shoulder normal

the technique below demonstrates how to identify normal anatomy. remember to assess all 2022年世界杯预选赛规则图解 anatomy dynamically and thoroughly.

we scan our shoulders with the patient erect, seated on a high swivel chair for ease and ergonomics.

long head biceps (lhb)

to identify the biceps tendon:

  1. patient with their hand resting on their lap. palm upwards (external rotation) is best.
  2. palpate the anterior humeral head (bicipital groove if you can) and place the probe transversely.
  3. slide the probe superiorly and inferiorly to assess the entire tendon from the musculo-tendinous junction.

tip: when you slide down, look for the pectoralis major tendon crossing over the biceps. this is the  level of the bicipital musculotendinous junction. you must extend beyond this point to check for retraction  if a tear is suspected.

once you identify the biceps tendon:

  1. is it in the bicipital groove? (enlocated)
  2. is it intact?
  3. assess it from the superior humeral head (at the rotator cuff interval) to the musculo-tendinous junction inferiorly.
  4. is there fluid or synovial thickening of the sheath.

normal appearance:

  1. transverse: echogenic and ovoid (proximally, it is usually against the medial edge of the bicipital groove)
  2. longitudinal: echogenic and fibrillar.
  3. sheath: a trace of simple fluid is physiologically normal.

transverse biceps tendon scan plane.

tip: you will need a cranial angle on the probe to avoid anisotorphy.

transverse ultrasound long head biceps

longitudinal biceps tendon scan plane

biceps tendon ls normal ultrasound

subscapularis

to identify the subscapularis tendon:

  1. from your transverse bicipital groove, keep the probe still and externally rotate the patient's arm to stretch subscapularis into view.
  2. slide the probe superiorly and inferiorly to assess the entire tendon width.

tip: when you slide up/down and 'fall off ' the lesser tuberosity, you have covered the entire subscapularis tendon.

once you identify the subscapularis tendon:

  1. is it fibrillar
  2. is there fluid/calcification?
  3. is the contour flattened?

dynamics:

internally and externally rotate the arm to:

  1. better view the entire length of the tendon.
  2. assess the overlying bursa for impingement against the coracoid process.

normal appearance:

  • longitudinal: echogenic and fibrillar. convex contour.
  • transverse: the tendon will have a slightly heterogeneous appearance due to the multi- pennate nature of the tendon.
  • the overlying sub-deltoid bursa (sdb) should be uniform and very thin (essentially no visible gap between the subscapularis tendon and the overlying deltoid muscle).

subscapularis scan plane.

tip: from your transverse bicep view, leave the probe stationary and externally rotate the arm. subscapularis will come into view.

normal subscapularis ultrasound

coraco-acromial ligament

to identify the coraco-acromial ligament:

  1. from your transverse subscapularis view, slide medially and adjust antil you have the coracoid process on the edge of your image.
  2. rotate the other end of the probe towards the acromion (keep the coracoid end fixed so the coracoid is always visible)

this ligament rarely suffers damage. instead, look deep to it for fluid (may be joint or bursal overlying subscapularis in this area).

normal appearance:

  • longitudinal: echogenic and fibrillar. flared ends at the insertions.

axial view of shoulder anatomy

from the bicipital groove, slide medially until you see the coracoid.

rotate the other end of the probe towards the acromion until the cal comes into view.

normal coraco-acromial ligament (cal) ultrasound.

supraspinatus

to stretch the supraspinatus tendon:

firstly you need to stretch the tendon out from beneath the acromion. to do this we must externally rotate and push the humeral head forwards.

position 1. ask the patient to turn their palm up and pull their elbow back (modified crass)

or/and

position 2. ask the patient to place the back of their hand against their lower back (crass position)

supraspinatus ultrasound patient position1
supraspinatus ultrasound patient position1
supraspinatus ultrasound position2 crass
supraspinatus ultrasound position2 crass

tip: if you only use position 2, you may have difficulty clearly visualising the anterior aspect of supraspinatus tendon because of the degree of internal rotation. this position is also more difficult for the patient.

