How To: The Shoulder - SD

Introduction and Setup

Hi, good afternoon.

We're going to do a routine exploration of the shoulder using an ultrasound machine, a brand spanking new logic P six.

This is Robert. This is gonna be my model and we're gonna ask Robert to take off his shirt. Okay? And I hope he is not too cold in this area.

Just put it on your lap. We're going to look at the shoulder by approaching it in four regions.

We're going to go anterior and then we're going to go superior. Then we're going to take a peek at the lateral, which actually becomes anterolateral. And finally we're going to look at the posterior shoulder.

Anterior Shoulder

Over the anterior shoulder. We're going to look at two structures. We're gonna look at the long head of the biceps tendon and the subscapularis over the superior portion.

Long Head of the Biceps Tendon

We're going to use the linear array transducer, confirming where the orientation marker is. The orientation marker is always to examiners left or examiner's head, sometimes patient's head, but definitely always examiners left.

We're going to now get the gel and I usually like to start by putting it on the transducer itself, like so we're going to have our model be in a neutral position.

So John, if you zoom out, you can show that his hand is on his thigh with a palm up. When he does that, he has some external rotation.

And with that, therefore we begin by holding transducer in a tripod fashion, meaning that the pinky and the fourth finger are going to be supported on this patient's skin.

So we're going to put it transversely across his body, but we're going to look for the short head longhead, the biceps tendon, we do that once we have a perspective.

And here on the white cursor, here's the long head of the biceps tendent.

So first you adjust by having perspective. Here's the boney acoustic landmark of the OID process. Then the boney acoustic landmark of the proximal humerus with the bicipital groove, the lesser tuberosity and the greater tuberosity.

So I'll go into the extracapsular portion of the longhead of the biceps.

With this perspective, I'm going to adjust the depth now. So in order to more or less magnify and fill up the screen, I'm going to adjust the window a little bit more gain please overall gain. And we can begin.

So this is the first view that we're going to take on the proximal part, short axis view of the longhead of the bicep tendon. And this would be my first picture, a static picture.

From here we're gonna go on down and go to the distal portion where we see the distal portion of the longhead of the bicep tendon in short axis view.

And once we've done that, then we make a sweep from the intra cap intracapsular portion. Here you could see the intracapsular portion of the longer of the biceps tendon to the extracapsular portion and the long in the short axis view.

Note that by tilting the tail of that transducer up or down, I can cause an isotropy of the tendon. And so you have to be careful in avoiding that.

And the other structures to remember in this short axis view, if I can park myself in the optimal plane, would be first would begin by looking at the longhead of the biceps tendon.

And then you can look at the transverse humal ligament and then the subs capillaries with a little bit of anisotropy over all of that.

You see the deltoid muscle with a thyroid night pattern. And then you get to see the subcutaneous panus or fat. And finally, the skin.

Don't forget that the most important structures I already aforementioned by talking about the lesser tuberosity and bicy groove and the greater tuberosity we have finished with the short axis view of the long end of the bicep tendon.

And I'm going to turn my probe counter clockwise in order to look at that tendon and the long axis view, you will be encountering the artifact known as an isotropy because the face of the probe is no longer perpendicular to the tendon.

So now John, can you zoom in on the transducer? This is the heel toe maneuver wherein I'm trying to bring the face of the transducer that is the face of the transducers on the skin surface.

And now you could see that I get a perfect filar pattern all the way from the intracapsular portion to the extracapsular portion, provided I continue maintaining a heel toe maneuver and avoiding the artifact of an isotropy.

This is an isotropy which may mimic make tendinosis.

Now I'm gonna move down all the way to the muscular tendonous junction because of the depth and the well-developed muscles of our model.

I'm going to adjust the depth and go a little bit more into the region of the musculoskeletal junction.

And here you see the fibular pattern. You see the fibular pattern of the tendon going into the penate structure of the biceps tendon.

And we go all the way back again in long axis view that finishes the examination of the first of two structures in the anterior region of the shoulder, which is the long end of the biceps tendon.

I'm gonna go back to the homepage and look at the long end of the biceps tendon in short axis view.

Subscapularis

And we're going to be addressing the subs capillaries, which is this tendon with its anisotropic artifact between the corco process and the lesser tuberosity.

Bob, I'm gonna be asking you to rotate your arm out here. Watch me please. Mm-hmm. Yeah, I want you to bring your arm out this way and bring it back in. Okay? Rotate it out and bring him back in.

So we're gonna start first with you in neutral. Let me position myself. Okay? And we're going to look for the longhand biceps tendon. Okay? And, okay, Bob, ready? Mm-hmm. Bring it out now. Okay. And stop. Bring it back in and stop. Bring it out and stop. Okay.

So with that, therefore we now are taking a look at the subs capillaries in external rotation. And if I rock the transducer one more time, I can see the fibrile pattern.

