This document discusses ultrasound evaluation of the shoulder. It begins with shoulder anatomy including the ball and socket glenohumeral joint formed by the humerus, scapula, and clavicle. It describes scanning techniques for evaluating the rotator cuff muscles, long head of the biceps tendon, subscapularis tendon, supraspinatus tendon, rotator interval, acromioclavicular joint, and impingement testing. Common pathologies like rotator cuff tears, biceps tendon subluxation, tendinosis, calcific tendinitis, and labral cysts are described. Examples of departmental cases demonstrate ultrasound findings of biceps

1. USG SHOULDER
Presented by : Dr. Kanishka Aggarwal R2/RD
Guide : Dr. Abhishek R3/RD
References : Rumack
Radiographics
ESSR Musculoskeletal Guidelines
Radiology Assistant

2. POINTS TO BE DISCUSSED
Anatomy
Scanning technique
Normal shoulder imaging
Pathological Conditions
Departmental cases

3. SHOULDER JOINT : BALL & SOCKET JOINT.
3 BONES : HUMERUS , SCAPULA, CLAVICLE
4 JOINTS: GLENOHUMERAL, ACROMIOCLAVICULAR,
STERNOCLAVICULAR, SCAPULOTHORACIC
MUSCLES OF ROTATOR CUFF : SUPRASPINATUS, INFRASPINATUS,
SUBSCAPULARIS, TERES MINOR

4. ROTATOR CUFF MUSCLES

5. SHOUDER ULTRASOUND
EVALUATION
Long head of biceps brachii tendon
Subscapularis tendon, excludes transient biceps tendon
subluxation or dislocation
Supraspinatus tendon and rotator interval
Acromioclavicular joint, subacromial-subdeltoid bursa, including
dynamic evaluation for subacromial impingement
Infraspinatus, teres minor and posterior labrum.
 All the tendons are viewed in short and long axis.
 A high frequency (7-12 MHz) probe is used.

6. LONG HEAD OF BICEPS
BRACHII
Place the arm in slight internal rotation (directed towards
the contralateral knee) with elbow flexed 90o, palm up.
Identify the biceps tendon in the bicipital groove.
Shift probe up to examine biceps in its intraarticular
course course and down to reach the myotendinous
junction.

9. Short axis view of LHBT
Long axis view of LHBT

10. SUBSCAPULARIS TENDON
Position:
• Rotate the arm externally fixing the elbow on iliac crest
to show subscapularis tendon and its insertion at lesser
tuberosity (slight supination of the hand may be helpful
to neutralize the tendency to lift and abduct the elbow
from the lateral chest wall) .
• This tendon should be evaluated along its long-
(transverse planes) and short- (sagittal planes) axis
during passive external and internal rotation with
hanging arm.

12. Insertion Of Subscapularis Tendon
Muscle tissue interposed between tendon
fascicles

13. SUBSCAPULARIS

15. SUPRASPINATUS TENDON
Place the patient’s arm posteriorly, placing the palmar side
of the hand on the superior aspect of the iliac wing with
the elbow flexed and directed posteriorly.

16. Long Axis

17. Short Axis

19. ROTATOR INTERVAL
It is a triangular space between the tendons of
subscapularis and supraspinatus and the base of the
coracoid process.
It is roofed by the rotator interval capsule, principally made
of coracohumeral ligament. It contains the tendon of the
long head of the biceps and the superior glenohumeral
ligament.
Clinical Importance : Coracohumeral and superior
glenohumeral ligament prevent long head of biceps
tendon from subluxation or dislocation.

21. ACROMIO-CLAVICULAR
JOINT
Place the transducer in the coronal plane over the
shoulder to examine the acromioclavicular joint.
Sweep the transducer anteriorly and posteriorly over this
joint to assess the presence of an os acromiale. Shifting
the probe posterior to the acromioclavicular joint, it is
possible to assess the status of the supraspinatus muscle.

24. IMPINGEMENT TEST
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.

26. SUBACROMIAL IMPINGEMENT
Repititive 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. INFRASPINATUS & TERES
MINOR TENDONS
Place the transducer over the posterior aspect of the
glenohumeral joint with the hand on the opposite shoulder
and increase the depth to include the structures of the
posterior fossa within the field-of-view of the US image.
Use the spine of the scapula as the landmark to
distinguish the supraspinous fossa (transducer shifted-up)
from the infraspinous fossa (transducer shifted-down) on
sagittal planes.

