View
2
Download
0
Category
Preview:
Citation preview
George A.W. Bruyn, Esperanza Naredo
EULAR on-line course on Ultrasound
LEARNING OBJECTIVES Describe and explain the basic application of MSUS in the shoulder.
Hold the probe and optimize the B-mode and Doppler settings of the US machine.
Identify normal US anatomy of the principal structures of the shoulder.
Perform the standard US scans of the shoulder.
Detect basic shoulder abnormalities (e.g. glenohumeral synovitis, biceps effusion and tenosynovitis,
subacromial-subdeltoid bursitis, full-thickness rotator cuff tears, rotator cuff calcification, and
cortical abnormalities such as erosions and osteophytes).
Sonoanatomy
Scanning technique and basic pathology of the shoulder
2
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
I. INTRODUCTION
Shoulder involvement is frequent in rheumatoid arthritis and other chronic arthritides. The glenohumeral and
acromioclavicular joints, the biceps tendon sheath and the subacromial-subdeltoid bursa may become
affected by synovitis that frequently results in rotator cuff and biceps tendon structural lesions and bone
erosions. Clinical differential diagnosis between inflammation and structural damage is difficult in the shoulder
due to its depth and function complexity (Murayama et al, 2013).
On the other hand, degenerative painful shoulder is one of the most common soft tissue diseases. It is a
clinical syndrome and the principal causes are rotator cuff and biceps tendon degeneration usually associated
with the chronic dynamic impingement of the rotator cuff under the acromion and the coracoacromial
ligament. Tendon degeneration or tendinosis may progress to partial and full-thickness tear of the rotator cuff.
Clinical differentiation between the above lesions is challenging and often inaccurate (Naredo et al, 2002).
Ultrasound (US) has demonstrated accuracy in the detection of shoulder inflammation and rotator cuff lesions
(Bruyn et al, 2009; Bruyn et al, 2010; Swen et al, 1999; Ottenheijm et al, 2010; Sakellariou et al, 2013; Ottaviani
et al, 2014). In addition, US can be used as a guide for performing accurate and safe periarticular or intra-
articular, intralesional or perilesional injections.
This module reviews the basic anatomy of the shoulder, the standardised US scanning technique, the basic
normal US findings and abnormalities as well as the principles in handing the probe and optimizing the settings
for shoulder US. Following this, US assessment of specific inflammatory shoulder conditions is discussed and
interactive cases will help to provide a more in-depth view of two selected conditions.
II. ANATOMY
A deep knowledge of musculoskeletal anatomy is mandatory for successful US examination. The shoulder is
made up of three bones: the humerus, the clavicle and the scapula. There are three joints: glenohumeral (GH),
acromioclavicular (AC) and sternoclavicular (SC) joints. The major joint of the shoulder is the GH joint. The latter
is surrounded by the rotator cuff, which is composed of four muscles and their corresponding tendons, the
subscapularis, supraspinatus, infraspinatus and teres minor. The subscapularis muscle is the most anterior
component of the rotator cuff, arises from the subscapular fossa of the scapula, and inserts into the humeral
lesser tuberosity (Figure 1). The supraspinatus is the most superior muscle, originates on the supraspinatus fossa
at the posterior aspect of the scapula, and inserts into the most anterior aspect of the humeral greater tuberosity
(Figure 2). The bipennate infraspinatus muscle runs from the infraspinatus fossa at the posterior aspect of the
scapula to the greater tuberosity just posterior and inferior to the supraspinatus tendon (Figure 2). The
subacromial-subdeltoid bursa, which covers the rotator cuff is lined by synovial membrane. The deltoid muscle
is located superficial to the above structures. The tendon of the long head of the biceps muscle originates from
3
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
the supraglenoid tubercle just above the shoulder joint from where its tendon passes down along the bicipital
groove between the greater and lesser tuberosities of the humerus (Figures 3 and 4). It is surrounded by a
synovial sheath on the bicipital groove. The humeral transverse ligament covers the proximal bicipital groove
and the pectoralis major tendon covers the distal bicipital groove. The GH joint capsule extends from the glenoid
rim to the anatomical humeral neck and is lined by synovial membrane. The fibrocartilaginous labrum surrounds
the glenoid rim. The AC joint contains a fibrocartilaginous intra-articular disk.
4
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
5
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
III. US SCANNING METHOD
US examination should be systematic and standardised (Backhaus et al, 2001; Naredo et al, 2007; Bruyn et al,
2011)(Table 1). Firstly, bony landmarks (i.e. humeral head, glenoid, coracoid process, acromion and clavicular
bone) should be identified in the corresponding standard scans. Transverse and longitudinal scans of the biceps
tendon groove, rotator cuff and subacromial-subdeltoid (SASD) bursa, transverse scan of the posterior GH recess
and glenoid labrum as well as longitudinal scan of the GH axillar recess and AC joint are performed in basic US
examination of the shoulder. Comparison with the opposite shoulder is very useful for diagnosing unilateral
shoulder abnormalities.
III-1 Anterior US Examination
In the anterior aspect of the shoulder the biceps tendon, the subscapularis tendon and the AC joint are evaluated
with the patient sitting, the shoulder in neutral position, the elbow flexed 90º and the hand supinated on the
thigh.