Remember that it is a quite a broad sheet, so you have to start from superior to inferior.

So again, you start very superior to the most superior portion until you see the inter capsular portion of the tendon and then into the lesser tuberosity and all the way down until you're out of the plane of the subs capillaries.

I'm gonna ask Bob to maximize his external rotation in order to see the tendon in its entirety.

And I will be documenting first the tendon in a partial rotation wherein I get to see the longer the biceps tendon and the subs capillaries.

And then I'm going to ask him to fully turn it out so I can see it in its full extension and its fibrillar pattern.

While I'm in this area, I'm going to turn the probe counterclockwise until I get to see the short axis of the subscapularis.

When I'm towards the cul tendus junction, I can mimic tendinosis because of the interdigitating muscle and tendon structures.

Therefore, you'll have hypo coic muscles, and then you have hyper coic tendons. So it may mimic tendinosis.

So to be perfectly accurate, therefore you may start at the muscular tendons junction. Slide over to the lesser tuberosity.

So one more time in short axis view, first the musculo tendonous junction where you see interrelated between the hyper coic tendons, the hypo coic muscle.

But I'm going to go all the way to the edge of the lesser tuberosity wherein I could see only tendon at this point.

So once I'm done, I go back to the long axis view of the subs capillaries, and then ask Bob to go back to the neutral position where we started.

And one more time, into the long head of the bicep tendon.

So we're through with the anterior part of the shoulder, and we're through with the first two structures, the long head of the bicep tendon, and the subs capillaries.

Superior Shoulder

Now we're going to look at the acro vicular joint.

The acromioclavicular joint is approached by coming in from the very top and landing at the vertex of the shoulder. And once you do that, then you should fall into the joint space itself.

If you fail in doing so, what we could do is we could always start from the lateral part of the shoulder or in, you get to see the eagle's beak of the supraspinatus, and you see the lateral edge of the acromion.

And then you proceed medially until you fall into the joint space.

I'm going to adjust the focus and then clearly see what's going to be the right acromion, the right clavicular or clavicle. And then, so I have the acromioclavicular joint.

Because it is a anterior posterior wide joint, I'm going to scan posterior to anterior and back.

So first identify the joint one more time. As you could see with a normal splaying of the dorsal capsule.

And you go posterior into the anterior portion, posterior to anterior portion towards the posterior area. You could see a mild distention of the capsule, but still within normal limits.

And that is what we'll see. Again, a single structure of the acrom canicular joint. Only a single structure noted for the superior shoulder.

Anterolateral Shoulder

Now we're going to go to the antral lateral portion of the shoulder.

We're going to ask Bob to sit at the edge of the chair. And first I'm gonna ask Bob to turn towards me and show you the position that he's going to be at.

Bob, I want you to put your arm behind you and try to reach for your opposite shoulder blade. This is the left shoulder examination where we're now stretching the supraspinatus.

Remember that? I'll be looking at the right shoulder. So if you look at the left shoulder, you're notice that it may be uncomfortable.

So I'm gonna ask Bob to put his thumb at his belt line. Okay? And so that's a modification at the belt line, at the belt line behind you. Okay? And then sometimes of course, we're going to modify the images by asking Bob to put his palm behind his hip pocket. Okay? But always keep the elbow behind him.

So that's the position we need to look at the supraspinatus and in infraspinatus. Are you ready? Mm-hmm. Okay.

So stay at the edge of the chair. Mm-hmm. Okay. And slide out. And we're going to be looking at your right shoulder.

So the command, the command is going to be put your hand behind you and reach for your opposite shoulder blade.

I like to start the examination by looking at the superspinatus and infraspinatus all the way to the terrace miner.

In the long axis view, the long axis of the humerus is the long axis of the rotator cuff. So therefore, the short axis of the humerus is also the short axis of the rotator cuff.

Notice that we're dealing with a radial contour, and so we're becoming radially across the entire section, whether on short axis or on long axis.

So like I said, I'd like to start on long axis. So let's begin by making sure that the orientation marker is towards the ceiling.

So one more time, you hold it in a tripod to hold a transducer in a tripod fashion. And we're going to look for the eagles beak appearance.

And once we have the eagles beak appearance, now we're ready to examine in a radial fashion the entire rotator cuff, supraspinatus and infraspinatus.

We begin by sweeping an medial and identify the different structures.

I'm going to pause here now that I have the perspective, and then release that and adjust the depth. So we can fill up the screen of the monitor and we'll park here.

We're going to be taking a look at the structures of the first, the mon acoustic landmark of the proximal humerus, composed of the footprint of the greater tuberosity, the brim of the greater tuberosity, and the lateral shelf of the greater tuberosity.

We go back to the footprint going to the anatomic neck, which separates the greater tuberosity from the convexity of the humus.

