<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>

<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>

<p begin="00:00:07.605" end="00:00:09.307" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.307" end="00:00:11.398" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.398" end="00:00:13.825" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.825" end="00:00:16.575" style="s2">of the posterior groove of the shoulder.</p>
<p begin="00:00:16.575" end="00:00:18.571" style="s2">The patient is in a sitting position</p>
<p begin="00:00:18.571" end="00:00:21.772" style="s2">with the arm flexed<br />and internally rotated.</p>
<p begin="00:00:21.772" end="00:00:24.076" style="s2">The examiner is positioned<br />behind the patient</p>
<p begin="00:00:24.076" end="00:00:27.586" style="s2">and the transducer is placed<br />posteriorly over the shoulder</p>
<p begin="00:00:27.586" end="00:00:31.172" style="s2">with the orientation marker<br />to the patient's left side.</p>
<p begin="00:00:31.172" end="00:00:34.451" style="s2">The posterior labrum is seen<br />as a triangular structure</p>
<p begin="00:00:34.451" end="00:00:36.711" style="s2">between the bright, hyperechoic glenoid</p>
<p begin="00:00:36.711" end="00:00:38.235" style="s2">and the humeral head.</p>
<p begin="00:00:38.235" end="00:00:41.577" style="s2">The arm is slowly externally<br />and internally rotated</p>
<p begin="00:00:41.577" end="00:00:44.052" style="s2">to evaluate the ball and socket motion</p>
<p begin="00:00:44.052" end="00:00:45.907" style="s2">of the glenohumeral joint.</p>
<p begin="00:00:45.907" end="00:00:48.612" style="s2">The fibrillar pattern of<br />the infraspinatus muscle</p>
<p begin="00:00:48.612" end="00:00:50.029" style="s2">is also apparent.</p>
<p begin="00:00:50.900" end="00:00:53.980" style="s2">The transducer is moved slightly medially</p>
<p begin="00:00:53.980" end="00:00:55.591" style="s2">to identify the groove between</p>
<p begin="00:00:55.591" end="00:00:58.149" style="s2">the spine of the scapula and the glenoid</p>
<p begin="00:00:58.149" end="00:00:59.943" style="s2">where the neurovascular bundle</p>
<p begin="00:00:59.943" end="00:01:03.333" style="s2">containing the suprascapular<br />nerve is located.</p>
<p begin="00:01:03.333" end="00:01:05.134" style="s2">Color Doppler should be used to confirm</p>
<p begin="00:01:05.134" end="00:01:09.301" style="s2">the location of the artery<br />with the accompanying nerve.</p>

<p begin="00:00:07.273" end="00:00:09.017" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.017" end="00:00:11.153" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.153" end="00:00:13.575" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.575" end="00:00:15.684" style="s2">of the glenohumeral joint.</p>
<p begin="00:00:15.684" end="00:00:17.552" style="s2">The patient is in a sitting position</p>
<p begin="00:00:17.552" end="00:00:19.569" style="s2">with the hand placed across the body,</p>
<p begin="00:00:19.569" end="00:00:21.954" style="s2">and grasping the opposite shoulder.</p>
<p begin="00:00:21.954" end="00:00:24.814" style="s2">The examiner is positioned<br />in front of the patient,</p>
<p begin="00:00:24.814" end="00:00:28.175" style="s2">and the transducer is placed<br />posteriorly over the shoulder,</p>
<p begin="00:00:28.175" end="00:00:32.518" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:32.518" end="00:00:35.898" style="s2">The posterior labrum is seen<br />as a triangular structure</p>
<p begin="00:00:35.898" end="00:00:38.769" style="s2">between the bright,<br />hyperechoic glenoid fossa</p>
<p begin="00:00:38.769" end="00:00:40.309" style="s2">and the humeral head.</p>
<p begin="00:00:40.309" end="00:00:43.298" style="s2">The anechoic black cartilage<br />of the glenohumeral joint</p>
<p begin="00:00:43.298" end="00:00:45.418" style="s2">can be seen in this view.</p>
<p begin="00:00:45.418" end="00:00:48.819" style="s2">The arm is slowly externally<br />and internally rotated</p>
<p begin="00:00:48.819" end="00:00:51.152" style="s2">to evaluate the ball-and-socket motion</p>
<p begin="00:00:51.152" end="00:00:53.273" style="s2">of the glenohumeral joint.</p>
<p begin="00:00:53.273" end="00:00:55.895" style="s2">The fibrillar pattern of<br />the infraspinatous muscle</p>
<p begin="00:00:55.895" end="00:00:57.312" style="s2">is also apparent.</p>

