Shoulder Sonography

Sharlene A. Teefey, MD

By Fathia Rianty, S.Ked

Lecturer: dr. Ali Imran, Sp. Rad
 Rotator cuff disease
 The third most prevalent musculosceletal disorder
 Highly correlates with increasing age
 Patients with a painful unilateral full-thickness tear
had a 35.5% prevalence of an asymptomatic tear
on the contralateral side
Accuracy of Sonography
 Can be used to accurately diagnose and
quantify full- and partial-thickness tears and
recurrent tears in the postoperative shoulder,
determine the tear location, and evaluate the
cuff muscles for fatty degeneration.
 Other disorders:
 Tendinopathy
 calcific tendinitis
 noncuff pathology of the biceps tendon
 acromioclavicular joint
 posterior labrum (paralabral cyst)
 Subdeltoid bursa
Sonographic Technique
 The radiologist stands behind the patient to
scan; however, at some institutions, the
radiologist sits and faces the patient

 Biceps tendon
 the arm is slightly externally rotated with the
forearm in a supinated position resting on the thigh
 The tendon is initially examined in a transverse
plane from the level where it emerges beneath the
acromion to the musculotendinous junction. The
transducer is then rotated 90° to examine the
tendon in a longitudinal plane.
 Subscapularis tendon
 further externally rotated
 The transducer is initially placed in a transverse
orientation at the level of the lesser tuberosity and
moved medially along the long axis of the tendon.
The transducer is then turned 90° to view the
tendon fibers perpendicular to their long axis
 Supraspinatus and infraspinatus tendon
 extend his or her arm posteriorly and place the
palmar side of the hand on the superior aspect of
the iliac wing with the elbow flexed and directed
toward the midline of the back
 The long axis of the cuff should be evaluated from
the most lateral aspect of the greater tuberosity
where it inserts to as far medially as possible
 Compress the transducer against the deltoid
muscle to detect any nonretracted tears
 The transducer is then turned 90° to visualize the
cuff in a transverse (short-axis) orientation
 Posterior glenohumeral joint and teres minor
tendons
 resting forearm on the thigh
 the transducer is placed immediately below the
scapular spine and angled slightly inferiorly

 the posterior cuff muscles

 The transducer is first placed superior to the scapular
spine to image the supraspinatus muscle and then
moved inferior to the scapular spine to visualize the
infraspinatus muscle. The transducer is then moved
slightly more inferiorly to visualize the teres minor
muscle and its short tendon
Sonographic Findings of Shoulder
Disorders

 a full-thickness cuff tear

is characterized by a
focal defect created by a
variable degree of
retraction between the
torn tendon ends. When
there is fluid between
the torn tendon ends, it
is easy to visualize a
tear.
 In the absence of an
effusion, the deltoid
muscle and peribursal
fat occupy the space
created by the defect
and oppose the
overlying humeral
head cartilage
 If the subdeltoid synovial tissue is thickened
and inflamed, the tissue will abut the
cartilage, and on sonography, a subtle loss of
the normal convexity of the cuff or flattening
of the cuff will be visualized.
 In a patient with a
massive tear, the cuff
is often not visualized
and is retracted
beneath the acromion
on longitudinal views
 Because of the size of
the tear, it is usually
not possible to
measure an accurate
width
 Partial-thickness tears
can be more difficult to
identif than full-thickness
tears. These tears usually
occur along the deep side
of the cuff at the level of
anatomic humeral neck
and can be recognized as
distinct hypoechoic or
mixed hyperechoic and
hypoechoic defects on
both longitudinal and
transverse views
 When fatty
degeneration is
severe, one or
more muscles will
become
homogeneously
hyperechoic
 Tendinopathy may be
a focal or diffuse
process; the cuff is
typically thickened,
heterogeneous, and
hypoechoic.
 The calcifications are
often located at the
most lateral aspect of
the greater
tuberosity
 Tenosynovitis is often
associated with an
effusion. A thickened
tendon sheath with or
without flow on color
or power Doppler
imaging is diagnostic
of tenosynovitis
 Bursitis can be diagnosed if the subdeltoid
bursa is thicker than the humeral head
cartilage
 A paralabral cyst is anechoic cysts, and
typically occur in the spinoglenoid notch and
may extend into the supraspinous or
infraspinous fossa
 A synovial cyst may be anechoic or contain
debris on sonography
 Osteolysis appears as joint space widening
and irregularity and erosions of the bony
margins
Conclusions
 Sonography is an excellent modality for
diagnosing rotator cuff disease
 Accurate, noninvasive, rapidly performed, and
less expensive than MRI, a dynamic, global
examination and can provide bilateral
information
 However, the results are operator dependent,
difficult to visualize the entire cuff in obese
patients and in patients with decreased range
of motion, and evaluation of the labrum, joint
capsule, ligaments, bone, and cartilage is
limited
Thank you for your attention