6
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
III-1-1 Transverse scan of the biceps tendon (i.e. tendon of the long head of the biceps muscle). VIDEO SHOULDER
part 1 – see Images library
The probe is placed transversely to the bicipital groove on the anterior aspect of the shoulder and is moved
superior and inferiorly following the bicipital groove. The bony landmarks that should be identified are the
bicipital groove, the greater tuberosity of the humerus, and the lesser tuberosity of the humerus. The biceps
tendon is visualized oval-shaped and hyperechoic into the bicipital groove, between the hyperechoic profiles of
the greater and lesser tuberosity of the humerus (Figure 5). The biceps tendon can be surrounded by a thin
hypoechoic halo which represents normal fluid within the synovial sheath. The hyperechoic transverse humeral
ligament covers the proximal bicipital groove. The tendon should be scanned from the proximal (Figure 6) to the
distal aspect of the bicipital groove where the insertion of the tendon of the pectoralis major is seen (Figure 7).
Figure 5. Transverse scan of the biceps tendon (right shoulder). gt, greater tuberosity; bg, bicipital groove; lt,
lesser tuberosity.
7
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 6. Transverse scan of the rotator cuff interval, proximal to the bicipital groove.
Figure 7. Insertion of the pectoralis major tendon at the distal bicipital groove.
8
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
III-1-2 Longitudinal scan of the biceps tendon (i.e. tendon of the long head of the biceps muscle) VIDEO SHOULDER
part 2 – see Images library
The probe is placed longitudinally to the bicipital groove, pressing slightly more with the lower pole of the probe.
The bony landmark that should be identified is the flat bicipital groove between the greater and lesser
tuberosities of the humerus. The biceps tendon shows a fibrillary hyperechoic pattern between the hyperechoic
humeral profile and the hypoechoic deltoid muscle (Figure 8). The tendon should be scanned from the proximal
to the miotendinous junction at the distal aspect of the bicipital groove.
Figure 8. Longitudinal scan of the biceps tendon. bg, bicipital groove.
III-1-3 Longitudinal scan of the subscapularis tendon
VIDEO SHOULDER part 3 – see Images library
The probe is placed transversely to the bicipital groove. The bony landmarks that should be identified are the
bicipital groove, the greater and lesser tuberosities of the humerus, and the coracoid process. Medial to the
biceps tendon, the insertion of the subscapularis tendon is identified on the lesser tuberosity with some fibres
continuing across the bicipital groove to form the humeral transverse ligament. To scan the subscapularis tendon
properly, the shoulder should be moved into external rotation. The subscapularis tendon has a convex superficial
margin and a hyperechoic echotexture (Figures 9 and 10). The hyperechoic profile of the coracoid process can
be seen medially to the subscapularis musculotendinous junction.
9
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figures 9 and 10. Longitudinal scans of the subscapularis tendon (right shoulder) in maximal external rotation
(Figure 9) and neutral position (Figure 10). lt, lesser tuberosity; cp, coracoid process.
10
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
III-1-4 Transverse scan of the subscapularis tendon
VIDEO SHOULDER part 4 – see Images library
The probe is placed transversely to the subscapularis tendon. The bony landmark that should be identified is the
lesser tuberosity of the humerus. The subscapularis tendon appears convex-shaped with hyperechoic
echotexture (Figure 11).
Figure 11. Transverse scan of the subscapularis tendon.
III-1-5 Longitudinal scan of the acromioclavicular joint
VIDEO SHOULDER part 5 – see Images library
Cranial to the biceps tendon, the AC joint is scanned. The probe is placed cranial to the bicipital groove,
longitudinally across the superior and anterior aspect of the AC joint. The hyperechoic profile of the acromion
and clavicle, the hyperechoic joint capsule, and the peripheral aspect of the intra-articular fibrocartilage are
visualized (Figure 12).
11
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 12. Longitudinal scan of the acromioclavicular joint (right shoulder). ac, acromion; cl, clavicle.
III-2 Anterolateral US Examination
In the anterolateral aspect of the shoulder the supraspinatus and infraspinatus tendons, the SASD bursa, the
humeral cartilage and the humeral cortex accessible for US are examined. The supraspinatus and infraspinatus
tendons should be examined with the patient´s shoulder in hyperextension and internal rotation (e.g. dorsum
of the hand resting over lumbar spine or over the opposite back pocket) in order to expose them from
underneath the acromion and to allow a maximal length of tendon to be visualized. This manoeuvre is also
referred to as the Crass position (Crass et al, 1987). If the above position is very painful for the patient, shoulder
internal rotation with the hand over the ipsilateral pocket also allows us to visualize the supraspinatus and
infraspinatus tendons.
III-2-1 Transverse scan of the supraspinatus and infraspinatus tendons, and subacromial-subdeltoid bursa
VIDEO SHOULDER part 6 – see Images library
For scanning the supraspinatus tendon, the probe should be placed transversely, just below the anterolateral
aspect of the acromion and moved laterally and up and down just below the acromion. The bony landmarks that
should be identified are the coracoid process, and the humeral head. Lateral to the coracoid process, the
intracapsular biceps tendon can be seen. The supraspinatus tendon is seen hyperechoic with convex superficial
margin, deep to the hypoechoic deltoid muscle, and covering the humeral head (Figure 13). The hyperechoic
humeral cortex and the humeral articular cartilage, which is seen as a thin anechoic layer between the tendon
12
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
and the humeral head are identified. The SASD bursa is visualized as a thin hypoechoic line with a variable
amount of peribursal echogenic fat between the deltoid muscle and the supraspinatus tendon. For scanning
the infraspinatus tendon, the probe is moved further laterally, up and down just below the lateral aspect of the
acromion. The infraspinatus also appears convex-shaped, the most posterior aspect usually thinner than the
supraspinatus tendon. In the posterolateral aspect below the acromion the infraspinatus miotendinous junction
is visualized (Figure 14).
