shoulder pathology

for normal anatomy and scanning protocol

biceps tendon

biceps effusion and tenosynovitis

the long head biceps tendon should be seen in the bicipital groove.
continuous to the musculotendinous junction.
a trace of fluid in the dependent aspect of the sheath, just distal to the bicipital groove.

longitudinal ultrasound view of the biceps tendon with a small effusion in the tendon sheath.

transverse ultrasound view of a biceps effusion.

ultrasound image- biceps tenosynovitis:
a markedly hyperaemic biceps tendon and sheath suggesting tenosynovitis.

longitudinal ultrasound view of biceps synovitis. there is only mild tendon thickening with hyperaemia of the thickened sheath.

ultrasound image- chronic synovitis:
the tight echogenic synovium surrounding the biceps tendon is suggestive of a chronic synovitis / capsulitis.

ultrasound image- adherent biceps tendon:
the biceps is adhered to the antero-lateral aspect of the sheath by the synovial thickening.

ultrasound image- loose calcification in the biceps tendon sheath.

dislocated biceps tendon

the long head biceps tendon always dislocates medially out of the groove. this is due to the medial tension as it pulls against the groove on its course to insert on the glenoid.
if the biceps is dislocated out of the groove, it indicates a disruption of the trans-humeral ligament which must involve a tear of subscapularis and/or supraspinatus.

ultrasound image- the biceps is seen against the medial edge of the biciptal groove. there is bony degenerative change.

bony irregularity within the bicipital groove is a contributing factor to tears and tenosynovitis

ultrasound image- the biceps tendon is very medial, overlying the subscapularis tendon.

ultrasound image- dislocated biceps tendon (green)

dislocating biceps tendon ultrasound

the biceps tendon is dislocated out of the groove and slides medially over the subscapularis down to the musculo-tendinous junction.

attempt to relocate a relocated biceps tendon

an attempt to relocate the dislocated biceps tendon by internally rotating the shoulder and applying transducer pressure.

ruptured biceps tendon

the long head biceps tendon generally tears at the musculotendinous junction
the patient will present with bruising of the anterior upper arm, a history of a painful snap/pop, but only mild tenderness or pain.
often it occurs in advancing age and requires no treatment.
the short head biceps is still functional resulting in only about a 20% loss of strength.

transverse ultrasound view. typical ruptured biceps at the musculotendinous junction.

ultrasound image- fluid along the long head biceps muscle belly secondary to a tear at the musculotendinous junction

ultrasound image- acute rupture of the long head biceps tendon.

subscapularis

tip:

beware the multi-pennate nature of the subscapularis tendon which creates heterogeneity of the echotexture in both longitudinal and transverse planes.

ultrasound of a subscapularis insertional tear (red arrow) and intratendinous calcification.
there is a small effusion in the overlying subdeltoid bursa.

ultrasound of a ruptured and retracted subscapularis tendon. the yellow indicates the retracted/bunched musculotendinous junction.

subscapularis bursal impingement

ultrasound of the subscapularis tendon during internal and external rotation. the overlying bursa bunches against the coracoid and short head bicep (shb) origin.

supraspinatus

for a chart to classify tendon tears .

normal shoulder anatomy.

move the cursor over the image to see a full thicknes tear v’s a complete rupture.

the humeral head (grey) is visible through the torn part of the tendon.

calcific tendinopathy

ultrasound image- calcification in the bursal surface of the supraspinatus tendon.

ultrasound image- a large calcification within the supraspinatus tendon. note the heterogeneous, likely torn insertion (red arrow).

tears

ultrasound image- a full thickness tear.
the blue arrows show the flattening of the deltoid due to transducer pressure.
the red arrows show dipping of the tendon contour disproportionate to the deltoid flattening. this is consistant with substance loss.
there is also loss of the normal fibrillar architecture in the area measured.

ultrasound image- a full thickness supraspinatis tear. this is full thickness because the tear extends from the bursal surface to the articular surface.

ultrasound image- partial thickness tear
the dipping of the tendon surface (arrows) indicates substance loss consistant with a partial thickness tear.

it is important not to compress the tendon with transducer pressure causing a false positive result. note the convexity of the overlying bursa eliminating this.

ultrasound image- an articular surface partial thickness tear of suraspinatus (ssp). the dipping of the tendon is readily seen with thickening of the overlying subdeltoid bursa (sdb).

avulsion fracture of the greater tuberosity

ultrasound image- an avulsion fracture of the greater tuberosity.
an associated tear of the supraspinatus can be seen, indicated by the small arrow heads.

xray showing the avulsed fragment off the greater tuberosity

bursae

the subdeltoid and subacromial bursae are subject to thickening, fluid, haemorrhage and calcification. any thickening will contribute to impingement.

