1) A 34-year-old male presented with left shoulder pain and weakness after a fall from his bike three months prior. X-rays after the injury were normal. 2) Ultrasound of the shoulder revealed a rupture of the supraspinatus tendon, which was supported by subsequent MRI findings. 3) Ultrasound is a highly accurate, cost-effective first-line imaging method for evaluating rotator cuff injuries like tendon ruptures, though it requires an experienced sonographer due to some technical challenges. MRI and MR arthrography can also accurately diagnose full and partial thickness tears but are more expensive and involve radiation with some techniques.

1. ROTATOR CUFF ULTRASOUND;
A CASE AND TECHNICAL CONSIDERATIONS
(RADIOLOGIC SOCIETY OF PAKISTAN)
Adnan Rashid, MD
Department of Diagnostic Radiology,
SIMS & SERVICES HOSPITAL, LAHORE

2. Case!
 34 years old male was referred to our
Ultrasound service for evaluation of “Left”
shoulder pain and abduction weakness.
 Pain started 3 months back after shoulder
trauma (falling from bike on to his “Left”
shoulder).
 Radiographs acquired after trauma were
normal.

3. D/D:
 Joint disease (post traumatic)
 Rotator cuff injury
Supra-spinatous injury (most common)

4. Methods/options to evaluate:
Ultrasound of the shoulder: High-resolution
linear transducer (5 to 13 MHz)
MRI:
 Coronal plane T1,T2, Fatsuppressed (STIR
or PDFS)
 Axial -T1, fatsuppressed
 Sagittal - T2 and fat suppressed.
MR- Arthrography:

5. Accuracy of MRI, MR Arthrography, and
Ultrasound in the Diagnosis of Rotator Cuff
Tears: A Meta-Analysis(65 articles..2009)
 MR arthrography is the most sensitive
and specific technique for diagnosing
both full- and partial-thickness rotator
cuff tears.
 Ultrasound and MRI are comparable in
both sensitivity and specificity.

6. Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean Leblond2,
François Desmeules3,4,Clermont E Dionne1,5, Joy C
MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5
Diagnostic accuracy of
ultrasonography, MRI and MR
arthrography in the characterisation
of rotator cuff disorders: a meta-
analysis(82 articles…2015)
Centre interdisciplinaire de recherche en réadaptation et en intégration sociale
(CIRRIS), 525, boulevard Wilfrid-Hamel, local H-1710, Quebec, Canada G1M 2S8

7. Diagnostic accuracy of imaging modalities for
Full-thickness RC tears
Similar performance of the three imaging
modalities for overall estimates of
Sn (0.90 to 0.91)
Sp (0.93 to 0.95)

8. Diagnostic accuracy of imaging modalities for
Partial thickness RC tear
Sensitivity:
 US and MRI were similar (0.68 and 0.67 respec)
 MRA has higher (Sn 0.83).
Specificity:
the three imaging modalities performed
equivalently (0.93–0.94).

9. Why shoulder Ultrasound??
 Sensitivities and specificities in excess of 90%.
 Easily available & Cost effective
 Focused use in clinics, operating room, & at
point of injury………Quicker diagnosis
 No radiation
 Useful in pts with Metallic prosthesis
 Dynamic &Interactive evaluation
 Allows therapeutic interventions as well

10. Pit-fall;
 Highly operator dependant; Requires skill to
ellucidate and identify a specific tendon.
 Due to Parallelism of collagen fibers within
the cuff; the echogenicity of the tendon
depends on the angle of the transducer.
Tendon may appear hypo-echoic
(torn/absent) when the angle of the beam is
not perpendicular (Anisotropy)

11. Technique of Shoulder Sonography

12. The rotator cuff anatomy
 Supraspinatus
Fails first >40Years
Most commonly injured
 Subscapularis
 Infraspinatus
 Teres minor (rarely affected)

13. Sonographic Anatomy

14. Steps in Shoulder Sonography
 Step 1 - Biceps brachii tendon, long head
 Step 2 - Subscapularis and biceps brachii tendon
 Step 3 - Acromioclavicular joint
 Step 4 - Supraspinatus and rotator interval,
Subacromial-subdeltoid bursa,
 Step 5 - Infraspinatus, teres minor & post- labrum

15. Biceps brachii
Step 1
Arm and forearm on
the patient’s thigh

16. Step 1a – Transverse Biceps
brachii
(long head)

17. Step 1 - Biceps brachii(long
head)

18. Subscapularis
Step 2

19. Step 2a – Subscapularis Long
axis)
 Step 2 - Subscapularis

20. Step 2b – Short axis/
Transverse

21. Acromioclavicular joint
Step 3

22. Supraspinatus
Step 4
extension &
internal rotation

23. Step 4a:Supraspinatus(Transverse)
Transducer is placed between the anterior acromion and the
coracoid & swept from the edge of the acromion down to the level
of the lateral greater tuberosity.

24.  Step 4 b – Supraspinatus(Long axis)
transducer is placed perpendicular to the curvature of the acromial
process ;Translate the probe anterior to posterior 2.5 cm lateral to long
Biceps tendon.

25. Infraspinatus, posterior
labrum andTeres Minor
Step 5

26. Step 5 – Infraspinatus, and posterior labrum
Long axis
Moving the transducer posteriorly and in the plane parallel to the scapular
spine. Optimal image contrast for detection of intra-articular fluid will
be obtained by bringing the arm in external rotation(B).

27. Transverse;

28. Teres minor insertion(Long-axis
view )
The probe placed parallel to the spine of the scapula and just
proximal to the prominence of the teres major …
The insertion appears hypoechoic, due to more muscle fibers

29. Dynamic evaluation
(for subacromial impingement)

30. Comparing patient positions

31. After learning the shoulder
ultrasound techniques!
Back to case….

32. Ultrasound Diagnosis??

33. Diagnosis??
Supra-spinatus tendon rupture!
Diagnosis supported with MRI

34. Coronal MRI, image in the middle third
Patient Normal

35. References:
1) Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis
of Rotator CuffTears: A Meta-Analysis:O. de Jesus1, Laurence
Parker,Andrea J. Frangos and Levon N. June 2009,Volume 192,
Number 6
http://www.ajronline.org/doi/abs/10.2214/AJR.08.1241Joseph )
2)Diagnostic accuracy of ultrasonography, MRI and MR arthrography
in the characterisation of rotator cuff disorders: a meta-
analysis;Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean
Leblond2, François Desmeules3,4,Clermont E Dionne1,5,Joy C
MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5
3)) The Rotator Cuff; MarnixT. van Holsbeeck, DzungVu, and J. Antonio
Bouffard…Chapter 22 ■The RotatorCuff 879, Rumack Ultrasound.
4) RSNA, US of the shoulder, January 2006

36. Thank you!