Figure 13. Transverse scan of the supraspinatus tendon. cp, coracoid process; hh, humeral head.
Figure 14. Transverse scan of the infraspinatus tendon. hh, humeral head.
13
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
III-2-2 Longitudinal scan of the supraspinatus and infraspinatus tendons, and subacromial-subdeltoid bursa
VIDEO SHOULDER part 7 – see Images library
The probed is placed obliquely to the arm, longitudinal to the supraspinatus and infraspinatus tendons. The
probe is moved laterally. The bony landmarks that should be identified are the greater tuberosity of the
humerus, the anatomic neck of the humerus, the humeral head, and the acromion. The supraspinatus (Figure
15) and infraspinatus (Figure 16) tendons are triangular, with convex superficial margin, extending from the
greater tuberosity and disappearing under the acromion. The hyperechoic humeral cortex and the anechoic
humeral cartilage are identified. The SASD bursa is seen as a thin hypoechoic line with a variable amount of
peribursal echogenic fat between the deltoid muscle and the above tendons.
Figure 15. Longitudinal scan of the supraspinatus tendon. gt, greater tuberosity; hn, anatomic humeral neck;
hh, humeral head.
14
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 16. Longitudinal scan of the infraspinatus tendon. hh, humeral head; ac, acromion.
III-3 Posterior US Examination
VIDEO SHOULDER part 8 – see Images library
The posterior US examination of the shoulder includes the posterior aspect of the infraspinatus tendon, the
posterior GH recess and the posterior labrum with the arm in neutral position, the elbow flexed 90º and the
hand supinated or the hand on the opposite shoulder. The probe is placed transversely to the arm, just below
the spine of the scapula. Dynamic external and internal shoulder rotation is performed to improve posterior GH
recess view. Identifiable bony landmarks are the posterior aspect of the humeral head, and the glenoid fossa
or cavity. The profile of the humeral head and the glenoid, the hyperechoic joint capsule covering the posterior
glenohumeral recess, and the infraspinatus tendon and muscle are identified (Figure 17). The cartilaginous
posterior labrum is imaged as a hyperechoic triangle separating the infraspinatus tendon from the glenoid. In
dynamic scanning (i.e. shoulder external and internal rotation), the posterior GH recess can be seen a thin
hypoechoic triangular structure (Video 1).
Video 1. Posterior glenohumeral recess (left shoulder) – see Images library
15
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 17. Posterior glenohumeral recess scan (left shoulder). hh, humeral head; gl, glenoid fossa.
III-4 Axillary US examination
VIDEO SHOULDER part 9 – see Images library
The axillary GH recess is scanned with the arm in 90º of abduction and the probe placed longitudinally to the
axilla (Koski, 1991). The bony landmarks that should be identified are the humeral head, and the surgical neck
of the humerus. The humeral head and humeral surgical neck profiles and the joint capsule which covers the
axillary GH recess are identified (Figure 18).
16
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Table 1. Scanning method for shoulder US examination
Standardised scans Patient position Probe placement Bony landmarks Transverse biceps tendon
Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh
Transversely to the bicipital groove on the anterior aspect of the shoulder, moved superior and inferiorly following the bicipital groove
Bicipital groove Greater tuberosity of the humerus Lesser tuberosity of the humerus.
Longitudinal biceps tendon
Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh
Longitudinally to the bicipital groove, pressing slightly more with the lower pole of the probe
Bicipital groove Greater tuberosity of the humerus Lesser tuberosity of the humerus.
Longitudinal subscapularis tendon
Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh. The patient moves the arm from neutral to full external rotation
Transversely to the bicipital groove, on the anterior aspect of the shoulder
Bicipital groove Lesser tuberosity of the humerus Coracoid process
Transverse subscapularis tendon
Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh. The patient moves the arm from neutral to full external rotation
Longitudinally to the bicipital groove, on the anterior aspect of the shoulder
Lesser tuberosity of the humerus Coracoid process
Acromioclavicular joint
Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh
Cranial to the bicipital groove, longitudinally across the superior and anterior aspect of the acromioclavicular joint
Acromion Clavicle
Transverse supraspinatus and infraspinatus tendons
Sitting, shoulder in maximal internal rotation and hyperextension, dorsum of the hand resting over lumbar spine
Transversely, just below the antero-lateral aspect of the acromion, and moved laterally and up and down just below the acromion
Coracoid process Humeral head
Longitudinal supraspinatus and infraspinatus tendons
Sitting, shoulder in maximal internal rotation and hyperextension, dorsum of the hand resting over lumbar spine
Obliquely to the arm, longitudinal to the supraspinatus tendon, and moved laterally
Greater tuberosity of the humerus Anatomic neck of the humerus Humeral head, acromion.