to identify the supraspinatus:

transverse

  1. begin with a transverse biceps tendon on the medial edge of your image.
  2. slide the probe up and over the humeral head.
  3. the supraspinatus will come into view (if it is present).
  4. the probe will be directed down towards the floor.
  5. examine anteriorly-posteriorly by sliding the probe.

longitudinal

  1. from the transverse view, rotate the probe 90degrees so the marker end is pointed towards the acromion.
  2. sweep the probe around the humeral head. anteriorly until you see the biceps tendon and posteriorly until you see the hypoechoic change of infraspinatus anisotrphy.
  3. ensure you rock (heel/toe) the transducer to view from insertion to musculo-tendinous junction.

tip:always keep the humeral head echo crisp. if it is blurry, you will not be perpendicular to the tendon)

once you identify the supraspinatus tendon:

  1. is it fibrillar
  2. is there fluid/calcification?
  3. is the contour flattened?

normal appearance:

  • longitudinal: echogenic and fibrillar. convex contour.
  • the supraspinatus tendon will become hypoechoic posteriorly related to the merging infraspinatus fibres
  • the overlying sub-acromial bursa (sab) should be uniform and very thin (less than 2mm).

tip: a thin bursa may still be adherent and symptomatically impinge so should be observed dynamically.

patient begins with arm by their side and abducts sideways to 90degrees. look for bunching of bursa or tendon against the acromion or coraco-acromial ligament.

normal supraspinatus ls ultrasound

normal sub acromial bursa

the subacromial and subdeltoud bursae are intimately against, and indistinguishable from, the overlying deltoid muscle.

the subacromial bursa ultrasound.

the bursae are subject to thickening and /or fluid.

this image shows both thickening and fluid. the measurement indicates how little is required to be symptomatic.

transverse supraspinatus tendon: note how far anterior the probe must be. biceps should be visible on the edge of the image.

normal supraspinatus transverse ultrasound

reference article

for a chart to classify tendon tears (246kb).

rotator cuff tear diagram

dynamic impingement assessment

patient position:

  • patient begins with arm relaxed by their side and abducts sideways to 90degrees.

what to check:

  • look for bunching of bursa/tendon against the coraco-acromial ligament or acromion.

where to check:

  • bunching is most likely to occur anteriorly under the coraco-acromial ligament.

scan plane:

  1. place the probe in a longitudinal supraspinatus plane, spanning the acromion and the greater tuberosity.
  2. slide anteriorly until the acromion disappears from view. this will be over the cal acromial origin and the most likely site for impingement.

tip: do not do test runs. if the patient performs ‘practice abductions’ they may smooth their symptomatic bursa so you miss the pathology when you perform the scan.

normal appearance:

  • the tendon and bursa should glide freely until they have passed beneath the cal/acromion.

nb record if the patient has pain or restriction of their range of motion (rom)

dynamic impingement assessment

  • patient begins with arm relaxed by their side and abducts sideways to 90degrees.

to assess for impingement:

  1. place the probe in a longitudinal supraspinatus plane, spanning the acromion and the greater tuberosity.
  2. slide anteriorly until the acromion disappears from view. this will be over the cal acromial origin and the most likely site for impingement.

tip: do not do test runs. if the patient performs 'practice abductions' they may smooth their symptomatic bursa so you miss the pathology when you perform the scan.

whilst the patient abducts:

  1. look for bunching of bursa/tendon against the coraco-acromial ligament or acromion.
  • the tendon and bursa should glide freely until they have passed beneath the cal/acromion.

nb record if the patient has pain or restriction of their range of motion (rom)

patient begins with arm by their side and abducts sideways to 90degrees. look for bunching of bursa or tendon against the acromion or coraco-acromial ligament.

normal supraspinatus longitudinal ultrasound at the level of the coraco-acromial ligament, before abduction.

axial view of shoulder anatomy
where to assess for shoulder impingement
when assessing for impingement with ultrasound, slide anteriorly off the acromion to view where the rotator cuff passes under the coraco-acromial ligament.

acromio clavicular joint (acj)

patient position:

  • patient begins with arm relaxed by their side.

scan plane:

  1. place the probe in a coronal plane, bridging the ac joint.
  2. slide anteriorly and posteriorly to interrogate the entire joint.

dynamic assessment:

  1. ask the patient to grip the side of the chair and pull downwards. look for widening of the acj.
  2. ask the patient to forward flex their shoulder and internally rotate (tipping a drink out). 

