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Role of Ultrasound in Clinical Evaluation
of Shoulder Pain
DR. MUHAMMAD BIN ZULFIQAR
SIMS & SERVICES HOSPITAL LAHORE
INTRODUCTION
• Shoulder Is one of the most sophisticated and
complicated joint of the body with great range of
movements.
• A series of complex ligaments and muscles help in
stability.
• Different pathologies especially related to rotator
cuff are encountered in patients presenting with
shoulder pain.
INTRODUCTION
• By assessing shoulder pain we ascertain integrity of
rotator cuff and extent of tear ,if any, in order to give
a plan to orthopedic surgeon for appropriate
treatment and further management.
• Shoulder ultrasound gives diagnostic sensitivities and
specificities in excess of 90%.
Learning Objectives
• Implications of the morphologic features and extent
of rotator cuff tears for glenohumeral joint
mechanics, treatment, and prognosis.
• Identify injuries to adjacent structures that may
accompany rotator cuff tears and discuss their
implications for treatment and prognosis.
• Describe the value of imaging and evaluating the
rotator cuff muscles.
Learning Objectives
• Distinguish between the potential contributing factors to
impingement syndrome.
• Determine if surgery is contraindicated.
• Radiologist must:
(a) identify and evaluate cuff lesions that may compromise
glenohumeral joint function, taking into account functional
anatomy.
(b) recognize imaging findings that decrease
the likelihood of favorable functional anatomic outcome after
cuff repair.
(c) identify and describe imaging findings that will assist in selecting
a repair technique.
Learning Objectives
• Tear dimensions, tear depth or thickness,
tendon retraction, and tear shape.
• Tear extension to adjacent structures, muscle
atrophy, size of muscle cross-sectional area,
and fatty degeneration.
• Information about the coracoacromial arch
and impingement.
ANATOMY
ANATOMY
Joints (shoulder complex)
Glenoid labrum
• Fibrocartilage similar to knee menisci
• Deepens the glenoid fossa
Bursae
Sonographic Anatomy of Shoulder
 Step 1 - Biceps brachii tendon, long head
 Step 2 - Subscapularis and biceps brachii tendon
 Step 3 - Supraspinatus and rotator interval
 Step 4 - Acromioclavicular joint, subacromial-
subdeltoid bursa,
 Step 5 - Infraspinatus, teres minor, and posterior
labrum
Step 1 - Biceps brachii tendon, long head
Sonographic Anatomy
Sonographic Anatomy
• Step 2 - Subscapularis
Step 2 - Subscapularis
Sonographic Anatomy
• Step 3 - Supraspinatus
Step 3 - Supraspinatus
Step 4 - Acromioclavicular joint
Dynamic evaluation for subacromial impingement
• Step 5 - Infraspinatus, teres
minor, and posterior labrum
Sonographic Anatomy
Pathologies
• Rotator Cuff
• Biceps tendon
• Labrum and capsule
• Osseous structures
• Arthritis
• Neural impingement
• Tumors
Rotator Cuff
• Tendinopathy
• Partial tears
• Full thickness tears
• Calcific tendinitis
Rotator cuff tendinopathy
Also known as -
• Rotator cuff tendinosis
• Definition – collagenous degeneration of
rotator cuff tendons, most commonly
supraspinatus (SST)
Tendinopathy
Mucinousdegeneration (Microscopic tears in
critical zone area)
• Intra substance in location delamination
• Begins at early 30 years
• Often asymptomatic
• At 60 tendon ruptures 60%
Rotator cuff tendinopathy
• Thickened hypoechoic
• Tears directly visible
• Less sensitive for partial thickness tears
• Advantage – allows dynamic evaluation with
pain correlation
Rotator cuff tendinopathy
• Supraspinatus “tendinitis”.
There is focal hypoechoic
swelling of the more
superficial fibers of
supraspinatus insertion
Rotator cuff tendinopathy
• Static imaging of the
supraspinatus tendon show
features of “tendinitis”
which included tenderness,
hypoechoic thickening of
the insertional fibers
(arrowheads)
Rotator cuff tears
• Clinical –
– Trauma (acute / chronic micro-trauma)
– Adults > 4o with impingement
– Collagen vascular diseases
– Partial more painful than complete tears !!!!