Posterior glenohumeral joint
Sitting, shoulder in neutral position, elbow flexed 90º, forearm supinated on the thigh or the hand on the opposite shoulder. Dynamic external and internal shoulder rotation
Transversely to the arm, just below the spine of the scapula
Posterior aspect of the humeral head Glenoid fossa
Axillary glenohumeral recess
Sitting, raised arm (90º of abduction)
Longitudinal plane of the axilla
Humeral head Surgical neck of the humerus
17
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 18. Axillary glenohumeral recess. hh, humeral head; hn, surgical humeral neck.
IV. HOLDING THE PROBE AND OPTIMISING THE GREY-SCALE AND DOPPLER SETTINGS
OF THE US SYSTEM
Equipment for evaluating the shoulder generally includes a linear broadband transducer with a range of 7 to 15
MHz. The use of stand-off pads is not necessary, but generous application of US coupling gel to the skin is
indispensable. Curved-array transducers may be used in evaluating deeper structures such as the axillary recess,
where it also nicely fits in to the anatomic concavity of the arm pit. It is recommended that any pathology is
confirmed in two orthogonal planes, and dynamic manoeuvres are extremely useful in evaluating pathology.
Sometimes, right-left comparison with the other side is advantageous. Dynamic examination can facilitate the
visualization of anatomic structure and the detection of subtle abnormalities (Corazza et al, 2015).
IV.1 Holding The Probe And Optimizing The Grey-Scale Settings.
The shoulder is examined according to a standard protocol. The examiner holds the probe like a pencil, with
extended wrist, when the examiner is seated in front of the patient. The patient usually is seated on a revolving
chair, making examination of anterior, lateral and posterior shoulder easier. Alternately, the examiner is
standing behind the seated patient and the probe is held with a flexed wrist. The probe should not be pressed
too firmly to the skin. During the anterior shoulder examination, the probe is moved from the anterior bony
landmark, the bicipital groove and its 2 tubercles, from medial to lateral. Then the probe is moved from proximal
18
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
to distal to include the full length of the course of the long head of the biceps tendon. Depending on the anatomy
of the patient, the frequency of the probe has to be changed, as well as the focus, gain and depth. A thorough
examination of the long head of the biceps tendon demands that the probe should be manoeuvred in a rocking
procedure as well as a tip-toe procedure, therefore optimizing the visualization of the biceps tendon and
minimising the natural anisotropy of this tendon. Examination of the anterior and lateral shoulder usually does
not require a low frequency or a curved-array transducer, as structures are lying superficially. However,
examination of the deeper seated structures of the posterior shoulder may require a lower transducer frequency
(< 7 MHz) or a curved-array transducer. Helpful procedures to optimize the visualization of posterior structures
include asking the patient to put the hand on top of the contralateral shoulder, thereby better visualizing the
spinoglenoid groove; another procedure is the external rotation manoeuvre of the arm, thus improving the
detection rate of small quantities of synovitis in the GH joint.
IV.2 Optimizing The Doppler Settings
The frequency of the Doppler examination for the shoulder is usually between 6-10 MHz, the PRF around 750
KHz, a low wall filter and the gain set just above the threshold when noise artefacts appear. One pitfall should
be mentioned when examining the anterior shoulder. It is important to make the distinction between
tenosynovitis and the normal presence of a signal due to the lateral branch of the anterior circumflex humeral
artery, just below the biceps tendon seen in the long axis plane and adjacent to the bone.
V. BASIC US PATHOLOGY OF THE SHOULDER
V.1 Synovitis (Synovial Hypertrophy And Effusion)
The GH joint, the AC joint, and the SC joint are synovium-lined joints and may become, either simultaneously or
sequentially, involved in inflammatory rheumatic disease. The shoulder joint can also be affected by
microcrystalline or septic processes. For editorial reasons, we will focus on the GH joint. Common inflammatory
diseases of the shoulder joint are rheumatoid arthritis (RA), psoriatic arthritis and other spondyloarthropathies,
and amyloid arthropathy in chronic haemodialysis patients. Clinical examination of the shoulder joint is
notoriously treacherous and shows a poor correlation with imaging techniques for swelling of the shoulder (Kim
et al, 2007; Luukkainen et al, 2007). US has become nowadays an indispensable tool for the rheumatologists
in finding synovitis of the shoulder joint. Over recent years, reproducibility and validity studies has been
conducted to establish the metric qualities of US for detection of shoulder disease in patients with RA. These
studies showed a fair to good correlation between US and MRI for the presence of fluid in the axillary and
posterior recesses (Bruyn et al, 2009). Reliability studies has showed a good intraobserver agreement for the
presence of fluid in posterior and axillary recesses and excellent agreement for synovial Doppler signal.
19
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Interobserver agreement varied from good to excellent for the detection of fluid in these recesses (Bruyn et al,
2009; Bruyn et al, 2010).