Invalid Credentials

<p begin="00:00:03.880" end="00:00:07.029" style="s2">this is a brief introduction to super<br />spin a dispatch ology</p>
<p begin="00:00:10.240" end="00:00:12.980" style="s2">we will begin by describing the bony<br />anatomy</p>
<p begin="00:00:12.980" end="00:00:16.470" style="s2">covered by the articular hailing<br />cartilage shown here</p>
<p begin="00:00:16.470" end="00:00:18.140" style="s2">in blue</p>
<p begin="00:00:18.140" end="00:00:22.580" style="s2">illustrated here is too long head of the<br />biceps tendon passing through the bicep</p>
<p begin="00:00:22.580" end="00:00:26.240" style="s2">ru to insert at the superior going on</p>
<p begin="00:00:26.240" end="00:00:29.650" style="s2">labor</p>
<p begin="00:00:29.650" end="00:00:32.520" style="s2">illustrated next is the supraspinatus<br />tendon</p>
<p begin="00:00:32.520" end="00:00:36.640" style="s2">as attach is to the greater tuberosity<br />at interior</p>
<p begin="00:00:36.640" end="00:00:39.860" style="s2">portion posteriorly the interest in a<br />distant</p>
<p begin="00:00:39.860" end="00:00:43.160" style="s2">wraps around the posterior surface the<br />humeral head</p>
<p begin="00:00:43.690" end="00:00:48.020" style="s2">to attach to the remainder the greater<br />tuberosity is lateral</p>
<p begin="00:00:48.020" end="00:00:51.020" style="s2">and post your your margins</p>
<p begin="00:00:51.820" end="00:00:55.590" style="s2">as the interest Benitez tendon attaches<br />to the post your your aspect of the</p>
<p begin="00:00:55.590" end="00:00:56.880" style="s2">greater tuberosity</p>
<p begin="00:00:56.880" end="00:01:02.330" style="s2">take note in about one-third Pittston<br />anti burst share an insertion point with</p>
<p begin="00:01:02.330" end="00:01:03.730" style="s2">two super spin eight assists</p>
<p begin="00:01:03.730" end="00:01:07.020" style="s2">post your your one-third its tendon as<br />well</p>
<p begin="00:01:07.020" end="00:01:10.050" style="s2">due to the oblique nature</p>
<p begin="00:01:10.050" end="00:01:14.690" style="s2">the interest in a dis is insertion<br />relative to the supraspinatus insertion</p>
<p begin="00:01:14.690" end="00:01:16.150" style="s2">to the greater tuberosity</p>
<p begin="00:01:16.150" end="00:01:20.100" style="s2">special care should be taken while<br />scanning through this section</p>
<p begin="00:01:20.100" end="00:01:23.100" style="s2">to avoid false-positive tears</p>
<p begin="00:01:24.109" end="00:01:27.759" style="s2">in developing these lateral rotator cuff<br />structures will be D</p>
<p begin="00:01:27.759" end="00:01:30.759" style="s2">subacromial sub deltoid versa</p>
<p begin="00:01:31.930" end="00:01:35.360" style="s2">this illustration shows a cross-section<br />the supraspinatus</p>
<p begin="00:01:35.360" end="00:01:38.360" style="s2">proximal to its insertion the greater<br />tuberosity</p>
<p begin="00:01:39.829" end="00:01:42.950" style="s2">primary focus this video will be the<br />relationship</p>
<p begin="00:01:42.950" end="00:01:46.140" style="s2">on the supraspinatus tendon with the<br />bicep tendon edits</p>
<p begin="00:01:46.140" end="00:01:49.110" style="s2">intercapital our segment</p>
<p begin="00:01:49.110" end="00:01:53.020" style="s2">this is the corresponding image the<br />supraspinatus tendon in cross-section</p>
<p begin="00:01:54.869" end="00:01:58.710" style="s2">highlighted here is the funeral at<br />proximal to the supraspinatus insertion</p>
<p begin="00:01:58.710" end="00:02:02.010" style="s2">the black gram is the articular<br />cartilage</p>
<p begin="00:02:02.010" end="00:02:05.190" style="s2">the lateral deltoid muscle run and cross<br />section as well</p>
<p begin="00:02:05.190" end="00:02:08.570" style="s2">at this level</p>
<p begin="00:02:08.570" end="00:02:12.350" style="s2">the interior super spin a distant is<br />well socialized while the posterior</p>
