shoulder ultrasound: miscellaneous pathology: beyond the ... · beyond the rotator cuff jon a....

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Shoulder Ultrasound: Beyond the Rotator Cuff

Jon A. Jacobson, M.D.

Professor of Radiology

Director, Division of Musculoskeletal Radiology

University of Michigan

Miscellaneous Pathology:

• Biceps brachii tendon

• Subacromial-subdeltoid bursa

• Acromioclavicular joint

• Labrum

• Greater tuberosity

• Pectoralis major

Biceps Brachii: pathology

• Tendinosis

• Tear: partial and full-thickness

• Subluxation and dislocation

• Association with:

– SLAP and anterior rotator cuff tears

• Causes: acute injury, repetitive injury, degeneration

Biceps Tendon:

• Glenohumeral joint effusion:– Collects around biceps

tendon

– Tendon sheath communication

– Seen in 97% with joint effusion

– Abnormal: > 1 mm1

Short Axis

Color Doppler

BTBT

1Zubler et al. Eur Radiol 2011; 21:1858

Shoulder Joint Recesses

• Long head biceps tendon sheath

• Posterior recess:

– Image with shoulder in external rotation

• Axillary recess

• Subscapularis recess

Biceps Tendon Sheath

• Intra-articular body

– Echogenic

– Possible shadowing

– Single or multiple

– Associated with glenohumeral joint osteoarthritis

Short Axis

Long Axis

BTBT

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Biceps Tendon:

• Tenosynovitis

Unlike joint effusion:

• Focal distention

• Hyperemia with color Doppler

• Pain with transducer pressure

• No effusion in posterior recess

Biceps Tendon: tenosynovitis

Short Axis

Long Axis

Biceps Tendon

• Tendinosis:• Hypoechoic• Swollen• No inflammatory cells

(not tendinitis)• Possible tenosynovitis

Biceps Tendon:

• Partial-thickness tear:

– Hypoechoic /anechoic cleft

– Tenosynovitis

– Sensitivity: 27%

– Accuracy: 88%

– Subluxation / spur• Important secondary signs

Split + tenosynovitis

Split + SubluxationSkendzel J, et al. AJR 2000;

197:942

Aponeurotic Expansion of Supraspinatus Tendon• Up to 49% of shoulders

• Cleft: coronal plane

• Origin: supraspinatus

• Distal: pectoralis or bicipital groove

Moser et al. Skeletal Rad 2015; 44:223

Biceps Tendon:

• Full-thickness tear:–Non-visualization proximally– Bicipital groove filled with

fluid / granulation tissue–Distal retracted tendon stump–Ultrasound: 88% sensitivity,

97% accuracy

Skendzel J, et al. AJR 2000; 197:942

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Biceps Tendon: full-thickness tear

Long Axis

Humerus

Biceps Tendon (long head): full-thickness tear

Short Axis: proximal Short Axis: distal

Bicipital Groove Short Head

Biceps Tendon

Subluxation Dislocation

**

Lesser Tuberosity

Lesser Tuberosity

Biceps Tendon Subluxation

Biceps Tendon Dislocation Biceps Tendon: Dislocation into subscapularis tendon

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• Labrum



Subacromial-subdeltoid bursa (SASD) vs. subscapularis recess (SSR) vs.

subcoracoid bursa (SCB)

SCB

SCB

SCB

SSR

SSR

SSR

SASD

SASD

C

C

C

A

Subacromial-subdeltoid Bursa:

• Normal:– Thin hypoechoic layer: fluid, synovium– Hyperechoic: bursal walls and

peribursal fat• Abnormal: >1 mm thick*

– Fluid: anechoic– Synovial tissue: hypoechoic to hyperechoic

*Invest Radiol 1985;20:311

Subacromial-subdeltoid Bursa: fluid

Coronal Coronal T2w

Deltoid

Suprasp.

Subacromial-subdeltoid bursa: anterior

Proximal Distal

Sagittal

Biceps

Humerus

Deltoid

Subacromial-subdeltoid Bursa

Anterior Posterior

BT Infraspinatus

LT Subscap

GlenoidHumerus

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Subacromial-subdeltoid Bursa and Biceps Tenosynovitis

Transverse Coronal

BT

GTLT

Calcific Bursitis

Impingement Syndrome

• Cuff impingement• Subacromial

enthesophyte or acromioclavicular joint osteophyte

• Associated tendon degeneration and tear

Supraspinatus

Impingement: bursal fluid

• Abnormal pooling of subacromial-subdeltoidbursal fluid

• Lateral acromion1:

– Coronal plane, active arm elevation

– Not visible in neutral position, no cuff tear• Thickened tendon or bursa

– Possible snapping of thickened bursa– “Gathering” of bursa: may be asymptomatic2

1Farin et al. Radiology 1990; 176:8452Daghir A et al. Skeletal Radiol 2012; 41:1047