Shoulder joint synovitis may be found ultrasonographically in various recesses and bursae. Synovitis on US is
characterized by anechoic or hypoechoic abnormal intraarticular material that displaces the shoulder joint
capsule on the axillary longitudinal scan (i.e. axillary GH recess) (Figure 19) and/or the posterior transverse scan
(i.e. posterior GH recess) (Figures 20-23). Synovitis can content fluid (displaceable) and/or synovial hypertrophy
(non displaceable and poorly compressible) (Wakefield et al, 2005). However, differentiation between synovial
hypertrophy and effusion using US might be difficult in deep anatomic areas such as the GH recesses (Wamser
et al, 2003). Anterior to the shoulder joint, fluid will collect in the biceps sheath, around the long head of the
biceps tendon, which communicates with the GH joint. Thus, an anechoic or hypoechoic halo around the biceps
tendon on transverse scan (Figure 24) and band on longitudinal scan (Figure 25) may be considered a feature of
synovitis of the GH joint.
Figure 19. Synovitis in the axillary glenohumeral recess. hh, humeral head; hn, surgical humeral neck.
20
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 20. Synovitis in the posterior glenohumeral recess. hh, humeral head; s, synovitis.
Figure 21. Synovitis in the posterior glenohumeral recess. hh, humeral head.
21
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 22. Synovitis (s) in the posterior glenohumeral recess and SASD bursitis (b).
Figure 23. Synovitis (s) in the posterior glenohumeral recess with Doppler signal. hh, humeral head
22
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 24. Biceps sheath effusion (arrowhead), transverse scan. gt, greater tuberosity; bg, bicipital groove; lt,
lesser tuberosity.
Figure 25. Biceps sheath effusion (arrowheads), longitudinal scan. bg, bicipital groove.
Dynamic external rotation of the patient´s shoulder facilitates the detection of synovitis in the posterior GS
recess (18)(Schmidt et al, 2008) (Video 2).
Video 2. Dynamic detection of synovitis at the posterior GH recess – see Images library
23
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
In addition, fluid may collect in the subcoracoid bursa and the superior subscapularis recess. The subcoracoid
bursa is located between the anterior surface of the subscapularis and the coracoid process. The subcoracoid
bursa does not communicate with the GH joint but it sometimes does with the SASB (Grainger et al, 2000).
The superior subscapularis recess, also known as the subscapularis bursa, is a genuine recess of the anterior
shoulder capsule and projects between the superior and middle glenohumeral ligaments. The recess lies deep
to the subscapularis muscle and anterior to the scapula; it may extend proximally in a manner that it may hang
over the superior margin of the subscapularis tendon like a saddle bag (Figure 26). Therefore, it is easy to confuse
an effusion within the superior subscapularis recess with an effusion of the subcoracoid bursa. The former may
be physiological, whereas the latter is probably due to a pathologic process. In addition, it must be kept in mind
that there is considerable variation in the number and size of anterior shoulder recesses (Rockwood et al,
2004) (Table 2).
The degenerative AC joint frequently shows effusion associated with massive tears of the rotator cuff. This
pathologic fluid distends the AC capsule. In one study, 126 AC joints of 63 healthy subjects were examined. One
of the prominent findings was that if US distance of the joint capsule was < 3 mm, there was no effusion on MRI
scans (Alasareela et al, 1997).
Figure 26. Synovitis in the subscapularis recess. cp, coracoid process.
24
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Table 2. Anatomical variation in the synovial recesses found within the anterior capsule of the shoulder joint
(Rockwood et al, 2004)
Type Description % Prevalence
Type I One recess above the middle glenohumeral ligament 7 % – Cadaveric study 30% - Cadaveric study
39% - Cadaveric study Type II One recess below the middle glenohumeral ligament 3% – Cadaveric study
2% – Cadaveric study 0% - Cadaveric study
Type III One recess above and below the middle glenohumeral ligament 89% – Cadaveric study 47% – Cadaveric study 46% – Cadaveric study
Type IV One large recess with absent middle glenohumeral ligament 1 case – Cadaveric study 9% – Cadaveric study 6% – Cadaveric study
Type V Two small synovial folds 0% – Cadaveric study 5.1% – Cadaveric study 0% – Cadaveric study
Type VI No recesses present 0% – Cadaveric study 11% – Cadaveric study 10% – Cadaveric study
V.2 Biceps Effusion and Tenosynovitis
The biceps sheath communicates with the GH joint. Thus, abnormalities detected in the biceps synovial sheath
frequently represent an extension of GH joint pathology. Biceps sheath effusion in most patients appears
associated with rotator cuff tears. In addition, biceps sheath effusion can be secondary to biceps tendinopathy,
rupture or dislocation. It is seen as a pathological hypoechoic or anechoic halo surrounding the biceps tendon
that can be displaced with the pressure of the probe. Biceps tenosynovitis is defined as hypoechoic or anechoic
thickened tissue with or without fluid within the tendon sheath, which is seen in two perpendicular planes and
which may exhibit Doppler signal (Wakefield et al, 2005) (Figures 27-30). The presence of tenosynovial
proliferation or hypertrophy is characteristic of inflammatory arthritides.
25
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 27. Biceps tenosynovitis, transverse scan. bg, bicipital groove.
Figure 28. Biceps tenosynovitis, longitudinal scan. bg, bicipital groove.
26
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 29. Biceps tenosynovitis with Doppler signal, transverse scan. bg, bicipital groove.
Figure 30. Biceps tenosynovitis with Doppler signal, longitudinal scan. bg, bicipital groove.
