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)
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
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
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
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
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:
- place the probe in a longitudinal supraspinatus plane, spanning the acromion and the greater tuberosity.
- 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 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.
acromio clavicular joint (acj)
acromio-clavicular joint (acj) scan plane.
ultrasound of a normal ac joint.
infraspinatus (isp) and teres minor (tm)
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)
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.
spino-glenoid notch
the antomy and neuro-vascular structures of the spino-glenoid notch and suprascapular notch.
- suprascapular nerve
- suprascapular vein
- suprascapular artery
- 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
supraspinatus muscle belly
rotator cuff interval
the complex pulley system involving involving the:
- biceps long head tendon
- coraco-humeral ligament
- superior gleno-humeral ligament
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
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
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.