Note on top of the humus is the highline cartilage of the proximal humus.

The next structure you're going to see is the fibrile pattern of the supraspinatus shape, like an eagle's beak inserting on the footprint of the greater tuberosity.

On top of that, you're going to appreciate the subacromial deltoid bursa with the imperceptible sac, which is represented the black stripe.

The two white stripes are make of the sinia or perver of fat pad. On top of that, you have the penate structure of a muscle and long axis view, which is the deltoid muscle.

So only in a long axis view underneath the fat of the skin, we can look again very medially and cruise on in a radial fashion all the way posteriorly.

We're now in the infraspinatus making sure that I'm moving in a radial fashion all the way back into the terrace miner. And so here you get to see the terrace miner.

So one more time. In long axis view, you have the supraspinatus with a accentuated anatomic neck. And then we're going to move to the infraspinatus with a more elongated B'S beak type of contour.

And then finally, as I go all the way posteriorly, I begin to catch part of the terrace minor, which is shown here.

And notice that while I'm moving from anterior to posterior, I still have to go cran and down. So you're actually moving up, down, and all around, up, down and all around.

So that would be the short, a long access view. But we know very well that any structure is to be looked at in long axis and also in short axis.

So that's how we are going to look at the structures. And in the case, therefore, after I have addressed the super supraspinatus in long axis, I'll now look at it in short axis.

So I'm gonna turn the probe counterclockwise and look at the rotator cuff in short axis.

Note that on the medial aspect, we catch the OID process. And then the next structure you see is the subc chondral plate of the proximal humerus.

On top of that, you have the hyper coic bristle pattern of the supraspinatus anter medially.

And I go back posteriorly to the infraspinatus and again to the terrace minor.

One more time, just like the long axis view, I'm going up, down and all around, back down, looking at the rotator cuff.

Notice that I can go all the way to the acromial level, and as I scoot down, I'm going to go to the greater tuberosity level.

So you're looking at it throughout its entirety, but let us pause here to look at the different structures in the short axis view.

In the short axis view, we're going to see first the bone acoustic landmark of the sub chondral plate, the black stripe with the highline cartilage.

You see the bristle pattern on short axis view of the supraspinatus infraspinatus.

And you see the subacromial deltoid bursa underneath the ty pattern of a muscle and short axis, which is the deltoid.

And then you have the subcutaneous fat and skin.

Notice that in this position, it's very difficult to look at the first square centimeters adjacent to the biceps tend. That is because the position that Bob is in makes it very difficult to look for the critical zone.

The critical zone is the part of the supraspinatus adjacent to the long of the biceps tendon.

So I'm going to ask Bob to move from a hyperextended internal rotation view of the arm into hyperextension.

Bob, can you very smoothly move from that position to the one wherein you put your palm on your hip pocket, okay, with your elbow out? Can you do that? Mm-hmm. Okay.

But let's do that dynamically so I can show them what's happening. You ready? Mm-hmm. Now remember, once you stop at the end, you need to stick your elbow behind you. You ready? Mm-hmm. Okay, here we go.

So I'm going to add just a little bit of perspective. And so we could catch the transition wherein we could see the cuff interval and the critical zone of the supraspinatus.

Go ahead. Bump very slowly notice that as he relaxes, keep going very smoothly, the longer the bicep tendon comes into view, okay?

As we could see here, the longer to the biceps tendon and the structure of the supraspinatus adjacent to it is the critical zone.

Bob, can you stick your elbow a little bit behind you now? Okay, that's it.

So here now therefore we get to see the subs capillaries, the longer to the biceps tendon, the critical zone of the supraspinatus. And this is the rotator cuff interval.

I'll try to catch it in its most orthogonal plane. And here you could see the cuff interval with the long head of the biceps tendon.

And it's very interesting. But our patient now shows a little bit of hypertrophy of one of his cuff slings here with the transition of the corco humal ligament. So that's within normal limits.

And now we're going to show you the critical zone first in short axis, okay? With this mild hypo coic change.

And then we're gonna show it in long axis. First, we're going to show you the long to the B tendon and long axis. And then in short axis, you'll be smack in the critical zone at about this area.

Okay? And the same hypo coic cleft that we were talking about, that probably has a something to do with the cortico humal ligament is shown here where my air is.

We do not think it's a tear, nor do we think it's a tendinosis.

So we're gonna end in this position. And like we said, you gotta go all the way up to the chromium and down.

As you go up to the acromion, you'll notice that you can bridge the corco process to the bone acoustic landmark of the acromion.

Now you could see the corco humeral ligament. This is the corco humeral ligament, which makes out the arc of the rotator cuff.

And as you move down, as you move down, you could see the rotator cuff itself.

So the corco humal ligament acromion, cricoid acrom curricular ligament, and the arch of the rotator cuff or the subacromial arch.

