Student:
Agnes Kaweme
Student Number: 17324438
Email Address:
Agnes.kaweme@postgrad.curtin.edu.au
School:
Science and Engineering
Workplace:
My Radiology Centre (MRC) Perth
Lecturer:
Le-Anne Grimshaw
Due Date:
30/05/2014
I declare that this assignment is my own work and has not been
submitted in any form for another unit, degree or diploma at any
university or other institute of tertiary education. Information
derived from the published or unpublished work of others has been
acknowledged in the text and a list of references is given. I warrant
that any disks and or computer files submitted as part of this
assignment have been checked for viruses and reported clean.
Student Signature: akaweme
Date: 30/05/2014
SHOULDER ULTRASOUND
BACKGROUND INFORMATION
The shoulder girdle comprises of the scapular, humerus and clavicle.
Below is a table of the muscles found in the shoulder, their points of
origin and insertion.
MUSCLE
ORIGIN
INSERTION
Anterior deltoid
Lateral 3rd aspect of
clavicle
Lateral body of
humerus
Middle (lateral)
deltoid
Acromion
Deltoid tuberosity of
humerus
Supraspinatus
Supraspinatus fossa
Greater tuberosity of
humerus
Subscapularis
Subscapular fossa
Lesser tubercle of
humerus
Long head of biceps
Supraglenoid
tubercle
Radial tuberosity and
bicipital aponeurosis
in elbow
Short head of biceps
Coracoid process of
Scapula
Anterior surfaces of
sternal portion of
clavicle and sternum
Radial tuberosity
Pectoralis major
Pectoralis minor
3rd 4th and 5th ribs
Crest of greater
tubercle of humerus
Coracoid process
Table 1: Anterior shoulder muscles and tendons (Human Anatomy
Atlas 2014)
PATHOLOGIES
The most common pathologies identified with shoulder ultrasound
include but are not limited to:
1) Bursitis-, which refers to fluid within the bursa.
2) Adhesive capsulitis-commonly known as frozen shoulder
3) Calcific tendinosis-calcium deposit within the tendons
4) Tendon tears- these include; partial bursal tear, partial
thickness tea, full thickness tear, intra-substance tear,
serpiginous tear, rim rent tear, complete massive tear (2)
PROTOCOL
The following is the protocol set for ultrasound of the shoulder (3)
 Biceps trans prox and mid
 Biceps long proximal and MTJ
 Coracohumeral ligament (CHL)
 Subscapularis long
 Subscapularis trans
 Supraspinatus trans with arm in “karate” position
Biceps tendon should be in view in this image
 Supraspinatus trans with arm behind back
 Supraspinatus trans at insertion
 Supraspinatus long anterior
 Supraspinatus long mid
 Supraspinatus long posterior
 Acromio-clavicular joint
 Infraspinatus long at insertion
 Glenoid labrum
 Suprascapular notch
Dual image left and right if there is full thickness tear of
supraspinatus
 Supraspinatus and bursa under the coraco-acromio ligament
with the arm abducted 90 degrees
SHOULDER EXAMINATION
TECHNIQUE
The following technique was used during the semester for shoulder
examination (Grimshaw 2014):
1) LONG HEAD OF THE BICEPS
• Patient was positioned -erect on a swivel stool facing me (I find
it hard to scan with patient’s back towards me). Maintaining a
straight back posture.
The forearm was supinated and elbow flexed, at 90 degrees the
humerus is in close contact with the patient’s body. Sometimes
the affected side is supported at the wrist joint by the opposite
hand
• The transducer was placed on the anterior aspect of the
humeral head, and the bicipital groove can be seen as a bony
curvature in the head of the humerus separating the greater
and lesser tuberosities, this space is also known as the rotator
interval. The Biceps tendon lies within the bicipital groove,
with the transducer in transverse plane the tendon was seen as
a round to oval echogenic structure, heel toeing the probe
helped to avoid anasotropy.
• Scanning the tendon in transverse from proximal humeral head
down along the shaft to the level of insertion of the pectoralis
major, on the lateral aspect of the bicipital groove, to the
muscle belly where the short head joins the long head to form a
fusiform muscle.
