The Shoulder Ultrasound Edition
 ask the expert:
Is this normal? Wide-spread
rotator cuff pathology- at what
point is ultrasound as a
modality exhausted?
 guest editorial:
Ultrasonic appearances of the
shoulder post -surgery. Can you
spot the changes?
Extensive
Rotator
Cuff
Pathology- When is Ultrasound
as a Modality Exhausted?
Introduction
Ultrasound is an affordable,
accessible and safe imaging
modality in the assessment of
rotator cuff (Bianchii). X-Ray is an
effective imaging modality is the
assessment of fractures, bony
changes to the greater tuberosity
and acromium. Should both
modalities be requested, a
sonographer
should
utilise
information extracted from the
radiographs as it may assist with
likely diagnosis. Arthrography is a
complimentary choice which can
effectively detect full thickness
tears but cannot assess the nature
of tendon fibres effectively. MRI is
plays an increasingly important
role, particularly in patients who
may benefit from surgery (Tuite).
Whilst ultrasound is often one of
the first imaging modalities of
choice, the follow case study is an
example of where ultrasound is
challenged.
Case Study
A 58 year old male presents with
extensive chronic right shoulder
pain and limited range of motion.
It is noted the patient is a farmer
and describes life-long episodes of
trauma to the shoulder. He cannot
By Caitlin Gardiner, BSc (BioMed), 2/3
Master of Medical Ultrasound. Ultrasound
Services, WA.
recall a recent trauma which has
attributed to his increase of pain
over the past 8 weeks.
The examination is carried out on
a GE Logic S8 with a high
frequency 8-15mHz linear probe
utilising a shoulder preset.
A brief clinical assessment in
undertaken where the patient
demonstrates limited mobility in
the abduction with full internal
rotator, lateral abduction and
external rotation, poor resistance
while flexing the forearm and the
inability to resist putting his arm
behind his back. All movement
cause the patient pain.
Ultrasound
assessment
commences with the patient’s
right arm flexed to 90 degrees
with the hand resting palm up on
the thigh scanning anteriorly for
the bicep tendon. There is
significant fluid in the bicipital
groove but no identifiable tendon
(see fig one). Longitudinal
visualisation cannot demonstrate
any tendon fibres or retraction of
the tendon (see Fig Two).
Fig One: Right shoulder transverse
image of the bicipitial groove
indicating free fluid but no
identifiable tendon.
Fig Two: Longitudinal section of the
location of the right shoulder bicep
tendon. There are no identifiable tendon
fibres.
External rotation of the arm in a
flexed position is carried out to
demonstrate
the
subscapularis
tendon. The subscapularis appears
heterogeneous with non-uniform
fibrilar pattern though there is
neither identifiable tear nor bursal
thickening (see Fig Three).
Fig Three: Right subscapularis in
external rotation demonstrating non
uniform fibrillar pattern and diffuse
heterogeneous echotexture.
The patient is prompted to place
their affected arm on the
ipsilateral hip and extend their
elbow posteriorly. Assessment of
the supraspinatus is undertaken
and demonstrates the appearance
of a full thickness tear with
retraction (see Fig Four). As can be
seen in the transverse image,
there is no identifiable tendon. A
longitudinal
visualisation
demonstrates significant bony
irregularity and a complete lack of
anterior fibres, consistent with
retraction.
Fig Four: Transverse and longitudinal
images
of
right
shoulder
suprascapularis tendon pathology
demonstrating a full thickness tear
with tendon retraction.
Assessment of the AC joint
indicated significant degenerative
changes and focal tenderness
under slight probe pressure (see
Fig Five).
Fig Five: Ultrasonic assessment of the
AC
joint
shows
significant
degenerative changes.
The patient was asked to place the
hand of the affected shoulder on
the contralateral shoulder to
enable visualisation of the
infraspinatus. A slightly posterior
probe position in transverse
indicated a heterogeneous tendon
with an area of calcification (see
Fig Six).
Figure
Six:
Right
shoulder
infraspinatus
indicated
diffuse
heterogeneous echotexture and an
area of calcification.
A
further
slight
posterior
movement of the probe indicated
the
teres
minor
position.
Visualisation of the tendon is
difficult and the tendon appears
to have atrophied (see Fig Seven).
Fig Seven: Poor visualisation of the
right shoulder teres minor.
All other structures of the
shoulder appeared normal (please
see selection in Fig Eight).
challenges posed by the extensive
pathology,
MRI
was
recommended to further assess
the structures.
Discussion
Fig Eight: A) Normal CA Ligament; B)
Normal posterior glenoid.