TYPES -
• Partial –
– supraspinatus most common
– Types – bursal surface
interstitial (not seen on arthroscopy)
articular surface
• Complete –
– supraspinatus most common
– Extends from bursal to articular surface
Dimensions of a Full-Thickness Tear
• small (1 cm),
• medium (1–3 cm),
• large (3–5 cm),
• massive (5 cm)
The dimensions of rotator cuff tears may have
implications for selection of treatment and surgical
approach, postoperative prognosis, and tear
recurrence
Partial tear
• Decreased echogenicity and thinning in
affected region
• Loss of convexity of tendon / bursae interface
in bursal surface tears
• Calcific foci in tendons
Partial tear
• Rt. image shows bursal surface tear
• Lt. image shows full thickness partial tear
Partial tear
Supraspinatus: Full thickness partial tear Supraspinatus: intrasubstance and
bursal surface tearing
Partial tear
Supraspinatus: Partial thickness tear, transverse
is posterior tear
Supraspinatus: Partial thickness tear,
transverse is anterior tear
Partial undersurface tear of the rotator cuff
Partial Tear
Supraspinatus tear with associated bursal fluid
Complete Tear
• Focal tendon interruption
• Fluid filed gap (hypoechoic)
• Loss of convexity of tendon / bursa interface
• Tendon retraction
• Uncovered cartilage sign
Complete Tear
Complete Tear
• Full thickness tear of the distal aspect of the Supraspinatus
tendon ( ) with retraction and effusion of the
subacromial bursae ( ). The humeral head cartilage is laid
bare ( ). There is also fluid in the Long Biceps sheath ().
Subscapularis tendon rupture
Rotator interval tears
• What is rotator interval ??
– Tunnel through which long head of biceps travels
from its origin at the supraglenoid tubercle
• Rotator interval tears – tears in the capsule
between the supraspinatus and subscapularis
tendons
• Can be classified as subtype of RTC tears
Normal rotator interval
Internal impingement
• Definition - Degeneration and tearing of posterior SST
and anterior infraspinatus tendons (undersurface /
articular surface) due to impingement by postero-
superior labrum and humeral head
• Postero-superior glenoid impingement (PSGI)
• Overhead throwing activities – athletes (throwers)
• Dynamic compression – occurs during abduction (> 120
degrees), retropulsion and extreme external rotation
(ABER)
Rotator cuff calcific tendinitis
Rotator cuff calcific tendinitis
• Calcium Hydroxyapatite deposition disease (HADD)
• Calcifying bursitis
• Not typical Ca++ of degenerative disease of tendons, but crystalline
Ca++
• Pathology – deposition of Calcium Hydroxyapatite in RTC tendons
• Etiology – Avascular change, trauma, abnormal Ca++ metabolism
• Housewives and clerical workers more affected
• Location – SST > IST > TM > SSC
• Peri-articular soft tissues like capsule, bursae may be involved
Rotator cuff calcific tendinitis
Longitudinal image
Rotator cuff calcific tendinitis
Transverse Image
Rotator cuff calcific tendinitis
Calcific tendinitis penetration of the cortex of the
greater tubercle
Tendon Tear Vs. Tendinosis
Tear
• Anechoic
• Well defined
• Homogeneous
• Thin
• Bone Irregularity
Tendinosis
• Hypoechoic
• Ill defined
• Heterogenous
• Swollen
• Smooth Cortex
Biceps tendon pathologies
Tendinosis
Tendinosis
• Degeneration of long head of biceps
• Long head of biceps –
– LHBT originates at supra glenoid tubercle
– Passes through the antero-superior joint
– Enters the humeral bicipital groove
• Chronic micro-trauma
• Acute trauma (rare cause)
• Accompanies RTC disease (especially impingement)
• Common with subacromial impingement (30-60%
association)
• Biceps tenosynovitis may accompany
USG
– Thickened hypoechoic tendon
– Tears often directly visible
– Allows dynamic evaluation
Biceps tendon tear
Biceps tendon tear
• Tendinosis predisposes
• Associated with SST tear
• Distal tendon edge may retract into upper
arm(popaye sign)
Biceps tendon tear
Biceps tendon tear
Popeye Sign
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Subacromial-Subdeltoid Bursa
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
THANK YOU

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Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar

  • 1. Role of Ultrasound in Clinical Evaluation of Shoulder Pain DR. MUHAMMAD BIN ZULFIQAR SIMS & SERVICES HOSPITAL LAHORE
  • 2. INTRODUCTION • Shoulder Is one of the most sophisticated and complicated joint of the body with great range of movements. • A series of complex ligaments and muscles help in stability. • Different pathologies especially related to rotator cuff are encountered in patients presenting with shoulder pain.