27
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
V.3 Bursitis
Bursitis may accompany rotator cuff lesions and impingement or be inflammatory , microcrystalline, traumatic,
or septic. Most frequently, bursitis involves the SASD bursa. The subcoracoid bursa, which can communicate
with the SASD bursa, can also be involved in inflammatory and degenerative conditions. Bilateral SASD bursitis
has been shown to be a hallmark of PMR and recently has been included in the EULAR/ACR criteria for
classification for this disease (Dasgupta et al, 2012). Bursitis appears as an increase of hypoechoic fluid and/or
tissue depending on its nature within the bursa and may show Doppler signals (Figures 31-35).
Figure 31. SASD bursitis (b), transverse scan. hh, humeral head.
28
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 32. SASD bursitis (b), longitudinal scan. gh, greater tuberosity.
Figure 33. SASD bursitis (arrowhead), longitudinal scan. gh, greater tuberosity, hn, anatomic humeral neck;
hh, humeral head.
29
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 34. Inflammatory SASD bursitis (asterisks), showing power Doppler signals. hh, humeral head; BT,
bicipital groove.
30
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 35. SASD bursitis containing large quantities of bursal fluid (bf) and proteinaceous material (pm).
V.4 Rotator Cuff Tears
US is highly sensitive and comparable to MRI in detecting rotator cuff tears (Fischer et al, 2015; Roy et al,
2015).Rotator cuff tears can be partial-thickness or full-thickness. Partial thickness tears can involve the articular
side, the bursal side or the inside of the rotator cuff tendons. Full-thickness tears that involve the entire width
of a tendon are called complete tears.
Full-thickness rotator cuff tears are those extending from the humeral cartilage to the SASD bursa. Most rotator
cuff tears involve the supraspinatus tendon and occur at the insertion site and frequently extend posteriorly to
involve the infraspinatus tendon and/or anteriorly to involve the subscapularis tendon.
31
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
US signs of full-thickness rotator cuff tears are non-visualization of the tendon (Figures 36 and 37), fibres defect
from the humeral head to the SASD bursa, usually filled with hypoechoic fluid (Figures 38 and 39) or superior
tendon convexity instead of concavity (Figures 40 and 41).
The main US sign of partial-thickness rotator cuff tears is a hypoechoic partial disruption of the tendon fibres
(Figures 42-45).
Figure 36. Supraspinatus and infraspinatus full-thickness, transverse scan. The US image shows absence of the
tendons and the deltoid muscle covering the humeral head. hh, humeral head.
32
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 37. Supraspinatus and infraspinatus full-thickness, longitudinal scan. The US image shows absence of
the tendons. The deltoid muscle is now on top of the humeral head. hh, humeral head; ac, acromion.
Figure 38. Supraspinatus full-thickness, transverse scan. The US image shows a hypoechoic defect of the
tendon fibres from the SASD bursa to the humeral cartilage. hh, humeral head; cp, coracoid process.
33
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 39. Supraspinatus full-thickness, longitudinal scan. The US image shows a hypoechoic defect of the
tendon fibres from the SASD bursa to the humeral cartilage. gt, greater tuberosity; hn, anatomic humeral
neck; hh, humeral head.
Figure 40. Supraspinatus full-thickness, transverse scan. hh, humeral head; cp, coracoid process.
34
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 41. Supraspinatus full-thickness, longitudinal scan. gt, greater tuberosity; hn, anatomic humeral neck;
hh, humeral head; ac, acromion.
Figure 42. Supraspinatus extensive partial-thickness (articular side) (asterisk), transverse scan. The US image
shows an extensive hypoechoic defect of the tendon fibres with a cortical break at the level of the tear. hh,
humeral head; cp, coracoid process.
35
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 43. Supraspinatus extensive partial-thickness (articular side) (asterisk), longitudinal scan. The US
image shows an extensive hypoechoic defect of the tendon fibres with a cortical break at the level of the tear.
gt, greater tuberosity; hn, anatomic humeral neck; hh, humeral head.
Figure 44. Supraspinatus partial-thickness (bursal side) (asterisk), transverse scan. hh, humeral head; cp,
coracoid process.
36
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 45. Supraspinatus partial-thickness (bursal side) (asterisk), longitudinal scan. gt, greater tuberosity;
hn, anatomic humeral neck; hh, humeral head.
Common US findings associated with rotator cuff tears are increased fluid within the biceps sheath and/or the
SASD bursa, and/or AC and GH mild effusion, greater tuberosity cortical irregularities, and the cartilage interface
sign (i.e. visualization of hyperechoic superficial cartilage surface in contact with fluid filling in the tendon
defect).
V.5 Rotator Cuff Calcification
Intratendon calcifications can show different morphology on US (i.e. arc-shaped, fragmented, punctuate).
Calcifications appear as hyperechoic curved lines or foci within the tendon substance (Figures 46 and 47). The
easiest to recognize are those that produce acoustic shadow. These can be asymptomatic or produce acute and
chronic impingement symptoms due to calcific tendinitis or bursitis.
37
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 46. Supraspinatus calcifications (arrowheads), transverse scan.
Figure 47. Supraspinatus calcifications (arrowhead), longitudinal scan.