Radiologist Review
Radiologist review confirmed a full
thickness
tear
of
the
supraspinatus
with
tendon
retraction, inability to identify the
long head of the biceps tendon,
tendonitis of the infraspinatus
tendon due to the heterogeneous
nature and focal calcification,
likely atrophy of the teres minor
due to poor visualisation and
degenerative changes of the AC
joint. It was noted there was no
bursal thickening or pathology of
the CA ligament, posterior glenoid
or SG notch. Due to the technical
The rotator cuff pathology
presented in this case study
posses
challenges
due
to
ultrasound limitations and the
experience of the sonographer at
recognising extensive tendon
disease.
Whilst for the operator this can be
of particular frustration and
disheartening to one’s confidence,
it is important to realise other
imaging modalities can assist in
such cases.
MRI has a positive predictive value
of rotator cuff tears of up to 100%
(Tuite).
Magnetic
resonance
arthrography allows distension of
the joint and forces contrast into
small defects with a reported
sensitivity and specificity of up to
100% in the detection of full
thickness and particular surface
partial tears *Tuite)
MRI is contraindicated in patients
with
cardiac
pacemakers,
ferromagnetic foreign bodies and
some cochlea implants. It is more
invasive and expensive than
Ultrasonography (Tuite).
Ultrasound provided the details of
extensive shoulder pathology
which now warrants further
imaging modality assessment.
Accurate diagnosis is crucial
where the limited range of
movement and severe pain is
having significant patient impact.
References
Bianchi S and Martionoli, 2007.
Ultrasound of the musculoskeletal
system. Springer, Philadelphia.
Rutton MJCM, Jager GJ and Blickman
JG, 2006. US of the rotator cuff;
pitfalls, limitations and artefacts.
Radiographics; 26(2):589-604.
Tuite MJ and Chew FS, 2013. Rotator
Cuff Injury MRI. Medscape.
By Caitlin Gardiner, BSc (BioMed), 2/3
Master of Medical Ultrasound. Ultrasound
Services, WA.
Post-surgical changes to the rotator cuffHow to recognise their sonographic
appearances.
The rotator cuff is the most
commonly torn structure in the
shoulder, typically presenting with
symptoms of weakness and pain
particularly on abduction. It has
been shown that an ultrasound
scan of the rotator cuff using
hand-held devices has a sensitivity
of 94.1% for partial-and 99.6% for
full-thickness tears. Specificity has
been reported at 96.1% for partialand 85.7% for full-thickness tears,
respectively (1).
As well as initial diagnosis of
rotator cuff pathology, ultrasound
plays a valuable role in the postoperative follow up of the
shoulder. Surgical changes to the
shoulder can result in an array of
varies appearances due to the
wide range of techniques utilized
and poses challenges to distinguish
expected and unexpected findings.
It can be a dilemma to distinguish
the differences between a
residual, recurrent problem, a
complication of the surgery or a
new problem.
Fortunately
postoperative
sonographic technique does not
differ from preoperative dynamic from the space in the shoulder
where the rotator cuff moves,
rotator cuff evaluation (1).
making more room for the rotator
This review summarizes some of cuff tendon so it is not pinched or
the commonly encountered repair irritated. If needed, this includes
options and their appearance shaving bone or removing bony
spurs from the point of the
post-surgery.
shoulder blade, sewing the torn
edges of the supraspinatus tendon
Rotator Cuff Repair
together and to the top of the
Surgery plays a crucial role in humerus. This can be done either
acute trauma causing rotator cuff by an open surgery, typically
tear where when performed in less reserved for larger tears, or by
than six weeks can avoid atrophy arthroscopy, which is less invasive
and only requires a small incision
of the muscle and tendon (2).
(3).
Rotator cuff surgery is indicated
for patients with good quality
tissue to uphold the repair. It is Ultrasound is a cost effective and
useful in situation of trauma and accessible modality to use in the
sudden weakness. In cases of assessment of the rotator cuff and
chronic pain and weakness, play an important role in postunresponsive to physiotherapy, surgical assessment. Up to 43% of
patient arthroscopically repairs
surgery can be considered.
rotator
cuff
large
tears
Surgery is contraindicated in demonstrate recurrent tears.
individuals with arthritis, severe These tears typically occur within
shoulder injury, obesity, diabetes, the early postoperative period
Parkinson’s
disease,
multiple (within the first three months) and
previous
shoulder
surgeries, are associated with inferior clinical
depression, narcotic use and heavy outcomes (4).
tobacco users (2).
Ultrasound assessment may show
Typically
surgery
involves elongated hyperechoic sutures
removing loose fragments of
within an operated tendon
tendon, bursa, and other debris
attaching to the greater tuberosity the subacromial subdeltoid bursa,
(arend).
resection of the coracoacromial
ligament,
acromioplasty
and
Postoperative deltoid atrophy
occasional resection of the distal
resembles
the
surgical
clavicle (3).
invasiveness
and
is
more
significant
in
open
repair Ultrasonic findings after the
procedures.
procedure consist of loss of the
normal convex contour of the
After rotator cuff repair, there is
supraspinatus
tendon
and
an
immediate
increase
in
replacement of the bursa by
subacromial bursa thickness and
granulation tissue. Care must be
posterior glenohumeral capsular
taken to not confuse the irregular
thickness, which are expected to
tendon surface with bursal
resume after 6 months. Tendon
thickening partial-thickness tears
thickness is typically unchanged.