  • 3. INTRODUCTION • By assessing shoulder pain we ascertain integrity of rotator cuff and extent of tear ,if any, in order to give a plan to orthopedic surgeon for appropriate treatment and further management. • Shoulder ultrasound gives diagnostic sensitivities and specificities in excess of 90%.
  • 4. Learning Objectives • Implications of the morphologic features and extent of rotator cuff tears for glenohumeral joint mechanics, treatment, and prognosis. • Identify injuries to adjacent structures that may accompany rotator cuff tears and discuss their implications for treatment and prognosis. • Describe the value of imaging and evaluating the rotator cuff muscles.
  • 5. Learning Objectives • Distinguish between the potential contributing factors to impingement syndrome. • Determine if surgery is contraindicated. • Radiologist must: (a) identify and evaluate cuff lesions that may compromise glenohumeral joint function, taking into account functional anatomy. (b) recognize imaging findings that decrease the likelihood of favorable functional anatomic outcome after cuff repair. (c) identify and describe imaging findings that will assist in selecting a repair technique.
  • 6. Learning Objectives • Tear dimensions, tear depth or thickness, tendon retraction, and tear shape. • Tear extension to adjacent structures, muscle atrophy, size of muscle cross-sectional area, and fatty degeneration. • Information about the coracoacromial arch and impingement.
  • 10. Glenoid labrum • Fibrocartilage similar to knee menisci • Deepens the glenoid fossa
  • 12. Sonographic Anatomy of Shoulder  Step 1 - Biceps brachii tendon, long head  Step 2 - Subscapularis and biceps brachii tendon  Step 3 - Supraspinatus and rotator interval  Step 4 - Acromioclavicular joint, subacromial- subdeltoid bursa,  Step 5 - Infraspinatus, teres minor, and posterior labrum
  • 13. Step 1 - Biceps brachii tendon, long head Sonographic Anatomy
  • 14. Sonographic Anatomy • Step 2 - Subscapularis Step 2 - Subscapularis
  • 15. Sonographic Anatomy • Step 3 - Supraspinatus Step 3 - Supraspinatus
  • 16. Step 4 - Acromioclavicular joint Dynamic evaluation for subacromial impingement
  • 17. • Step 5 - Infraspinatus, teres minor, and posterior labrum
  • 19. Pathologies • Rotator Cuff • Biceps tendon • Labrum and capsule • Osseous structures • Arthritis • Neural impingement • Tumors
  • 20. Rotator Cuff • Tendinopathy • Partial tears • Full thickness tears • Calcific tendinitis
  • 21. Rotator cuff tendinopathy Also known as - • Rotator cuff tendinosis • Definition – collagenous degeneration of rotator cuff tendons, most commonly supraspinatus (SST)
  • 22. Tendinopathy Mucinousdegeneration (Microscopic tears in critical zone area) • Intra substance in location delamination • Begins at early 30 years • Often asymptomatic • At 60 tendon ruptures 60%
  • 23. Rotator cuff tendinopathy • Thickened hypoechoic • Tears directly visible • Less sensitive for partial thickness tears • Advantage – allows dynamic evaluation with pain correlation
  • 24. Rotator cuff tendinopathy • Supraspinatus “tendinitis”. There is focal hypoechoic swelling of the more superficial fibers of supraspinatus insertion
  • 25. Rotator cuff tendinopathy • Static imaging of the supraspinatus tendon show features of “tendinitis” which included tenderness, hypoechoic thickening of the insertional fibers (arrowheads)
  • 26. Rotator cuff tears • Clinical – – Trauma (acute / chronic micro-trauma) – Adults > 4o with impingement – Collagen vascular diseases – Partial more painful than complete tears !!!! TYPES - • Partial – – supraspinatus most common – Types – bursal surface interstitial (not seen on arthroscopy) articular surface • Complete – – supraspinatus most common – Extends from bursal to articular surface