38
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
V.6 Cortical abnormalities (Erosions and Osteophytes)
Erosions and osteophytes are common findings on imaging evaluation of the shoulder. Such bony changes can
be easily visualized with US. In particular, US is able to detect early erosions in RA(Amin et al, 2012). In an in-
vitro study using a bone phantom model, Koski found that ultrasonographers were successful in distinguishing
healthy bones from bones with erosions (Koski et al, 2010). In the above study, US was valid and reliable in
detecting cortical bone erosions in vitro, when the round erosion is at least 1 mm deep and 1.5 mm wide. Bony
changes of the shoulder should be looked for with US anteriorly, laterally and especially posteriorly, where endo-
and exorotation of the arm can expose more surface of the hyaline cartilage.
Shoulder involvement is a critical issue in patients with rheumatic disorders. In RA, literature data indicate
radiographic shoulder damage in 50% of patients after two years and 96% of patients with 12 years of disease.
Ongoing synovial inflammation is the primary driving force for the onset of humeral head erosions. US erosions
are defined as intraarticular discontinuities of the bone surface that is visible in two perpendicular planes
(Wakefield et al, 2005) (Figures 48-51). Although erosions may point to in chronic arthritides, particularly RA,
they can also be found in other conditions and even in normal subjects. Other conditions that feature erosions
include avulsion fracture of the greater tuberosity (Figure 52-54), haemodialysis-related amyloid arthropathy,
crystal arthropathy, post-traumatic cortical changes of a Hill-Sachs lesions, post-shoulder surgery and post-
septic arthritic changes. In a comparative study between conventional radiography, US, and MRI in 43
rheumatoid arthritis patients, erosions were found in 60% of patients with radiography, in 70% with US, and in
91% with MRI (Hermann et al, 2003). Bruyn et al found good intra- and interobserver reliability for US detection
of shoulder erosions in patients with RA (Bruyn et al, 2009; Bruyn et al, 2010).
39
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 48. Humeral head erosion (arrowhead), transverse plane.
Figure 49. Humeral head erosion (arrowhead), longitudinal plane.
40
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 50. Humeral head erosions (arrowheads), transverse plane.
Figure 51. Humeral head erosions (arrowheads), longitudinal plane.
41
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 52. Greater tuberosity fracture (arrowhead), longitudinal scan.
Figure 53. Greater tuberosity fracture (# of humeral head (HH), longitudinal scan.
42
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 54. Greater tuberosity fracture (#), and accompanied by SASD bursitis (bf), longitudinal scan.
Osteophytes can occur in the GH and the AC joint. In general, these point to degenerative changes in elderly
individuals, though they may also occur in younger persons after trauma The osteophytes of the GH joint are
usually more pronounced at the humeral head compared to the glenoid cavity (Figure 55). At the AC joint,
osteophytes may appear at either site. US can be helpful to identify these, particularly at the AC joint.
Osteophytes appear as prominences at the joint margins (Figure 56).
Figure 55. Humeral head osteophytes (arrowhead), axillary recess. hh, humeral head; hn, humeral neck.
43
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Figure 56. Acromioclavicular osteophytes (arrow). Hypoechoic AC effusion can be also visualized. hh, ac,
acromion; cl, clavicle.
44
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
SUMMARY POINTS
Shoulder joint US is best performed by using a linear array broadband transducer with frequencies
ranging from 5 -15 MHz.
It is recommended to perform shoulder US by adhering to a standard protocol.
US of the shoulder joint is more sensitive for picking up GH joint synovitis than clinical examination
and more sensitive for detection for erosions than conventional radiography.
Shoulder joint synovitis may be apparent by detecting fluid in the biceps tendon sheath, axillary
pouch or posterior recess. Synovitis is ultrasonographically characterized by anechoic or
hypoechoic areas with elevation of the capsule, visible on the longitudinal axillary scan or the
transverse posterior scan.
Biceps tenosynovitis is defined as hypoechoic or anechoic thickened tissue with or without fluid
within the tendon sheath, which is seen in two perpendicular planes and which may exhibit
Doppler signal.
Bursitis may accompany rotator cuff lesions and impingement or be inflammatory or
microcrystalline.
Bilateral SASD bursitis has been shown as a hallmark of PMR.
Bursitis appears as an increase of hypoechoic fluid and/or tissue depending on its nature within
the bursa, is very accurate in the detection of rotator cuff lesions. US signs of rotator cuff full-
thickness tears are non-visualization of the tendon, fibres defect from the humeral head to the
SASD bursa, usually filled with hypoechoic fluid or superior tendon convexity instead of concavity.
Rotator cuff calcifications appear as hyperechoic curved lines or foci within the tendon substance
with or without acoustic shadow.
Erosions (cortical breaks) can be found in a healthy person.
45
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
VI. REFERENCES
Alasareela E, Revonen O, Takalo R, Lahde S, Suramo I. Ultrasound evaluation of the acromioclavicular joint. J
Rheumatol 1997; 24: 1959-63.
Alasareela E, Revonen O, Takalo R, Lahde S, Suramo I. Ultrasound evaluation of the acromioclavicular joint. J
Rheumatol 1997; 24: 1959-63
Amin MF, Ismail FM, El Shereef RR. The role of ultrasonography in early detection and monitoring of shoulder
erosions, and disease activity in rheumatoid arthritis patients; comparison with MRI examination. Acad Radiol.
2012 Jun;19(6):693-700.
Backhaus M, Burmester GR, Gerber T, et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann
Rhem Dis 2001; 60:641-9.