29. INFRASPINATUS

30. TERES MINOR

32. POSTERIOR STRUCTURES &
POSTERIOR GLENOHUMERAL
JOINT RECESS
Examine these infraspinatus and teres minor tendons separately
on their long-axis (transverse planes) during external and
internal rotation of the arm in neutral position by placing the
probe over the posterior aspect of the glenohumeral joint.
Look at the posterior labrum-capsular complex and check the
posterior recess of the joint for effusion during scanning. In thin
subjects the posterior labrum can be clearly seen.
Move the transducer medial to the labrum on transverse plane
to visualize the spinoglenoid notch. It is often necessary to
increase the depth of the field-of-view not to miss this area. A
paralabral cyst originating in this area should be sought.

33. HH : Humeral Head
Curved Arrow : Bony glenoid
Asterisk : Spinoglenoid notch
Arrow heads : Posterior Labrum

34. POSTERIOR LABRUM

36. ROTATOR CUFF
PATHOLOGIES
Rotator cuff tears
Biceps tendon subluxation/dislocation
Tendinosis
Calcific tendinitis
Labral cysts

37. ROTATOR CUFF TEARS
2 types : Partial thickness and full thickness tear.
Etiology : acute or chronic trauma, sports related injuries,
collagen vascular diseases.
Most common : Supraspinatus tendon
Most common age group : >40 years

38. USG CRITERIA OF ROTATOR
CUFF TEARS
Non- visualisation of the cuff
Focal non-visualisation of the cuff
Focal abnormal echogenicity
Discontinuity in the cuff

39. Partial thickness tears :
Articular
Interstitial
Bursal
Associated with impingement and degenerative changes.
On X-ray:
Acromial spurs
Type III acromion
Humeral head arthritic changes at greater tuberosity
AC degenerative changes

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

41. Full Thickness Tears :
ON USG:
1.Focal tendon interruption
2.Fluid filled gap
3.Loss of convexity of tendon/bursal interface
4.Cartilage interface sign.
5.Tendon retraction.

42. Partial Thickness Tear of
Supraspinatus

43. Full Thickness Tear of
Supraspinatus

44. BICEPS TENDON
SUBLUXATION/DISLOCATION
Long head of biceps brachii travels
through the bicipital groove and is
stabilized by 2 main ligaments
coracohumeral and superior
glenohumeral, forming the rotator cuff
interval.
Disruption of the stabilizing ligament or
shallow bicipital groove can cause
subluxation/dislocation of biceps tendon.

46. TENDINOSIS
Degeneration of long head of biceps brachii.
Etiology:
1.Chronic microtrauma
2.Accompanies with rotator cuff disease
3.Associated with subacromial impingment
4.May accompany tenosynovitis
On USG:
-- Thickening of long head of biceps
-- Fluid surrounding biceps tendon

47. tendinosis

48. CALCIFIC TENDINITIS
Deposition of calcium hydroxyapatite crystals in various
shoulder tendons.
Most common site is within the supraspinatus tendon near
its insertion.
At US, calcium deposits may have a fluffy appearance,
with echogenic foci without posterior shadowing, or may
appear as typical discrete, well-circumscribed
calcifications with posterior shadowing.
US is very sensitive for detecting even tiny calcium
deposits.

50. PARALABRAL CYSTS
May represent a synovial cyst, ganglion cyst or
pseudocyst.
Etiology : A/W glenoid labral tears
MC Location : posterior > anterior > superior aspects of
the glenohumeral joint. The postero-superior location is
most common.

52. DEPARTMENTAL CASE
A 40 year old female presented with the complaint of left
shoulder pain with restricted movement since 12 days with
history of fall 12 days back.

53. Long head of biceps tendon

54. Long axis - LHBT

60. SUBSCAPULARIS

63. DEPARTMENTAL CASE
A 47 year old male presented with the complaint of right
shoulder pain with restricted shoulder movement since 25-
30 days.
No history of trauma.

64. Discontinuity along fibers of supraspinatus tendon

65. Calcific focus – calcific tendinitis

68. Fluid collection around the biceps tendon

69. Fluid collection around the tendon

70. Fluid collection around the tendon near articular surface

71. Interstitial tear of subscapularis

73. DEPARTMENTAL CASE
A 40 year old female came with the complaint of left
shoulder pain with restricted movement of the shoulder
and with history of RTA 15 days back.

74. Fluid collection around the LHBT with tear in LHBT with medial subluxation

76. Subdeltoid effusion

77. Full thickness tear in supraspinatus

79. THANK YOU !