(3).
(5).
The first few months after surgery
will demonstrate an increased Smooth and Repair
vascular
response
with
angiogenesis at the bone-tendon In cases where there is minimal
quality tendon to uphold a repair a
surface (3).
‘smooth and move’ surgery is
Full thickness recurrent tears can often performed. In this procedure
be assessed by performing graded all scar tissue and rough edges of
compressions in various shoulder tendon and bone are removed
positions, which typically present from the shoulder and a gentle
without pain for around 3 months manipulation is carried out so that
post-surgery. Another indicator a full range of passive motion is
would be the visualization of achieved (2). Such a surgery is
suture material within the tear (3). particularly prevalent in the
elderly and poses minimal postTendon echogenicity assessment surgical changes given the tendons
the
pre-operative
in the case of tendinopathy is from
challenging post operative and tendopathy presentation.
almost requires imaging presurgery for comparison. Affected Arthroplasty
tendons do not return to normal
even after successful surgical A shoulder arthroplasty is often
the procedure of choice to treat
intervention (3).
pain and articular damage
Isolated Subacromial Depression unresponsive to conservative
treatments such as NSAIDs, rest
Isolated Subacromial Depression is and cortisol injections. The
best
reserved
for
surgical procedure can be undertaken
treatment
of
subacromial irrespective of the underlying
impingement without rotator cuff pathology including osteoarthritis,
tears and consists of removal of rheumatoid arthritis, rotator cuff
arthropathy, avascular necrosis
etc. Technique utilised are
dependent of the surgeons
preference and experience as well
as patient pathology. Most
commonly a metallic prosthesis
with a modular humeral head that
articulated with the native glenoid
(2).
The main complications with
shoulder
arthroplasty
are
loosening, shoulder migration,
subluxation or dislocation of the
humeral head and post-operative
rotator cuff tear. Ultrasound is the
modality of choice post surgery as
MRI is limited due to the metallic
prosthesis. US appearances of the
humeral head are a linear
echogenic interface with moderate
posterior reverberation artefact.
The prosthesis does not hinder
assessment of the rotator cuff
though certain changes will be
likely. The subscapularis is
removed during surgically and
reattached more medially than
normal, at the humeral head
resection. Loosening of the cup
can be depicted by dynamic
assessment showing instability of
the metallic prosthesis to the bony
humerous. Moderate to severe
muscle atrophy, particularly of the
deltoid and teres minor, is
frequently encountered (6).
Conclusion
Using the intra-operative findings
as the gold standard, it has been
reported that ultrasound can
correctly identified recurrent tears
of the rotator cuff with a
sensitivity and specificity of 91%
and 86%, respectively, with an
accuracy of 89%. This is a slight
drop in the sensitivity reported by
the same researchers pre-surgery, the rotator cuff. J Bone Joint Surg
which could reflect the increased Br; 90(10)1341-1347
complexity post-operation (1).
2. Matsen FAm Warne WJ, 2013.
Previous imaging and surgical Rotator Cuff Tear: When to Repair
details should always be sought for and When to Smooth and move
and can improve the diagnostic the shoulder. UW Medicine,
accuracy
of
post-operative Orthopaedics
and
Sports
ultrasound diagnosis. Clinical Medicine.
feedback
from
orthopedic
3. Arend CF, 2013. Ultrasound of
surgeons and general practitioners
the Shoulder. Master Medical
is
important
to
improve
Books.
sonographic advancements.
4. Miller BS, 2010. When do
rotator cuff repairs fail: serial
1. Levy O, Venkateswaran B et al. ultrasound examination after
Mid-term clinical and sonographic arthroscopic repair of large and
outcome of arthscopic repair of massive rotator cuff tears. Am J
sports Med; 39(10(2064-2070.
References
5. Tham ER, Briggs L et al.
Ultrasound changes after rotator
cuff repair: is supraspinatus
thickness related to pain? Journ
Shoulder and elbow Surgery; 22(8)
6. Bianchi S and Martionoli, 2007.
Ultrasound of the musculoskeletal
system. Springer, Philadelphia.
7.
American
Academy
of
Orthopedic
Surgeons
and
American Academy of Pediatrics
(2010). Rotator cuff tears. In JF
Sarwark, ed., Essentials of
Musculoskeletal Care, 4th ed., pp.
311–316. Rosemont, IL: American
Academy of Orthopedic Surgeons.