Bruyn GAW, Schmidt WA. Introductory Guide to musculoskeletal ultrasound for the rheumatologist. Bohn
Stafleu van Loghum 2011. Second edition. Houten, the Netherlands.
Bruyn GAW, Naredo E, Moller I, et al. Reliability of ultrasonography in detecting shoulder disease in patients
with rheumatoid arthritis. Ann Rheum Dis 2009; 68:357-61.
Bruyn GA, Pineda C, Hernandez-Diaz C, et al.Validity of ultrasonography and measures of adult shoulder
function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis
using magnetic resonance imaging as a gold standard. Arthritis Care Res (Hoboken). 2010;62: 1079-86.
Corazza A, Orlandi D, Fabbro E, et al. Dynamic high-resolution ultrasound of the shoulder: how we do it. Eur J
Radiol. 2015;84:266-77.
Crass JR, Craig EV, Feinberg SB. The hyperextended internal rotation view in rotator cuff ultrasonography. J
Clin Ultrasound 1987; 15: 416-20.
Dasgupta B, Cimmino MA, Maradit-Kremers, et al. 2012 provisional classification criteria for polymyalgia
rheumatic: a European League against Rheumatism/American College of Rheumatology collaborative
initiative. Ann Rheum Dis 2012; 71: 484-92.
Fischer CA, Weber MA, Neubecker C, et al. Ultrasound vs. MRI in the assessment of rotator cuff structure prior
to shoulder arthroplasty.J Orthop. 2015;12:23-30.
Grainger A, Phillip F. J. Tirman, J. et al. MR Anatomy of the subcoracoid bursa and the association of
subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval. AJR 2000;174:1377–
1380.
46
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Hermann KG, Backhaus M, Schneider U, et al. Rheumatoid Arthritis of the Shoulder Joint. Comparison of
Conventional Radiography, Ultrasound, and Dynamic Contrast-Enhanced Magnetic Resonance Imaging.
Arthritis Rheum 2003; 48: 3338-49.
Koski JM, Alasaarela E, Soini I, et al. Ability of ultrasound imaging to detect erosions in a bone phantom
model. Ann Rheum Dis 2010;69:1618-22.
Koski JM. Validity of axillary ultrasound scanning in detecting effusion of the glenohumeral joint. Scand J
Rheumatol 1991; 20:49-51.
Kim HA, Kim SH, Seo Y. Ultrasonographic findings of the shoulder in patients with rheumatoid arthritis and
comparison with physical examination. J Koran Med Sci 2007; 22: 660-6.
Luukkainen R, Sanila MT, Luukkainen P. Poor relationship between joint swelling detected on physical
examination and effusion diagnosed by ultrasonography in glenohumeral joints in patients with rheumatoid
arthritis. Clin Rheumatol 2007; 26: 865-67.
Murayama G, Ogasawara M, Nemoto T, et al. Clinical miscount of involved joints denotes the need for
ultrasound complementation in usual practice for patients with rheumatoid arthritis. Clin Exp Rheumatol
2013;31:506-14.
Naredo E, Aguado P, De Miguel E, et al. Painful shoulder: comparison of physical examination and
ultrasonographic findings. Ann Rheum Dis 2002; 61:132-6.
Naredo E, Uson J, Acebes C, et al. Joint ultrasonography. Sonoanatomy and examination technique. Ed
EUROMEDICE, Ediciones Médicas, SL, Barcelona, 2007
Ottenheijm RP, Jansen MJ, Staal JB, et al. Accuracy of diagnostic ultrasound in patients with suspected
subacromial disorder. A systematic review and meta-analysis. Arch Phys Med Rehabil 2010; 91:1616-25.
Ottaviani S, Gill G, Palazzo E, et al. Ultrasonography of shoulders in spondyloarthritis and rheumatoid arthritis: a case-control study. Joint Bone Spine 2014;81:247-9.
Rockwood CA, Matsen FA, Wirth MA, Lippitt SB (editors). The shoulder. Saunders, 2004.
Roy JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the
characterisation of rotator cuff disorders: a meta-analysis. Br J Sports Med. 2015 Feb 11.
Sakellariou G, Iagnocco A, Filippucci E, et al. Ultrasound imaging for the rheumatologist XLVIII. Ultrasound of the shoulders of patients with rheumatoid arthritis. Clin Exp Rheumatol. 2013;31:837-42.
Schmidt WA, Schicke B, Krause A. Which ultrasound scan is the best to detect glenohumeral joint effusions?
Ultraschall Med 2008; 29: 250-5.
47
Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4
©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University
Swen WAA, Jacobs JWG, Algra PR, et al. Sonography and magnetic resonance imaging equivalent for the
assessment of full-thickness rotator cuff tears. Arthritis Rheum 1999;42:2231-8.
Wakefield R, Balint PV, Szkudlarek M, et al. Musculoskeletal Ultrasound Including Definitions for
Ultrasonographic Pathology. J Rheumatol 2005; 32:2485-7.
Wamser G, Bohndorf K, Vollert K, et al. Power Doppler sonography with and without echo-enhancing contrast
agent and contrast-enhanced MRI for the evaluation of rheumatoid arthritis of the shoulder joint:
differentiation between synovitis and joint effusion. Skeletal Radiol 2003; 32: 351-9.
Recommended