• The probe was rotated through a 90-degree angle for a
longitudinal plane, displaying long linear echogenic fibers of
the tendon structure. Angling and scanning superiorly at the
rotator cuff interval demonstrates the coracohumeral ligament.
IMAGES PRODUCED AT THE BEGINNING OF SEMESTER
Image 1: BICEPS TENDON- transverse view of the biceps tendon in the bicipital groove. This
shows normal anatomy.
Image 2: BICEPS longitudinal view- normal echogenic fibres of the biceps
Image 3: Coracohumeral ligament can be seen supporting the biceps in normal position
2) SUBSCAPULARIS TENDON
• Patient remained in the same position as for biceps, was asked
to rotate the forearm externally to obtain a longitudinal view of
the tendon with the transducer in a transverse plane. The
scapularis has a convex margin shows echogenic linear fibers,
which inserts into the lesser tuberosity.
• The transducer was turned through 90° to obtain a short axis
(transverse plane), of the tendon which appeared
heterogeneous with hypoechoic clefts interposed related to
muscle fibers mixed with hyperechoic tendon fibers are
visualised.
Image 4: SUBSCAPULARIS LONG TENDON- insertion on the lesser tuberosity
Image 5:Mid portion of the subscapularis tendon-normal fibres
Image 6:Posterior portion of the subscapularis- normal fibres
Image 6: shows transverse view of the subscapularis tendon – displaying heterogeneous tendon
fibres interposed with muscle fascicles
3) SUPRASPINATUS TENDON-LONG
• The patient’s elbow was pushed backwards in a “karate
position” or in a modified Crass position, scanning superiorly
on the humeral head keeping in mind the transverse biceps
tendon as a landmark.
• The articular surface of the tendon is on the greater tuberosity
of the humeral head.
• The tendon is demonstrated as an echogenic structure with the
bursal surface perpendicular to the humeral head.
SUPRASPINATUS LONG- ANTERIOR
Image 7:showing longitudinal plane of the supraspinatus tendon anterior fibres insertion on the
greater tuberosity of the humerus
SUPRASINATUS LONG-MID
Image 8:showing normal mid fibres of the tendon insertion on the greater tuberosity
SUPRASPINATUS LONG POSTERIOR
Image 9:Normal posterior fibres of the supraspinatus tendon inserting on the greater tuberosity
4) ACROMIO-CLAVICULAR JOINT
• With the affected arm relaxed and placed in the initial position,
that is- flexed at the elbow joint and the forearm in supination,
the transducer was placed superiorly on the humeral head the
whole area was scanned to examine the acromio-clavicular
joint to rule out pathology of the joint like osteoarthritis
AC-JOINT
Image 10:Normal acromio-clavicular joint
5) INFRASPINATUS TENDON
• The patient was asked to bring the affected arm across the
chest and the hand positioned on the opposite shoulder.
• The probe was placed in longitudinal plane on the posterolateral aspect of the shoulder gliding the probe from the
greater tuberosity to the infraspinatus fossa the tendon is well
demonstrated and assessed for possible tears and
tendinopathy
INFRASPINATUS LONG
Image 11:Normal infraspinatus tendon
6) POSTERIOR LABRUM
• With the patient in the same position as for Infraspinatus and
scanning inferio-posterior to the humeral head in longitudinal
plane the posterior labrum comes into view with the articular
cartilage aligned to the humeral head and the deep fibres of the
infraspinatus follow the contour of the humerus. The area was
assessed for possible joint fluid collection, tears or labrum
cysts
Image 12: Normal appearances of the posterior labrum
7) SPINOGLENOID NOTCH
• The patient remains in the same position as for the
infraspinatus tendon and posterior labrum the depth was
increased and scanning medially brought the spinoglenoid
notch into view with the labrum still showing at the same level.