ultrasound image- normal subacromial bursa (green).
the subacromial and subdeltoid bursae are intimately against, and indistinguishable from, the overlying deltoid muscle.

ultrasound image- the subacromial bursa. 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.

ultrasound image- thickening of the subacromial bursa.

ultrasound image- the coraco-acromial ligament impresses on the thickened bursa.

ultrasound image- a large bursal effusion.

ultrasound image- bursal fluid spanning the biceps tendon and the bicipital groove.

ultrasound image- acute bursitis, markedly increase vascularity seen with power doppler. a focus of ‘soft’ calcification is present in the bursa.

ultrasound image- impingement of the bursal calcification against the coraco-acromial ligament during abduction.

bursal impingement

the primary zone for bursal entrapment is beneath the acromial end of the coraco-acromial ligament (cal). when assessing for causes of impingement, this is where you should initially assess, rather than at the acromion itself. find the acromion in a coronal plane and slide your probe anteriorly until you slip off the acromion. you will be slicing the cal in it’s short axis.

more details on impingement dynamic assessment

gleno-humoral joint

posterior joint recess

a transverse plane with the probe on the posterior humeral head.
assess dynamically with internal and external rotation and ‘stop-sign’.
use either a linear or curvi-linear probe to obtain better penetration and an adequate field of view.

posterior shoulder joint probe position.

a curved probe is useful on larger patients or if you require a better over-view.

ultrasound image- an effusion in the posterior joint recess of the shoulder.

posterior gleno humeral joint effusion

internally and externally rotating the arm distends the effusion. note the irregular shape of the humeral head and flattened labrum consistant with chronic disease.

posterior joint arthritis

ultrasound of osteo-arthritis of the posterior shoulder joint. there is marked bony irregularity and a complex effusion. the labrum is hyper-mobile (yellow).

spino glenoid notch vein distension

ultrasound showing the normal distension of a vein in the spino-glenoid notch of the posterior shoulder during external rotation. not to be confused with a neural ganglion, synovial cyst or joint effusion. all of which may be seen occupying the notch.

anterior shoulder subluxation on ultrasound

ultrasound demonstrating an anteriorly subluxing shoulder during external rotation, viewed from posteriorly. the humeral head and glenoid should remain in a fixed position relative to each other (green line and red arrow). however the humeral head drops abruptly away (yellow arrow).

ultrasound of a labral cyst arising from the posterior glenohumeral joint.

this is suggestive of a labral tear.

small simple effusion in the inferior recess of the posterior glenohumeral shoulder joint,

spinoglenoid notch ganglion

ultrasound of a spinoglenoid notch gangion likely causing entrapment of the suprascapula nerve (image courtesy of pan sook yee)

anterior joint recess

a transverse plane with one end of the probe on the coracoid process.
assess dynamically with internal and external rotation and ‘stop-sign’.
use either a linear or curvi-linear probe to obtain better penetration and an adequate field of view.

probe position to view the anterior joint recess.

a transverse plane. the deeper anterior joint may be better visualised with a curvi-linear probe.

ultrasound image- anterior shoulder joint labral cysts suggestive of a likely labral tear. mri would be required to investigate the labrum if clinically indicated.
images courtesy of mrs jody ferguson.

ultrasound of the anterior shoulder joint effusion

anterior labral cysts

ultrasound of the anterior shoulder joint labral cysts seen sliding under the coracoid during internal rotation. labral cysts are suggestive of a likely labral tear. mri would be required to investigate the labrum if clinically indicated. images courtesy of mrs jody ferguson.

ultrasound image- the large, complex fluid collection extends down off the ac joint.

ultrasound image- a small synovial cyst from the acromio-clavicular joint.

abduction and impingement

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.

sub acromial bursal bunching impingement ultrasound

the subacromial bursa is thickened. during abduction, the bursa is seen to bunch against the coraco-acromial ligament (cal) -red arrow. pain and tightness limited this patients range of motion to approximately 60degrees.

sub acromial bursal bunching

despite the bursa being relatively thin, it still bunches painfully against the ca ligament at 45degrees abduction. the patient was able to continue and the bursa forces beneath the ligament at approximately 70-80 degrees with an improvement of symptoms.

subacromial bursal effusion bunching ultrasound

the small bursal effusion is squeezed and trapped behind the coraco acromial ligament during abduction. there is also synovial thickening of the bursa.

shoulder bursal bunching during abduction

the sub acromial bursa bunches against the cal. with continued abduction, the bursa ‘pop’s beneath the ligament with a palpable click

other shoulder pathology

deltoid muscle and tendon

ultrasound of a haematoma in a deltoid muscle tear following trauma.

ultrasound of a deltoid muscle tear transverse and longitudinal sections. the measurements indicate the size of the haematoma.