This document provides information about shoulder ultrasound scanning techniques and normal and pathological findings. It discusses the anatomy of the shoulder joint and describes the scanning protocol. Normal ultrasound images of structures like the biceps tendon, subscapularis tendon, and supraspinatus are presented. Common pathologies like rotator cuff tears, biceps tendon subluxation, calcific tendinitis, and tendinosis are described. Criteria for diagnosing tears and classifications of partial and full thickness tears are outlined.

1. USG
SHOULDER
 PRESENTED BY: DR. RAJ VAGHASIYA
 GUIDENCE : DR. NALIN G. PATEL (H.O.D. & PROF. RADIOLOGY DEPT.)
 REFERENCE: RHUMACK.
RADIOGRAPHICS.
MUSCULOSKELETAL USG
GUIDELINE.

2. Point to be discussed:
 Anatomy
 Scanning technique
 Normal shoulder imaging
 Pathology

3. NORMAL SHOULDER
ANATOMY

4.  Shoulder joint is complex ball and socket
joint.
 Consist of:
3 bones: 4 joints:
1.Humerus 1.Glenohumeral joint
2.Scapula 2.Acromioclavicular joint
3.Clavicle 3.Sternoclavicular joint
4.Scapulothoracic joint

6. SHOULDER USG
PROTOCOL
I. Bicep brachii tendon,long head
II. Subscapularis and bicep tendon
subiuxation/dislocation
III. Supraspinatus and rotator interval
IV. AC joint, subacromial-subdeltoid bursa and
dynamic evaluation for subacromial
impingement
V. Infraspinatus,teres minor and posterior
labrum.

7. Scanning Technique
I.BICEP TENDON LONG HEAD
1. Place Ipsilateral arm in slight internal rotation
with elbow flexed 90 with palm up.
2. By finding long bicep tendon in between
greater and lesser tuberosity.
3. Shift probe up to examine bicep in its
intraarticular course and down reach the
myotendinous junction.

8. SHORT AXIS VIEW OF BICEP
TENDON

9. LONG AXIS OF
BICEP

11. II.SUBSCAPULARIS
TENDON
 Position:
rotate the arm externally fixing the elbow
on iliac crest to show subscapularis
tendon and its insertion at lesser
tuberosity.

12. LONG AXIS VIEW
Deltoid

14. SHORT AXIS SCAN

15. III.SUPRASPINATOUS
 Place the arm posteriorly placing the
palmar side of hand on superior aspect
of iliac wing with elbow flexed and
directed posteriorly.

17. LONG AXIS VIEW

18. SHORT AXIS VIEW

19. Rotator interval
 Defination: tunnel through which long head of
bicep travels from its origin at supraglenoid
muscle
 In rotator interval,long head of bicep brachii
seen in short axis between supraspinatus and
subscapularis tendons.

20. Bicep tendon

21. IV.Acromio-clavicular joint
 Place the transducer in the coronal
plane over the shoulder to examine the
AC joint.
 Sweep the transducer anteriorly and
posteriorly over joint to assess presence
of an os acrominale shifting the probe
posterior to AC joint,it is possible to
assess the status of supraspinatus
muscle.

22. c
A
A-Acromion
C-Clavicle

23. SUBACROMIAL
IMPINGMENT
 Dynamic assessment of subacromial
impingment can be attempted by placing the
tranducer in coronal plane with its medial
margin at the lateral margin of the acromion.
 Patient is ask to abduct his arm while in
internal rotation.with this manoeuvre,the
supraspinatus and bursa can be seen passing
deep to coracoacromial arch.

25. IMPINGEMENT TEST
 Repetative friction results bursal
thickening and is often accompanied by
minimal fluid accumulation.
 During dynamic testing the thickened
bursal tissue may be seen to bunch up
against the outer edge of the
acromion,failing to pass beneath it.

27. V. INFRASPINATUS
 Place the transducer over posterior aspect of
glenohumeral joint with hand on opposite
shoulder.
 Use spine as landmark to distinguish
supraspinatus from infraspinatus fossa in
saggital plane.
 Look at the infraspinatus and tere minor
muscle as individual structure filling
infraspinatus fossa deep to deltoid.

28. POSITIONING

29.  Long axis view

30.  Short axis view

31. Posterior structure of
shoulder
 Examine the tendon separately on their
long axis during external and internal
rotation of arm by placing probe over
posterior aspect of glenohumeral joint.

32. HH
HH-Humeral head
I- Infraspinatus
I

33. HH-Humeral head
T-Teres minor

35. PATHOLOGICAL
CONDITIONS
 Rotator cuff ruptures
 Tendinosis
 Bicep tendon subluxation/dislocation
 Rotator cuff interval tears
 Rotator cuff calcific tendinitisS

36.  Rotator cuff tear
 Trauma(acute / chronic microtrauma)
 Adult >40 yrs
 Collagen vascular disease
 Partial tear >>full thickness tear.
 Types: complete and partial tear.
 m/c muscle involved “supraspinatus”.

37. Criteria for diagnosis of
rotator cuff tear
 Non-visualization of cuff
 Focal non-visualisation
 Discontinuity
 Focal abnormal echogenicity.

38. TYPES OF PARTIAL
TEAR
 Southern California rotator cuff
classification depending upon location:
1.Bursal
2.Interstitial
3.Articular surface
 Ellman Grading:
Grade 1:<3 mm in thickness
Grade 2:3-6 mm in thickness(not more than
half of thickness)
Grade 3:>6 mm.

40. Partial tear on USG:
 Decreased echogenicity and thinning in
affected region.
 Loss of convexity of tendon / bursal interface
in bursal surface tear.
 Calcific foci in tendon.

41.  Full thickness tear
 Etiology is similar to partial thickness tear.
 Same radiology features
 ON USG:
1.Focal tendon interruption
2.Fluid filled gap
3.Loss of convexity of tendon/bursal interface
4.Uncovered cartilage sign.
5.Tendon retraction.

42. Ellman and Gartsman
classification
1. Crescent
2. Reverse L
3. L shaped
4. Trapezoidal
5. Massive tear full thickness rotator cuff
tear.

45. Bicep tendon
dislocation/subluxation
 Dislocation of long head of bicep from
bicipital groove.
 Subscapularis and coracohumeral
ligament are major stabilizer of bicep.
Etiology:
 Due to disruption of stabilizing ligaments
 Shallow bicipital groove

47. Rotator cuff calcific
tendinitis
 Calcium hydroxyapatite deposition
disease.
 Calcifying bursitis
 Etiology:
1.Avascular change
2.Trauma
3.Abnormal calcium deposition

48.  Location :
Supraspinatus>>infraspinatus>>tere
minor>>subscapularis
CT better localization of calcium.

49. Calcific focus in supraspinatus

50. TENDINOSIS
 Degeneration of long head of bicep
 Etiology:
1.Chronic microtrauma
2.Accompanies with rotator cuff disease
3.A/W subacromial impingment
4.May accompanies tenosynovitis

51.  On USG:
Thickening of long head of bicep
Fluid surrounding bicep tendon

53. THANK YOU