  • 27. Dimensions of a Full-Thickness Tear • small (1 cm), • medium (1–3 cm), • large (3–5 cm), • massive (5 cm) The dimensions of rotator cuff tears may have implications for selection of treatment and surgical approach, postoperative prognosis, and tear recurrence
  • 28. Partial tear • Decreased echogenicity and thinning in affected region • Loss of convexity of tendon / bursae interface in bursal surface tears • Calcific foci in tendons
  • 29. Partial tear • Rt. image shows bursal surface tear • Lt. image shows full thickness partial tear
  • 30. Partial tear Supraspinatus: Full thickness partial tear Supraspinatus: intrasubstance and bursal surface tearing
  • 31. Partial tear Supraspinatus: Partial thickness tear, transverse is posterior tear Supraspinatus: Partial thickness tear, transverse is anterior tear
  • 32. Partial undersurface tear of the rotator cuff
  • 33. Partial Tear Supraspinatus tear with associated bursal fluid
  • 34. Complete Tear • Focal tendon interruption • Fluid filed gap (hypoechoic) • Loss of convexity of tendon / bursa interface • Tendon retraction • Uncovered cartilage sign
  • 37. • Full thickness tear of the distal aspect of the Supraspinatus tendon ( ) with retraction and effusion of the subacromial bursae ( ). The humeral head cartilage is laid bare ( ). There is also fluid in the Long Biceps sheath ().
  • 39. Rotator interval tears • What is rotator interval ?? – Tunnel through which long head of biceps travels from its origin at the supraglenoid tubercle • Rotator interval tears – tears in the capsule between the supraspinatus and subscapularis tendons • Can be classified as subtype of RTC tears
  • 41. Internal impingement • Definition - Degeneration and tearing of posterior SST and anterior infraspinatus tendons (undersurface / articular surface) due to impingement by postero- superior labrum and humeral head • Postero-superior glenoid impingement (PSGI) • Overhead throwing activities – athletes (throwers) • Dynamic compression – occurs during abduction (> 120 degrees), retropulsion and extreme external rotation (ABER)
  • 42. Rotator cuff calcific tendinitis
  • 43. Rotator cuff calcific tendinitis • Calcium Hydroxyapatite deposition disease (HADD) • Calcifying bursitis • Not typical Ca++ of degenerative disease of tendons, but crystalline Ca++ • Pathology – deposition of Calcium Hydroxyapatite in RTC tendons • Etiology – Avascular change, trauma, abnormal Ca++ metabolism • Housewives and clerical workers more affected • Location – SST > IST > TM > SSC • Peri-articular soft tissues like capsule, bursae may be involved
  • 44. Rotator cuff calcific tendinitis Longitudinal image
  • 45. Rotator cuff calcific tendinitis Transverse Image
  • 46. Rotator cuff calcific tendinitis Calcific tendinitis penetration of the cortex of the greater tubercle
  • 47. Tendon Tear Vs. Tendinosis Tear • Anechoic • Well defined • Homogeneous • Thin • Bone Irregularity Tendinosis • Hypoechoic • Ill defined • Heterogenous • Swollen • Smooth Cortex
  • 50. Tendinosis • Degeneration of long head of biceps • Long head of biceps – – LHBT originates at supra glenoid tubercle – Passes through the antero-superior joint – Enters the humeral bicipital groove • Chronic micro-trauma • Acute trauma (rare cause) • Accompanies RTC disease (especially impingement) • Common with subacromial impingement (30-60% association) • Biceps tenosynovitis may accompany
  • 51. USG – Thickened hypoechoic tendon – Tears often directly visible – Allows dynamic evaluation
  • 53. Biceps tendon tear • Tendinosis predisposes • Associated with SST tear • Distal tendon edge may retract into upper arm(popaye sign)