m court-payen, md, phd - dept of musculoskeletal imaging ...€¦ · van holsbeeck mt, introcaso...

M Court-Payen, MD, PhD - Dept of Musculoskeletal Imaging GHP Gildhøj Private Hospital Copenhagen - Denmark

US of the Shoulder – Examination Technique

• High Frequency Linear Array : 12-10 MHz • Rotating Chair

• Very Systematic • Different Specific Patient Positions

• Comparison with Contralateral Side • Dynamic • Interactive ++

Longitudinal

Long Head of the Biceps

Rotator Cuff

US of the Shoulder – Examination Technique

• High Frequency Linear Array : 12-10 MHz • Rotating Chair

• Very Systematic • Different Specific Patient Positions

• Comparison with Contralateral Side • Dynamic • Interactive ++

US of the Shoulder – Examination Technique

• High Frequency Linear Array : 12-10 MHz • Rotating Chair

• Very Systematic • Different Specific Patient Positions

• Comparison with Contralateral Side • Dynamic • Interactive ++

US of the Shoulder – Examination Technique

• High Frequency Linear Array : 12-10 MHz • Rotating Chair

• Very Systematic • Different Specific Patient Positions

• Comparison with Contralateral Side • Dynamic • Interactive ++

US of the Shoulder

• Anatomy of the Shoulder

• Systematic US Examination of the Shoulder

• Dynamic Examination of the Shoulder

• (US-guided Injection)

Glenohumeral Joint

Acromioclavicular Joint Sternoclavicular Joint

Scapulothoracic Space

Subacromial Space

The  Shoulder  =  5  “Joints”

Long Head of the Biceps

Supraspinatus

Infraspinatus

Teres Minor Subscapularis

Lateral Scapula

Biceps Subscapularis

Supraspinatus

Infraspinatus Teres Minor

CA ligt

AC joint Acromion

Superior Shoulder

Anterior Shoulder

Coracoid Process

Lesser Tuberosity

Greater Tuberosity

Acromion AC joint

Bicipital Groove

Anterior Shoulder

Subscapularis

Biceps

Anterior Shoulder

SDSA Bursa Deltoid

Anterior Shoulder

LH Biceps

Subscap

CA Ligt

AC Joint

+ SASD Bursa

Long Head of the Biceps

Rotating Chair

Supination

Patient Sitting

Long Head of the Biceps

Rotator Cuff Interval

Biceps Muscle

Pectoralis Tendon

Transv Humeral Ligt

Transversal

Long Head of the Biceps Rotator Cuff Interval

Retropulsion

Coraco-Humeral Ligt

Anterior Sling !

Superior Glenohumeral

Ligt

Biceps Muscle

Rotator Cuf Interval

Long Head of the Biceps

Longitudinal

Subscapularis Tendon

External Rotation +

Adduction

Cor

Subscapularis Tendon

- Volume - Structure - Upper Margin

External Rotation +

Adduction

Subscapularis Tendon

Rotator Cuff

Deltoid

Coracoid Acromion

Coracoacromial Ligament

Bursa

Acromioclavicular Joint Anatomical Variations

Compaire

to Contralateral ++

SASD Bursa

No Fluid Van Holsbeeck MT, Introcaso JH, Musculoskeletal Ultrasound 2001, p 472

Hypoechoic Layer < 1.5 mm Milgrom C et al. J Bone Joint Surg [Br] 1995, 77-B, 296-298 Van Holsbeeck MT, Introcaso JH, Musculoskeletal Ultrasound 2001, p 476

Unless Steroid Injection within 48 h Major NM, Skel Radiol 1999, 28, 628-631

Lateral Shoulder

Supraspin

+ SASD Bursa

Supraspinatus Tendon

Neutral

Supraspinatus Tendon

Internal Rotation +

Retropulsion Crass JR, J Clin Ultrasound 1987, 15, 416-420

Neutral

Supraspinatus Tendon

Head Neck Great

Tuberosity

Deltoid SASD Bursa

< 1.5 mm

Cartilage

• Convexe Upper Margin

• Progressive Thining

• Echorich Fibrillar Structure

• Regular Bony Surface

• Thickness : 5 - 7 mm (neck)

Normal Supraspinatus Tendon - 5 Histologic Layers

Clark JM et al. J Bone Joint Surg Am. 1992 Jun;74(5):713-25

5 4 3

2 1

5 4 3

2 1

Modified from Guérini et al. Actualité en Echographie de l´Appareil Locomoteur, Sauramps Médical 2008:21-33

Normal Supraspinatus Tendon - 2 BioMechanical Layers

5 4 3

2 1

Modified from Guérini et al. Actualité en Echographie de l´Appareil Locomoteur, Sauramps Médical 2008:21-33

Normal Supraspinatus Tendon - 2 Layers

Homogeneous But Pitfalls ... Supraspinatus Tendon

Oblique Scan

Supraspinatus Tendon Homogeneous But Pitfalls ...

No : Muscle Layer (Young ++)

Intratendinous Lesion ?

Supraspinatus Tendon Homogeneous But Pitfalls ...

Biceps Hiatus Deltoid Septation

Homogeneous But Pitfalls ... Supraspinatus Tendon

Supraspinatus Tendon

Humeral Head

Biceps

Deltoid SASD Bursa SS 2 cm

Supraspinatus Tendon

Modified Position

Biceps

SS 2 cm

Greater Tuberosity

Humeral Head Post Recess

Spinoglenoid Notch

Posterior Shoulder

Posterior Shoulder

Infraspinatus

Teres Minor

Posterior Shoulder

Teres Minor

Infraspin

Spinoglenoid Notch

+ SASD Bursa

Muscles

Head

Neck GT

Deltoid SASD Bursa

Cartilage

Infraspinatus Tendon

Labrum

Infraspinatus Tendon

Head

Normal Irregularity Neck

TM IS

Deltoid

Infraspinatus + Teres Minor Muscles

SS

Trap

Sp

Cl

Supraspinatus Muscles

SS

Trap Ac

Supraspinatus Muscles

Spinoglenoid Notch

Spine Neck

Suprascapular Neurovascular Bundle

Infraspinatus

Neer CS, J Bone Joint Surg 1972;54-A:41-50

Painful Arc

Tendinitis Tendinosis Tendon Tear Bursitis

Subacromial Impingement

Longitudinal Movement Longitudinal US Scanning

1 2

Subacromial Impingement

Dynamic US Examination Longitudinal Views of the Supraspinatus Tendon

1- At the level of the Acromion 2- At the level of the CAL

Subacromial Impingement Bulging of Bursa and Blocking of Tendon

Calcific Tendinopathy

Thank You