This document provides information on using ultrasound to examine the shoulder, including: 1) It describes the anatomy that can be visualized with ultrasound and how it compares to MRI, outlines the ultrasound technique for examining various shoulder structures like the biceps tendon, rotator cuff muscles, and joints. 2) It explains the diagnostic and therapeutic uses of ultrasound for the shoulder, such as guiding injections and assessing tears, injuries, or other soft tissue abnormalities. 3) Examples of ultrasound images are provided to illustrate normal anatomy as well as various pathologies that may be detected like tears, tendonitis, fractures.

1. Ultrasound of the Shoulder
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. Objectives
• Uses of ultrasound
• Shoulder anatomy
• Sono-anatomy
• Ultrasound shoulder exam

3. Diagnostic Uses
• Soft tissue disorders • Joint disorders
– Tears – Erosions on bones
• Muscle, tendon, ligament – Loose bodies
– Inflammation – Pannus
• Plantar fasciitis, tenosynovitis – Inflammation
– Masses – Effusion
• Hematoma, cyst, solid tumors, calcific
tendonitis
– Nerve disorders • Bone disorders
• Morton’s neuroma, neuropathies, – Fractures
trauma
– Stress fractures
– Foreign bodies
– Infections

4. Therapeutic Uses
• Injections • Biopsy
– Marcaine/Lidocaine • Removal of foreign bodies
– Cortisone
– Hyaluronic acid
– PRP
• Aspiration
– Drain joints
– Drain hematomas
• Surgical adjunct to arthroscopy

5. SHOULDER ANATOMY

6. SHOULDER SONO-ANATOMY

7. Shoulder U/S Tissue Types
• Bone
• Fat
• Tendon
• Muscle
• Cartilage
• Bursa

8. Other Signals
• Synovial fluid
• Foreign Body
• Air

9. ULTRASOUND SHOULDER EXAM

10. Ultrasound Technique: Shoulder
• Biceps tendon
– Longitudinal & Transverse
– Superior & Inferior
• Subscapularis
• Infraspinatous
– Longitudinal & Transverse
– Longitudinal & Transverse
• Coracoid - Subscapularis
• Glenohumeral jt & Labrum
– Subcoracoid impingement
• AC joint
• Supraspinatous
– Longitudinal & Transverse
– Anterior & Posterior
– Subacromial bursa

11. Biceps Tendon - Transverse
• Arm position: Neutral
• Tip: Find bicipital groove
• MRI equivalent: Axial plane

12. Biceps Tendon – Trans / Sup vs Inf
• Superior: Deep bicipital groove
• Inferior: Flattened bone with transition to muscle

13. Biceps Subluxed & Subscap Torn

14. Biceps Subluxing

15. Biceps Tendon: Biceps Split

16. Biceps Tendon - Longitudinal
• Arm position: Neutral
• Tip: Find transverse view, keep groove centered then turn probe 90o
• MRI equivalent: Sagittal plane

17. Biceps Tenosynovitis

18. Subscapularis - Longitudinal
• Arm position: External rotation
• Tip: Find bicipital groove @ neutral then ER
• MRI equivalent: Axial plane

19. Subscapularis - Transverse
• Arm position: External rotation
• Tip: Find longitudinal view, then turn probe 90o
• MRI equivalent: Sagittal plane

20. Partial Subscapularis Tear

21. Coracoid-Subscapularis
• Arm position: ER <-> IR, with Flex/Add/IR
• Tip: Move medial once found Longitudinal Subscap
• MRI equivalent: Axial plane

22. Coracoid-Subscapularis

23. Subscapularis Cyst

24. Subcoracoid Loose Body

25. Supraspinatous - Longitudinal
• Arm position: Extended
• Tip: Probe parallel plane [Contralateral shoulder : Ipsilateral hip]
• MRI equivalent: Coronal plane

26. Supraspin. – Long / Ant vs Post
• Anterior: Step off pronounced on tuberosity
• Posterior: Flatter transition of head to tuberosity

27. Subacromial Bursitis

28. Supraspinatous - Transverse
• Arm position: Extended
• Tip: Probe parallel plane [Ipsilateral shoulder : Contralateral hip]
• MRI equivalent: Sagittal plane

29. Supraspin. – Trans / Ant vs Post
• Anterior: Note biceps tendon
• Posterior: See black cartilage layer over bone

30. Partial-thickness RC Tears

31. FT RC Tears

32. RCT - Full Thickness?

33. Calcific Tendonitis

34. Ca Tendonitis

35. Chronic RCT w/ Cystic Changes

36. Infraspinatous - Longitudinal
• Arm position: Neutral
• Tip: Stay more lateral and find edge of humeral head
• MRI equivalent: Axial plane

37. Infraspinatous - Transverse
• Arm position: Neutral to flexed
• Tip: Find longitudinal view, then turn probe 90o
• MRI equivalent: Sagittal plane

38. Infraspinatous - Tear

39. Glenohumeral Joint
• Arm position: Neutral
• Tip: Find longitudinal view infraspinatous, then move medial, rotating arm
• MRI equivalent: Axial plane

40. Posterior Labral Tear
USA: Ultrasound Arthrogram

41. Posterior Instability

42. AC Joint
• Arm position: Neutral
• MRI equivalent: Coronal plane
• Tip: Palpate the joint for easy localization