 

statically:

  1. narrowing of the joint.
  2. bony irregularity
  3. fluid, cysts or synovial bulging
  4. joint stability

dynamically:

  1. look for bony contact in the joint.

tips: 

  • clinically correlate...is it painful?
  • scan through from anterior to posterior as pathology will not always be central.

normal appearance:

  • smooth bone contours.
  • bones separated by hypoechoic central synovium.
  • gently convex contour of the ac ligament.

acromio-clavicular joint (acj) scan plane.

ultrasound of a normal ac joint.

infraspinatus (isp) and teres minor (tm)

patient position:

  • patient's arm by their side, internally rotated. ensure their entire arm is internally rotated, not just their forearm.

tip: common practice is to place the affected hand across to the opposite shoulder. whilst this tightens the infraspinatus and teres, it also creates an oblique angle on the tendons. we find simply internally rotating to be far simpler for the operator and patient.

to identify the infraspinatus tendon:

  1. place your probe across the lateral edge of the acromion.
  2. slide the probe inferiorly.
  3. as you drop off the acromion, you should see the humeral head and the infraspinatus tendon, longitudinal plane.

to identify the teres minor tendon:

  1. from the infraspinatus tendon, slide your probe inferiorly slightly.
  2. teres will be immediately inferior to the infraspinatus tendon.

tip:

  • the isp insertion is more anterior than most people expect.
  • you may need to 'rock' the probe anteriorly to see the insertion fully.

assess for:

  1. homogeneous fibrillar tendons.

normal appearance:

  • infraspinatus: echogenic and fibrillar. convex contour.
  • teres: thinner than isp with a small bony defect (nutrient foramen).

infraspinatus scan plane: patient’s arm internally rotated.

infraspinatus ultrasound

 

teres minor scan plane: imediately inferior to infraspinatus.

ultrasound of the teres minor tendon.

posterior gleno-humeral joint (ghj)

patient position:

  • patient's arm relaxed hanging by their side.

to identify the posterior glenohumeral joint:

  1. from your infraspinatus view, simply slide and roll your transducer around the humeral head.
  2. slide the probe superiorly and inferiorly to assess the entire joint.
  3. ask the patient to internally/externally rotate their arm to assess for joint effusions.

tip: a joint effusion will become visible during external rotation when the posterior capsule is not under tension.

assess for:

  1. bony irregularity
  2. fluid
  3. synovial cysts

tips:

  • this is the best scan plane for ultrasound guided joint injections
  • a curvi-linear probe will provide better views in larger patients (muscular or otherwise).
  • a curvilinear probe is also useful for needle visualisation (when the image is optimised appropriately).

normal appearance:

  • bony contour: smooth humeral head.
  • labrum: smooth, homogeneous echogenic triangular structure arising from the glenoid.

posterior ghj scan plane: linear probe.

posterior gleno humeral joint ultrasound using a linear probe.

posterior ghj scan plane: curvi-linear probe.

posterior gleno humeral joint ultrasound using a curvi linear probe.

this is helpful in larger patients and guiding injections/aspirations.

posterior glenohumeral joint
assess dynamically during internal/external rotation.

spino-glenoid notch

patient position:

  • patient's arm relaxed down by their side.

 

to identify the spino-glenoid notch

  1. in the same plane as the ghj, apply pressure to the medial end of the probe until parallel to the scapula.

assess for:

  1. bony irregularity
  2. a hypoechoic mass. ganglion of the scapula nerve

tips:

  • beware the false positive of a joint effusion pushing across into the notch

normal appearance:

  • smooth bony notch.
  • hypoechoic tissue (neurovascular) in but not protruding from, the notch.

the antomy and neuro-vascular structures of the spino-glenoid notch and suprascapular notch.

  1. suprascapular nerve
  2. suprascapular vein
  3. suprascapular artery
  4. superior transverse scapular ligament (stsl).

ref: j. clin. med. 2018, 7(12), 491; https://doi.org/10.3390/jcm7120491

spino-glenoid notch scan plane

spino-glenoid notch ultrasound.

you can often see the neurovascular bundle contained in the deep area of the notch.

suprascapular notch

patient position:

  • patient's arm relaxed down by their side.