Image 13 Normal appearance of the spinoglenoid notch
8) DYNAMIC MANOUVERS
• With the patient in erect position the affected arm was raised
laterally, slowly abducting the limb, dynamically watching the
supraspinatus tendon and the subacromial bursa (SAB) pass
under the acromion and coracoid ligament. The SAB was noted
to be filled with fluid indicating bursitis
ABDUCTION- SAB
Image 14: Dynamic imaging Showing fluid collection in the subacromial bursa (SAB) on with arm
abduction at 60degrees
Image 15:Dynamic imaging of the shoulder showing the extent of fluid collection in the bursa
IMAGES PRODUCED MID- SEMESTER
The images taken in mid semester appear to be of better quality
compared to those taken at the beginning of the semester. This could
be attributed to the practical experience gained during the course of
the semester.
70% of the muscle skeletal referrals that come to our imaging centre
are shoulder problems, the aim is to examine the shoulder and
produce quality images of diagnostic value. It is easy to miss
pathology as a beginner and because we work as a team this has gone
a long way in helping me to evaluate my work and develop a firm and
steady hand when scanning. Dynamic manoeuvre Images above were
achieved as a result of that, the fluid in the bursa was not identified
until the motion scanning was applied. This has helped me to
remember to carryout internal, external rotation and abduction as
major part in my scanning the shoulder.
Images below are self explanatory, that I have come a long way in
achieving this standard and hoping to improve further.
The pathology shown in the images below
A young athlete presented with history of trauma, which happened to
be a shoulder dislocation, x-ray radiographs, showed the dislocationno bony injury. 2 weeks post reduction of the dislocation the patient
still complained of pain in the posterior shoulder region arm still in
an arm sling, hence his appointment for ultrasound.
Upon scanning this patient-all tendons appeared normal, but
demonstrated a depression fracture of the Posterolateral humeral
head, most likely from the impaction of the head of the humerus
against the glenoid rim. The labrum appeared bulky with ill-defined
borders. While doing a dynamic manoeuvre the patient was very
tender in external rotation, looking at the posterior shoulder in
motion showed the presence of fluid in the labrum (see video clip)
the diagnosis would possibly be posterior labrum effusion.
According to Chloros et al (2013), posterior shoulder pain in athletes
could be due to injuries inflicted on the glenoid labrum. The anatomy
is made up of the glenoid labrum rims and glenoid cavity; these are
made of articular cartilage. It is possible to have a focal detachment
of the labrum due to a possible tear the fluid appears echogenic
suggestive of haemorrhage (Zlatkin and Sanders 2013).
MID SEMESTER SHOULDER IMAGES
I mage 16 Transverse view of the biceps showing the coracohumeral ligament
Image 17: Transverse view of the biceps tendon in the bicipital groove
Image 18 Longitudinal view of the biceps tendon
Image 18: extension of the longitudinal view of the biceps tendon showing the muscle tendon
junction
I mage 19 shows normal longitudinal view of the subscapularis tendon
Image 20 shows Transverse view of normal subscapularies with anisotropy
Image 21 showing normal insertion of the supraspinatus tendon anterior fibres
Image 22 shows normal mid fibres of the supraspinatus tendon
Image 23 shows the normal posterior fibres of the supraspinatus tendon
I mage 24 shows normal Infraspinatus in longitudinal view showing Hill Sach’s
fracture.
I mage 25 shows the posterior labrum –bulky patients symptoms localised in this
region
I mage 26 shows fluid in the posterior labrum
Image 27 shows the effect of dynamic manoeuvre
Image 28 showing the fluid in the labrum recess on external rotation
Reference
Bianchi,S., and C. Martinoli. 2007. Ultrasound of the Musculoskeletal
System: New York: Springer
http://www.curtin.eblib.com.au.dbgw.lis.curtin.edu.au/patron
/SearchResults.aspx?q=Bianchi%2CS.%2C+and+C.+Martinoli.+
2007+ultrasound+of+the+musculoskeletal+system%3ASpring
er&t=quick
Chloros ,George D., Peter, Haar J.,Thomas, Loughran P and Curtis,
Hayes W.2013.”Imaging of Glenoid labrum lesions.” Clinics in
sports medicine 32(3): 361-390.
Grimshaw, Le-Anne.2014 “Module Two- Shoulder Ultrasound.”
Lecture notes. http://
Zlatkin, Michael and Sanders,Timothy.2013. “Imaging of the athletic
injuries of the upper extremity.” Radiologic Clinics of North
America 51(2): 279-297.