A beginners Introduction into Ultrasound Examination of the Shoulder
Competency 1- Demonstrate appropriate examination technique
Ultrasound of the shoulder is used as diagnostic study used to evaluate the rotator cuff, biceps tendon and
acromio-clavicular joint. The Ultrasound is able to detect a range of pathologies such as; rotator cuff
pathology, bursitis & impingement, degeneration changes and shoulder instability (Daenen, Houben, Bauduin,
& Meulemans, 2007). As per the request form, ultrasound can be for bilateral shoulders or one sided. In order
to assess the shoulder correctly a set protocol should be followed.
It is important that such a protocol be followed so that the reporting doctor can easily follow the examination
and any further follow up ultrasounds can be accurately compared. All images need to be labeled with the
anatomical side and specific region.
Prior to beginning the examination you must be aware of any previous relevant shoulder imaging. For example
if the patient has had previous shoulder x-rays the sonographer should view these to asses for any bony
irregularities which could indicate signs of impingement (Hide & Chew, 2013).
One of the main benefits of ultrasound in evaluation of the shoulder is applying dynamic scanning. Not every
patient has the full range of movement with their shoulder; however the ability to move the arm into various
positions helps to highlight particular regions of the shoulder and to assess for impingement and fluid
movement (AIUM, 2012).
The protocols will be discussed using an example of a Left shoulder ultrasound for ongoing pain I performed
early on in my training. I will also provide an example of an examination I have performed towards the end of
the training to demonstrate the importance of experience and adjustment of technique. Accurate detection
of pathologies within the shoulder is strongly dependent on the experience and technique of the operator
(Bianchi & Martinoli, 2007).
1) I begin the examination at the biceps
tendon in transverse. I scan superiorly to
inferiorly ensuring I have assessed the
entire length of the tendon. My first image
is of the biceps tendon within the bicipital
groove in transverse.
2) Scanning superiorly at the intraarticular tendon you are able to
visualise the biceps, subscapularis,
supraspinatis and Coracohumeral
ligament.
3) Continuing inferiorly a take a second transverse
image demonstrating the biceps tendon. I also apply
external rotation of the arm to assess the stability of
the biceps tendon
4) Turning longitudinally on the biceps tendon
you can visualise the fibers in long. I take my
first image superiorly
5) Continuing inferiorly to the
musculotendinous junction .
6) I then ask the patient to externally rotate the arm with
the elbow pinned to the side to assess the subscapularis
tendon. Assessing from anterior to posterior. First image
is of the tendon in longitudinal
7) Second image with the tendons in
transverse.
8) Bring arm across the body and place hand on
opposite shoulder, elbow pinned close to body. I
then assess the Infraspinatus tendon. Scanning
anterior to posterior with a transverse image.
9) With the patient remaining in the same position
slide placing the probe over the posterior aspect of
the shoulder and slide inferiorly to assess the
Glenoid Labrum. Apply movement of the arm away
from the body to assess for joint effusion.
10) From the Posterior labrum move the
transducer superior- medially to assess the
spinoglenoid notch and take an image in
transverse.
11) Relax the arm down by the patient’s
side and continue the probe superiorly to
the border of the scapular to assess the
suprascapular notch
12) Bring the patients arm behind the patients
back and placing the hand on the hip, thumb
pointing forwards and fingers pointing backwards.
Ensuring the elbow is pointing backwards. This
positioning can vary depending on patient’s
mobility. Transverse image of the anterior portion
of the supraspinatus with biceps tendon in view.
13) Second image in transverse
demonstrating mid-posterior portion.
14) Longitudinal image of the anterior
portion of the tendon
16) Longitudinal image of the posterior
portion of supraspinatus.
15) Longitudinal image of the mid portion of
the tendon
17) Patients arm relaxed down by their side.
Transducer placed in transverse over the AC joint.
Check to see whether the patient is tender over the
joint my applying mild pressure.
18) From the AC joint scan inferiorly
towards the anterior portion of the shoulder
to assess the subacromial bursa.
19) If fluid is seen within the bursa, apply abduction to
the arm and assess for impingement.
Images- http://www.ultrasoundpaedia.com/normal-shoulder/ http://www.essr.org/html/img/pool/shoulder.pdf
Once the scan is complete the sonographer must complete a worksheet discussing the examinations findings.
Acknowledgements
I have used ideas and taken direction from Perth Radiological Clinic Protocol’s.
Bibliography
AIUM. (2012). Musculoskeletal Ultrasound Examination. Retrieved April 2014, from American Institute of Ultrasound in
Medicine: http://www.aium.org/resources/guidelines/musculoskeletal.pdf
Bianchi, S., & Martinoli, C. (2007). Ultrasound of the Musculoskeletal System. Berlin: Springer.
Daenen, B., Houben, G., Bauduin, E., & Meulemans, J. (2007). Ultrasound of the Shoulder. JBR-BTR , 325-337.
Hide, G., & Chew, F. S. (2013). Ultrasonography for Rotor Cuff Injury. Retrieved April 2014, from Medscape:
http://emedicine.medscape.com/article/401595-overview#a30