 

to identify the suprascapular notch:

  1. from your spino-glenoid notch view, remain in a horizontal plane and  slide the transducer up over the spine of scapula.
  2. once you are passed the scapula spine, angle/fan the probe back inferiorly.
  3. the transducer will almost be aimed towards the floor.

tip:

  • you have angled down enough when the bony  floor of the suprascapular fossa becomes clear and crisply echogenic.

assess for:

  1. bony irregularity
  2. a hypoechoic mass. ganglion of the suprascapula nerve.
  3. a cyst (which may arise secondary to a labral tear).

tips:

  • beware the false positive of a joint effusion pushing across into the notch

normal appearance:

  • the suprascapular notch has a similar appearance to the spinoglenoid notch.

suprascapular notch scan plane.

note how steeply you need to angle down.

ultrasound of the suprascapular notch.

supraspinatus muscle belly

patient position:

  • patient's arm relaxed down by their side.

 

to identify the supraspinatus muscle belly:

  1. place the probe in a para-sagittal plane on the posterior shoulder.
  2. the non-marker (heel) end of the transducer should be on the scapula spine.
  3. slide the probe medially and laterally assessing the supraspinatus belly.

assess for:

  • if the muscle is diffusely echogenic or has a concave contour it is abnormal (fatty involution and atrophy).

normal appearance:

on ultrasound, the supraspinatus muscle belly should have:

  • a slightly convex contour.
  • hypoechoic echogenicity with echogenic internal fibres. (the 'starry-sky' appearance of a normal transverse muscle).

supraspinatus muscle belly scan plane

supraspinatus muscle belly ultrasound normal appearance

ultrasound assessment supraspinatus muscle belly
ultrasound the supraspinatus muscle belly for atrophy or fatty involution. it should become slightly convex (bulge) when the arm is moved from neutral to behind the back (crass position).

rotator cuff interval

the complex pulley system involving involving the:

  • biceps long head tendon
  • coraco-humeral ligament
  • superior gleno-humeral ligament

patient position:

  • patient's arm relaxed on their lap.

to identify the rotator cuff interval:

  1. identify the biceps tendon in the bicipital groove (transverse view).
  2. slide the probe superiorly. ensure the humeral head remains a sharp echogenic line (usually a caudal angle)
  3. as you exit the groove, the rci will be visible.

normal appearance:

  • thin fascia and bursa overlying the humeral head.
  • coracohumeral ligament superficial to the biceps
  • glenohumeral ligament deep to the biceps.

tip: both ligaments are subtle echogenic wedges.

assess for:

  • thickening of the entire complex
  • increased vascularity on colour doppler.
  • overlying bursal effusion.

tip: this is the junction point between the subdeltoid and subacromial bursae. so th bursa is commonly thicker here (up to 2mm0

rotator cuff interval ultrasound. rotator cuff interval ultrasound with highlighted anatomy.

ultrasound of the rotator cuff interval (rci).

the reflecting pulleys of the superior gleno-humeral ligament (sghl) and the coraco-humeral ligament(chl) stabilise the biceps as it courses medially to it’s origin on the anterior glenoid.

videos of patient movements

subscapularis assessment
when assessing the subscapularis tendon and stability of the biceps tendon, position the patient palm up as shown. internally and externally rotate the arm, keeping the elbow close to the patient’s side.
abduction
when assessing for impingement, ultrasound with the patient abducting their arm laterally. ensure they do not hunch or lean.
infraspinatus and posterior joint
when assessing the infraspinatus tendon, teres minor tendon or the posterior shoulder joint, position the patient’s arm by their side. ask them to internally/externally rotate to assess dynamics and tighten the tendons.

scan protocol

role of ultrasound

ultrasound is essentially used for the rotator cuff complex of the shoulder. ultrasound is a valuable diagnostic tool in assessing the following indications;

  • muscular, tendonous and some ligamentous damage (chronic and acute)
  • bursitis
  • joint effusion
  • vascular pathology
  • haematomas
  • soft tissue masses such as ganglia, lipomas
  • classification of a mass eg solid, cystic, mixed
  • post surgical complications eg abscess, oedema
  • guidance of injection, aspiration or biopsy
  • some bony pathology.

limitations

it is recognised that ultrasound offers little or no diagnostic information for internal structures such as the gleno-humeral ligaments. ultrasound is complimentary with other modalities, including plain x-ray, ct, mri and arthroscopy.

patient position

patient seated on chair in front of ultrasound machine. have the patient’s chair at an appropriate height to be ergonomically comfortable for you to scan.

