<p begin="00:00:07.420" end="00:00:08.846" style="s2">- [Voiceover] A linear<br />array transducer with a</p>
<p begin="00:00:08.846" end="00:00:11.191" style="s2">musculoskeletal exam type,</p>
<p begin="00:00:11.191" end="00:00:13.228" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.228" end="00:00:16.057" style="s2">of the subscapularis tendon.</p>
<p begin="00:00:16.057" end="00:00:17.682" style="s2">The patient is in a sitting position,</p>
<p begin="00:00:17.682" end="00:00:21.380" style="s2">with the patients hand palm<br />up and resting on the knee.</p>
<p begin="00:00:21.380" end="00:00:24.028" style="s2">The examiner is positioned<br />in front of the patient</p>
<p begin="00:00:24.028" end="00:00:26.160" style="s2">and the transducer is placed transversely</p>
<p begin="00:00:26.160" end="00:00:27.938" style="s2">over the head of the humerus,</p>
<p begin="00:00:27.938" end="00:00:29.722" style="s2">with the orientation marker directed</p>
<p begin="00:00:29.722" end="00:00:31.504" style="s2">to the patient's right.</p>
<p begin="00:00:31.504" end="00:00:33.069" style="s2">The deltoid muscle is seen</p>
<p begin="00:00:33.069" end="00:00:34.782" style="s2">as the most superficial structure.</p>
<p begin="00:00:34.782" end="00:00:37.284" style="s2">The bright hyperechoic greater and lesser</p>
<p begin="00:00:37.284" end="00:00:38.948" style="s2">tuberosities of the humerus,</p>
<p begin="00:00:38.948" end="00:00:41.546" style="s2">surround the oval shaped, biceps tendon.</p>
<p begin="00:00:41.546" end="00:00:44.102" style="s2">The arm, is then externally rotated</p>
<p begin="00:00:44.102" end="00:00:47.676" style="s2">to bring the bird's beak<br />shaped subscapularis tendon</p>
<p begin="00:00:47.676" end="00:00:51.843" style="s2">to view, as it inserts<br />into the lesser tuberosity.</p>
<p begin="00:00:57.385" end="00:00:59.975" style="s2">The fibular tendon lies<br />between the superficial</p>
<p begin="00:00:59.975" end="00:01:02.141" style="s2">deltoid muscle and the intense bright</p>
<p begin="00:01:02.141" end="00:01:05.575" style="s2">hyperechoic reflection<br />of the humerus below.</p>
<p begin="00:01:05.575" end="00:01:07.770" style="s2">The subscapularis tendon<br />should be evaluated</p>
<p begin="00:01:07.770" end="00:01:10.180" style="s2">by sweeping the transducer from it's</p>
<p begin="00:01:10.180" end="00:01:12.544" style="s2">proximal musculotendinous insertion,</p>
<p begin="00:01:12.544" end="00:01:15.908" style="s2">on the lesser tuberosity<br />to the inferior portion.</p>
<p begin="00:01:15.908" end="00:01:18.288" style="s2">The examiner can provide<br />gentle resistance against</p>
<p begin="00:01:18.288" end="00:01:20.497" style="s2">the subject's arm during internal rotation</p>
<p begin="00:01:20.497" end="00:01:23.275" style="s2">to highlight subtle pathology.</p>
<p begin="00:01:23.275" end="00:01:26.506" style="s2">The transducer is then<br />rotated 90 degrees clockwise,</p>
<p begin="00:01:26.506" end="00:01:28.721" style="s2">to evaluate the subscapularis tendon</p>
<p begin="00:01:28.721" end="00:01:31.073" style="s2">with a short axis view.</p>
<p begin="00:01:31.073" end="00:01:32.805" style="s2">Note the three distinct tendon bundles</p>
<p begin="00:01:32.805" end="00:01:34.894" style="s2">visible in the transverse axis.</p>
<p begin="00:01:34.894" end="00:01:36.885" style="s2">The deltoid muscle is seen as</p>
<p begin="00:01:36.885" end="00:01:38.492" style="s2">the most superficial structure.</p>
<p begin="00:01:38.492" end="00:01:40.624" style="s2">The bright hyperechoic greater and</p>
<p begin="00:01:40.624" end="00:01:42.874" style="s2">lesser tuberosities of the humerus,</p>
<p begin="00:01:42.874" end="00:01:45.844" style="s2">surround the oval shaped bicep's tendon.</p>