Once we are finished with that, we're going to ask Bob to bring back to his neutral position. And then with his palm up, we're going to ask him now to completely turn around and face away from me.

Posterior Shoulder

So we can look at the posterior shoulder.

In a posterior shoulder, we're going to look for the glenohumeral joint. And to do that, what we're gonna do is first visualize a point of the vertex of the shoulder, a point at the posterior axillary fold.

Imagine a virtual line connecting those two points. And then at the junction of the upper third and middle third of that virtual line is where we park the transducer.

Notice that we're going to go deeper. So we'll actually, we will be adjusting the depth of the transducer.

Once we got that, we'll look at the glenohumeral joint posteriorly.

One more time. The orientation marker is going to be to examiner's left. And so therefore, I'm going to be visualizing the patient on the monitor as a posterior study.

And so we're going to again, adjust the depth quickly and then park the transducer at the junction where we talked about.

And here we see the glenohumeral joint. First you see the bony glenoid, then you see the convexity of the humerus and the triangle of the glenoid labrum.

And I'm going to leave myself there and give Bob a simple instruction.

Bob, do you remember how I asked you to bring your arm out? Mm-hmm. And then in, can you do that for me? Sure. But short arcs. Okay. More in than out short arcs. Okay.

Okay. We'll begin. Let me position myself first. Okay, so here again, I'm supposed to be at the glenohumeral joint.

It is a ball and socket structure that when he, when Bob externally rotates his arm, go ahead please. And then back in all the way in, out, in, out, in, out, in, out. Completely out. Okay. Completely out. Good.

And I'm going to save that on a cny loop and then go ahead and project it in such a way that we could look at the different structures here.

Therefore, we get to see one more time the cny loop. We get to see the glenohumeral joint, like a ball and socket maneuver.

You see the glenoid, you see the humerus, you see the glenohumeral joint, the labrum, and of course the infraspinatus as it translates in and out.

And of course, all of those structures are underneath the deltoid muscle.

And so now you've seen the glenohumeral joint. But around that area too, we have to look for another structure known as the spinal glenoid groove.

And we do that by moving medially from that glenohumeral joint.

So let's have a little bit more of depth on this individual, on Bob. And so from the glenohumeral joint and infraspinatus tendon, we now move medially.

Notice that I'm going to can the transducer a little bit counterclockwise in order to catch the spinal glenoid groove.

And within the spinal glenoid groove, you have the neurovascular bundle of the subscapular artery and nerve.

Here, of course, you could see pulsation of the artery. And why don't we try to see if we can catch the vessel on Doppler please, and then adjust the cane. Okay.

So there you're, okay. Thank you very much.

So that is the spinal Glen group.

Subacromial Deltoid Bursa and Impingement Test

The last part of the examination is going to consist of looking at the subacromial deltoid bursa and rotator cuff.

We're gonna ask our model to bring his hand all the way down, okay. In a neutral position and relax attitude.

Then we're gonna ask him to elevate his arm up and then bring it down.

What we're looking for now is impingement of the glenoid, sorry, of the humerus, the rotator cuff and the bursa.

We do that by asking the patient to start in a neutral position. And then we're going to begin by taking a peek from the posterior area.

Notice that it has a raven, the bird, raven bird type of configuration wherein you see the head of the raven and the beak of the raven.

We're going to ask Bob now to gingerly elevate his arm up all the way down, all the way down, a little faster, up and much faster down. All the way up, okay? And much faster down. Okay?

And we're going to capture it on a video clip. And so we can project it while our patient relaxes.

And here we could see that the both the bony structure, which is the greater tuberosity and the bird speak, appearance of the supraspinatus, goes underneath the subacromial subacromial space without any effort and without any friction.

So we can complete the routine examination of the right shoulder in exactly the way we showed it.

Conclusion: Left Shoulder Examination

But before we finish today, let's show you the position we have ourselves. When we look at the left shoulder.

I'm going to collect all the gel first, and I'm going to ask Bob to step aside while I adjust his seat.

The examination of the left shoulder, again, both examiner and patient, are going to be shoulder to shoulder.

And I'm gonna ask Bob to sit down now facing the monitor with me one more time, the marker to my left. Okay? And that's the way I'll be examining the patient. When I look at the left shoulder.

I'm going to ask Bob just to start neutral position, and we'll just quickly show the long head of the biceps tendon in short axis. And in long axis,

Some of the examiners like the folks out in Mallinckrodt, doctors Middleton, and tfi, would be examining the patient.

But I'm gonna ask you to turn towards John. Okay? Keep turning. Okay.

And they'd be examining the patient from the back if they're looking at the left shoulder with a heel toe maneuver or the right shoulder for the same way.

So this is how most of them will do it. That's all folks.

Thank you very much.