 

equipment setup and technique

use of a high resolution probe (7-15mhz) is essential when assessing the superficial structures of the shoulder. careful scanning technique to avoid anisotropy (and possible misdiagnosis) beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. good colour / power / doppler capabilities when assessing vessels or vascularity of a structure. be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

common pathology

  • tendinopathy
  • tendon tears
  • calcific tendinosis
  • bursal effusion
  • bursal thickening
  • joint effusion and synovitis
  • osteo arthritis of the ghj and acj
  • dynamic impingement
  • muscle atrophy and or fatty involution
click here

to view pathology examples

scanning technique

patient position

patient seated on chair in front of ultrasound machine. have the patient’s chair at an appropriate height to be ergonomically comfortable for you to scan.

long head biceps (bt)

for example images of pathology, click here to goto the shoulder pathology page.

  • patient rests hand palm up on thigh.
  • scan transversely over the anterior humeral head.
  • visualize the bicipital groove. identify the biceps tendon in the groove (if not identified it may be either torn or subluxed medially out of the groove). follow down to the muscle belly.
  • rotate into longitudinal and re-examine.
  • the tendon should be a uniform fibrillar structure, generally less than 5mm thick.
  • examine dynamically in a transverse plane during internal/external rotation to ensure it doesn’t sublux medially.

subscapularis (ssc)

for example images of pathology, click here to goto the shoulder pathology page

  • again in a transverse plane at the bicipital groove, externally rotate the patient’s arm.
  • the ssc tendon will be visible inserting medial to the groove.
  • it will be seen as an elongated slightly convex tendon

supraspinatus (ssp)

for example images of pathology, click here to goto the shoulder pathology page

  • position the patient palm up with their elbow flexed and pulled back passed their side so their hand is near their hip.

identify the ssp tendon supero-lateral to the bicipital groove. in a coronal plane, the tendon emerges from beneath the acromion to insert on the greater tuberosity of the humerus.

it should be uniform, fibrillar & ‘beak shaped’ (convex superiorly).

infraspinatus (isp)

for example images of pathology, click here to goto the shoulder pathology page

  • ask the patient to place their affected hand across their chest towards the contralateral shoulder.

the isp can be seen by placing the probe immediately inferior to the spine of the scapula and following the tendon to it’s insertion postero-laterally on the humeral head.

it will have a similar appearance to subscapularis.

dynamic assessment

  • biceps: assess it’s stability within the bicipital groove during external rotation.
  • subscapularis: assess for any overlying subdeltoid bursal bunching against coracoid during internal rotation
  • supraspinatus: assess for bunching of the tendon &/or overlying subacromial bursa against the acromion or coraco-acromial ligament during abduction.
  • ensure the patient does not hunch their shoulder or lean towards the contralateral side during abduction.
  • posterior joint recess: during internal/external rotation, assess for a gleno-humeral joint effusion. this will be most evident during external rotation
  • acromio-clavicular joint: during forward flexion with internal rotation look for boney contact or ganglia of the acj.

basic hardcopy imaging

document the normal anatomy and any pathology found, including measurements and vascularity if indicated.

a shoulder series should include the following minimum images:

  • long head biceps tendon – long, trans
  • subscapularis tendon
  • coraco-acromial ligament
  • supraspinatus tendon
  • infraspinatus tendon
  • acromio-clavicular joint
  • posterior joint recess
  • pre & post abduction views
  • document the normal anatomy. any pathology found in 2 planes, including measurements and any vascularity. detail any limitation to range of movement and degree that pain or symptoms begin.