<p begin="00:01:45.844" end="00:01:49.631" style="s2">The subscapularis lies<br />below the deltoid muscle.</p>
<p begin="00:01:49.631" end="00:01:51.746" style="s2">The subscapularis tendon approaches the</p>
<p begin="00:01:51.746" end="00:01:54.546" style="s2">bright hyperechoic coracoid process,</p>
<p begin="00:01:54.546" end="00:01:56.839" style="s2">with internal and external rotation,</p>
<p begin="00:01:56.839" end="00:02:00.839" style="s2">and can be a cause of<br />coracohumeral impingement.</p>

<p begin="00:00:07.103" end="00:00:08.828" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.828" end="00:00:11.759" style="s2">with a musculoskeletal exam type is used</p>
<p begin="00:00:11.759" end="00:00:13.738" style="s2">to perform an ultrasound-guided injection</p>
<p begin="00:00:13.738" end="00:00:16.776" style="s2">of the shoulder via a medial approach.</p>
<p begin="00:00:16.776" end="00:00:18.887" style="s2">Alternatively, a curved array transducer</p>
<p begin="00:00:18.887" end="00:00:21.114" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:21.114" end="00:00:23.299" style="s2">can be used in a large patient.</p>
<p begin="00:00:23.299" end="00:00:25.945" style="s2">The patient is in a<br />lateral decubitus position</p>
<p begin="00:00:25.945" end="00:00:27.930" style="s2">with the arm flexed across the body.</p>
<p begin="00:00:27.930" end="00:00:30.634" style="s2">The examiner is positioned<br />behind the patient,</p>
<p begin="00:00:30.634" end="00:00:33.293" style="s2">and the transducer is placed posteriorly</p>
<p begin="00:00:33.293" end="00:00:34.898" style="s2">over the head of the humerus,</p>
<p begin="00:00:34.898" end="00:00:37.985" style="s2">with the orientation marker<br />directed to the patients' right.</p>
<p begin="00:00:37.985" end="00:00:40.210" style="s2">The examination begins by locating</p>
<p begin="00:00:40.210" end="00:00:42.036" style="s2">the glenohumeral joint space,</p>
<p begin="00:00:42.036" end="00:00:43.669" style="s2">which lies below the deep fibers</p>
<p begin="00:00:43.669" end="00:00:46.969" style="s2">of the infraspinatus muscle<br />and the glenoid labrum,</p>
<p begin="00:00:46.969" end="00:00:48.298" style="s2">which appears as a bright,</p>
<p begin="00:00:48.298" end="00:00:51.812" style="s2">hyperechoic region in the<br />mid portion of the image.</p>
<p begin="00:00:51.812" end="00:00:53.408" style="s2">The humeral head can be seen</p>
<p begin="00:00:53.408" end="00:00:55.476" style="s2">on the right of the screen as a rounded,</p>
<p begin="00:00:55.476" end="00:00:57.556" style="s2">bright hyper-reflective image.</p>
<p begin="00:00:57.556" end="00:01:00.535" style="s2">The transducer is<br />adjusted so it is centered</p>
<p begin="00:01:00.535" end="00:01:02.968" style="s2">over the glenohumeral joint line.</p>
<p begin="00:01:02.968" end="00:01:04.721" style="s2">The needle is inserted in the skin,</p>
<p begin="00:01:04.721" end="00:01:07.303" style="s2">just proximal to the transducer.</p>
<p begin="00:01:07.303" end="00:01:08.863" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:08.863" end="00:01:11.199" style="s2">to lie in-plane to the transducer beam,</p>
<p begin="00:01:11.199" end="00:01:12.479" style="s2">and is seen as a bright,</p>
<p begin="00:01:12.479" end="00:01:14.824" style="s2">hyperechoic linear structure.</p>
<p begin="00:01:14.824" end="00:01:16.443" style="s2">The needle is slowly advanced</p>
<p begin="00:01:16.443" end="00:01:18.387" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:18.387" end="00:01:20.059" style="s2">until the tip is seen to lie</p>
<p begin="00:01:20.059" end="00:01:21.475" style="s2">within the shoulder joint space,</p>
<p begin="00:01:21.475" end="00:01:25.392" style="s2">where an injection, or<br />aspiration, can be done.</p>