Impingement TestImpingement Syndrome

AA

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Impingement: supraspinatus Impingement: supraspinatus





• Labrum



Acromioclavicular Joint:

• Osteoarthritis: common by age 40– Thick capsule > 2 mm

– Narrow, irregular, osteophytes

• Trauma:– Wide, possible subluxation

– Thick capsule >2 mm

• Cyst versus geyser sign– Geyser: joint fluid tracking through ACJ via full-thickness

rotator cuff tear

Acromioclavicular Joint

Osteoarthrosis Prior Trauma

AC joint: subluxation

Axial T2w

Sagittal T2w

AcromionClavicle

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Post-traumatic Osteolysis of the

Clavicle

Large Full-thickness Tear: geyser sign

Long Axis Coronal T1w

Clavicle

Acromion





• Labrum



Glenoid Labrum:

• Hyperechoic

• Some areas difficult to visualize

• Hypoechoic cleft: tear

• Diffuse hypoechoic: degeneration

• Consider MRI to confirm

Labrum: normal

Axial

Posterior Labral Tear

Axial Axial T1w post-gado

HumerusGlenoid

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Paralabral Cysts:

• Periarticular shoulder cyst

• May cause pain simulating rotator cuff tear

• Associated with labral tears

Tung et al. AJR 2000; 174:1707

Labral Tear and Labral Cyst

Pitfall: suprascapular vein dilation





• Labrum



Greater Tuberosity Fracture:

• Cortical step-off

• Point tenderness

• Differentiate from osteophyte

• Correlate with radiographs

Patten et al. Radiology 1992; 182:201

Fracture: greater tuberosity

Long Axis Coronal T1w

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Fracture: greater tuberosity

Long Axis Short Axis





• Labrum



Pectoralis Major

• Clavicular head:

– Forms anterior layer

• Sternal head:

– Forms posterior layer and inferior aspect of anterior layer

• Each layer: 2 mm thick

• “U” shaped

• Fuses 11 mm proximal to insertion

Chiavaras MM et al.Skeletal Radiol 2015; 44:157

Pectoralis Major

S

S

C

C

D

B

B

B

S = sternal head; C = clavicular headD = deltoid; B = bicep brachii

Clavicular head reflectedLateralMedial

Fused layers

Chiavaras MM et al.Skeletal Radiol2015; 44:157

Pectoralis Major: ultrasound

• Begin short axis over bicipital groove

• Identify bicep brachii long head

• Scan inferior to identify pectoralis major tendon superficial to biceps tendon

Curved arrow = anterior layerStraight arrow = posterior layer

S = sternal headC = clavicular head

B = biceps brachii long headH = humerus

(Right side of image = lateral)

Pectoralis Major: short axis (sagittal plane)

S = sternal and C = clavicular heads; Arrowheads: sternal head tendonsCurved arrow = anterior layer; Straight arrow = posterior layer

1: Medial

4: Lateral

2

3

Superior Inferior

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Pectoralis Major: ultrasound

• Distal tendon: short axis (sagittal)

• Fused anterior and posterior layers

• Identified over biceps brachii tendon

Arrowheads: fused anterior and posterior layers

B = biceps brachii long headH = humerus

(Right side of image = inferior)

Case 1: full-thickness, full-width tear

Longitudinal Axial T2w

Long Axis

Curved arrow = torn and retracted pectoralis major* = short head biceps brachii + coracobrachialis

Arrowhead = biceps brachii long head; D = deltoid

Lateral

Axial

Case 3: partial-thickness,full-width sternal head tear (surgically created)

Longitudinal Axial T2wCurved arrow = torn sternal head (S); Arrow = posterior layer

* = short head biceps brachii + coracobrachialisM = pectoralis minor; D = deltoid

Clavicular head (C) reflected

Chiavaras MM et al.Skeletal Radiol 2015;

44:157

Case 3: partial-thickness,full-width sternal head tear (surgically created)

Longitudinal Axial T2w

Curved arrow = torn sternal head (S); Arrow = posterior layerNote: intact fused anterior and posterior layers (arrowheads) over

biceps brachii long head tendon (B)* = short head biceps brachii + coracobrachialis

D = deltoid; H = humerus

Axial Sagittal

Case 5: partial-thickness, full-width sternal head tear (arrow)

Longitudinal Axial T2wLong Axis Short Axis

Clavicular Head

Coracobrachialis + short head biceps brachii

Clavicular Head

Note: intact fused anterior and posterior layers (open arrows)

LateralMedial InferiorSuperior

Take-home Points

• Biceps brachii:– Don’t overcall tenosynovitis

– Dynamic evaluation

• Subacromial-subdeltoid bursa:– Covers SST, IST, subscapularis, BT

• ACJ: cyst versus geyser

• Labrum: suprascapular vein pitfall

• Greater tuberosity: fracture

• Pectoralis: anatomy

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shoulder ultrasound: miscellaneous pathology: beyond the ... · beyond the rotator cuff jon a....

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