into his waistband rather than trying to touch his scapula
in the posterior portion.
As the probe moves posteriorly, you begin
to appreciate the convexity of the humerus,
but also the bristle pattern of the infraspinatus.
Going to the more muscular terrace minor above it,
you see the sty night appearance
of the posterior deltoid bundle.
The insert here from Jag Dandu from Toronto
and myself is a drawing with superimposed supraspinatus
infraspinatus and ending up finally with a terrace minor.
So you have to go from the anterior portion off the shoulder
and going to the posterior portion off the shoulder in order
to appreciate the extent of the rotator cuff.

Posterior Region: Glenohumeral Joint

Let's finish by looking at the posterior region
and in this fourth
and last region, we want to look at the glenohumeral joint,
but also a landmark which is a hyper coic appearing
triangle, which is the posterior glenoid labrum
where are going to try
to identify a point which is the vertex off the shoulder.
Another point, which is the posterior axillary fold.
In between these two points, we'd like to imagine
a virtual line Connecting these two points at the upper
and lower thirds of this virtual line is going to
be the portion that you're going to be looking.
If you look back at the insert of the glenohumeral joint,
and once we more or less know the upper
and middle third junction of this virtual line
of the posterior shoulder, we can plant our probe.
One of the first things that might jump at you only
after you have adjusted the depth
of your transducer is going to be a triangle
representing the posterior glenoid labrum.
This is going to be a hyper coic triangle
as seen now on the black
and white image of the ultrasound, a hyper coic triangle
that is the O-ring to the bony glenoid.
This is the posterior glenoid labrum.
Underneath that, between the bony glenoid
and the convexity of the humus,
you have the glenohumeral joint
where you could have abnormal fluid.
Above that, you see the multipennate structure
of the infraspinatus,
and further above that would be the deltoid muscle.
The smaller insert
below the large insert on your left hand side represents the
patient who is going to be swinging his arm in
and out, in
and out in order to accentuate the ball
and socket appearance of the glenohumeral joint.
Here you see a nice example of the glenohumeral joint.
You see the triangular labrum
and underneath it, the glenohumeral joint.
Note that the ultrasound image shows you a bit of fluid
as the patient externally rotates above that.
Aside from the multipage structure,
you see the fibular pattern of the infraspinatus,
and so if the patient swings her arm in and out, in
and out, you create this ball and socket maneuver.
Remember that I told you medial
to the glenohumeral joint is the spinal glenoid groove.
This is the region where you have the neurovascular bundle
here transversely across the patient's back you see the bony
glenoid and the convexity of the humerus.
For the glenohumeral joint capping, that is the
triangular hyper coic posterior glenoid labrum.
As you slide medially, you see this little groove
where you could identify not only the connective tissue
and fat, but also in short axis view,
but a vessel presumably the vein,
so the spinal glen groove is just medial
to the glenohumeral joint.

Dynamic Examination of the Shoulder

Let's finish our examination by showing you one
of the dynamic portions
of routine exploration of the shoulder.
Here you could see that Dr.
Sum Lee, who was our visiting fellow,
is planting the transducer over the patient's shoulder,
identifying what is going
to be the acromion from the greater
tuberosity as the patient.
Ab ducks or our professional model, ab ducks
or arm, both the subacromial deltoid bursa
and the supraspinatus have to glide underneath the acromion
with no obstruction and without friction.
So if you look at that on great scale imaging,
first identify the bone acoustic landmark.
You identified the top portion of the bone acoustic landmark
of the acromion, and then the footprint
of the greater tuberosity.
You all know that the paired beak, fibular pattern
of the supraspinatus inserts on the footprint
of the greater tuberosity.
So as the patient ab ducks her arm, note
that the pared beak snags, they're obstructed.
It can no longer glide in completely
underneath the acromion.
Likewise, you'll see bunching up
of the subacromial deltoid bursa.
That is just one way of to look at the shoulder.
But what's more important to remember is that try
to remember where to put your transducer by
identifying the topographical landmark where you want
to land with your transducer.
From there, remember
that the bony acoustic landmarks are going to be the point
of interest that will identify
where your soft tissue structures are.
And once you know the soft tissue structures,
therefore you should be able to identify the lesions
and locate them and further measure them.
Last but not least, try to remember that all
of us will have our own routine protocol,
but always create to your best advantage the acoustic
window that you'll be needing.
Thank you very much.