Intro to Musculoskeletal
Ultrasound
of the Shoulder
John Hill, DO
Tim Mazzola, MD
University of Colorado
Office Based Sports Medicine
Saturday, May 17, 2014
Disclosure Statement
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Newton Shoes:
Physician Advisory
Board
MuscleSound:
Physician advisor for
software development
to determine muscle
glycogen content.
Objectives
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Discuss the normal ultrasound appearance of
the shoulder and the individual structures
Describe the AIUM standard shoulder exam
Discuss the uses of dynamic imaging
Shoulder
The Standard Examination
Sonography of Shoulder
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Complex structure
containing
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Muscles
Tendons
Bursa
Bone
Labrum
Fixed and Dynamic
evaluations
Sonography of Shoulder
Physician Practice
Guideline is established
by AIUM & ACR for the
Shoulder U/S
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Biceps tendon
Subscapularis tendon
Supraspinatus tendon
Infraspinatus tendon
Teres minor
Dynamic evaluation
Sonography of Shoulder
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Examination of:
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Joint effusions
Bursa effusions
Comparison of
contralateral side
Evaluate for:
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Bursal thickening
Loose bodies
Tendon calcification
Muscle & bone
abnormalities
Biceps Tendon- Short Axis
Transverse
Normal Notch view
Normal transverse
Biceps Tendon- Short Axis
Transverse
Acute Tendinopathy
Chronic Tendinopathy
Biceps Tendon - Long Axis
Long Axis
Normal Biceps LA
Normal Long Axis
Biceps Tendon - Long Axis
Chronic Tendinopathy
Fluid in tendon sheath
Long Axis
Acute Tendinopathy
Long Head of Biceps Tendon
Normal internal/external motion
Normal long axis appearance
Is there subluxation of the Long
Head of Biceps Tendon?
Subscapularis Tendon
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Short Axis view of Subscap
Instruct patient to place their
arm in full EXTERNAL
rotation
Sagittal view (Short axis)
Short Axis Subscap
Subscapularis Tendon
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Long Axis view of Subscap
Instruct patient to place their
arm in full EXTERNAL
rotation
Transverse view (Long axis)
Long Axis Subscap
Subscapularis Tendon
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Short Axis view of Subscap
Instruct patient to place their
arm in full EXTERNAL
rotation
Transverse view (Long axis)
Sagittal view (Short axis)
Long Axis Subscap
Supraspinatus Tendon
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SST Normal Long Axis view
Instruct patient to place their
arm in INTERNAL rotation
Place hand in back pocket
(Long axis)45 degrees
Coronal/ Sagittal
SST WNL
Supraspinatus Tendon
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SST, internal shoulder rotation SA view
Instruct patient to place their
arm in INTERNAL rotation
Place hand in back pocket
(Short axis) 90 degrees
Rotation of long axis
SST Short Axis WNL
Supraspinatus Tendon
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SST with Tendinopathy
Instruct patient to place their
arm in INTERNAL rotation
Place hand in back pocket
(Long axis)45 degrees
Coronal/ Sagittal
(Short axis) 90 degrees
Rotation of long axis
SST WNL
Supraspinatus Tendon-Long Axis
Subacromial Bursa
GT
Supraspinatous, birds beak view (insertion)
Supraspinatus Tendon-Short Axis
WNL
SAB
Dynamic Motion
Good Humeral Head Depression
Rotten Humeral Head Depression
Poor Posture, Weak Scapula Stability
Infraspinatus Tendon
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Instruct patient to place their arm
in full INTERNAL rotation
Place hand in back pocket
Similar to Supraspinatus, but
moved posteriorly
(Long axis)45 degrees Coronal/
Sagittal
(Short axis) 90 degrees Rotation
of long axis
Infraspinatus Tendon
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Long Axis appearance of IST
Instruct patient to place their arm
in full INTERNAL rotation
Place hand in back pocket
Similar to Supraspinatus, but
moved posteriorly
(Long axis)45 degrees Coronal/
Sagittal
Normal appearance of IST
Teres Minor Tendon
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Instruct patient to place their
arm in full INTERNAL
rotation
Place hand in back pocket
Similar to Infraspinatus, but
moved Inferiorly
(Long axis)45 degrees
Coronal/ Sagittal
(Short axis) 90 degrees
Rotation of long axis
Teres Minor Tendon
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Normal Long Axis of Teres minor
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Instruct patient to place their
arm in full INTERNAL
rotation
Place hand in back pocket
Similar to Infraspinatus, but
moved Inferiorly
(Long axis)45 degrees
Coronal/ Sagittal
Teres Minor Tendon
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Normal Short Axis of Teres minor
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Instruct patient to place their
arm in full INTERNAL
rotation
Place hand in back pocket
Similar to Infraspinatus, but
moved Inferiorly
(Short axis) 90 degrees
Rotation of long axis
Contralateral Comparison
Long Axis Views
Left SST is WNL
Right SST Thickened chronic Tendinopathy
AC Joint
AC Joint
AC Joint
AC Joint
If the person is very thin, you might need
standoff/interface disc
AC Joint
Arthritic Changes but no effusion
Less evidence of DJD, but effusion present
Summary
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Many structures in the shoulder are superficial and can
be examine accurately with MSK ultrasound
Diagnostic Ultrasound should incorporated static and
dynamic image
If you examine many normal shoulders, then you will
soon be able to pick-up even subtle changes