<p begin="00:02:12.350" end="00:02:14.470" style="s2">supraspinatus tendon is less</p>
<p begin="00:02:14.470" end="00:02:17.860" style="s2">identifiable due to its merger with the<br />interest in Ames</p>
<p begin="00:02:17.860" end="00:02:21.950" style="s2">highlighted in this image is the bicep<br />tendon also in cross-section with the</p>
<p begin="00:02:21.950" end="00:02:23.230" style="s2">supraspinatus tendon</p>
<p begin="00:02:23.230" end="00:02:26.120" style="s2">anterior margin</p>
<p begin="00:02:26.120" end="00:02:29.030" style="s2">from the transverse or cross-section<br />image we will now</p>
<p begin="00:02:29.030" end="00:02:33.840" style="s2">switch to the long axis more saddle cut<br />the supraspinatus tendon</p>
<p begin="00:02:33.840" end="00:02:36.840" style="s2">at the interior margin a greater<br />tuberosity</p>
<p begin="00:02:39.170" end="00:02:43.310" style="s2">here's the corresponding long axis<br />section the supraspinatus tendon</p>
<p begin="00:02:43.310" end="00:02:47.450" style="s2">as in search to greater tuberosity<br />highlighted here is the humeral head</p>
<p begin="00:02:47.450" end="00:02:52.500" style="s2">in greater tuberosity in profile it is<br />not uncommon to see a long axis deltoid</p>
<p begin="00:02:52.500" end="00:02:53.069" style="s2">muscle</p>
<p begin="00:02:53.069" end="00:02:58.319" style="s2">in relation to the long axis the<br />supraspinatus tendon highlighted in the</p>
<p begin="00:02:58.319" end="00:02:59.180" style="s2">next image</p>
<p begin="00:02:59.180" end="00:03:03.010" style="s2">is the long axis the supraspinatus<br />tendon as it answers to the greater</p>
<p begin="00:03:03.010" end="00:03:05.260" style="s2">tuberosity</p>
<p begin="00:03:05.260" end="00:03:08.260" style="s2">super spin anus pathological images</p>
<p begin="00:03:09.150" end="00:03:12.799" style="s2">this image demonstrates an interior<br />full-thickness tears well as a</p>
<p begin="00:03:12.799" end="00:03:16.299" style="s2">personal surface mid segment tear the<br />supraspinatus tendon</p>
<p begin="00:03:18.700" end="00:03:23.070" style="s2">here we have multiple terror citing no<br />volume loss identified</p>
<p begin="00:03:23.070" end="00:03:26.070" style="s2">in the transverse image</p>
<p begin="00:03:26.890" end="00:03:29.719" style="s2">here we have interior articular surface<br />tearing</p>
<p begin="00:03:29.719" end="00:03:33.290" style="s2">demonstrating by in los as Hypoluxo like<br />absence</p>
<p begin="00:03:33.290" end="00:03:35.700" style="s2">tendon fibers</p>
<p begin="00:03:35.700" end="00:03:38.430" style="s2">he rehashed post-operative retailer</p>
<p begin="00:03:38.430" end="00:03:42.030" style="s2">the interior super spin a distended<br />locating the exact site</p>
<p begin="00:03:42.030" end="00:03:46.530" style="s2">this terror is difficult as the bicep<br />tendon is not in its normally situated</p>
<p begin="00:03:46.530" end="00:03:51.390" style="s2">by typical group scanning from the<br />indeed biceps group posteriorly</p>
<p begin="00:03:51.390" end="00:03:55.970" style="s2">will reveal arced first in best landmark<br />the lateral greater tuberosity in</p>
<p begin="00:03:55.970" end="00:03:56.629" style="s2">profile</p>
<p begin="00:03:56.629" end="00:04:01.290" style="s2">scanning to post early may reveal<br />falsely normal rotator cuff as</p>
<p begin="00:04:01.290" end="00:04:03.690" style="s2">demonstrated in blue</p>
<p begin="00:04:03.690" end="00:04:07.900" style="s2">here's a corresponding normal rotator<br />cuff with the normally situated bicep</p>
<p begin="00:04:07.900" end="00:04:09.330" style="s2">tendon highlighted in blue</p>
<p begin="00:04:09.330" end="00:04:13.320" style="s2">where the dislocated is in red in this<br />case a long axis greater tuberosity</p>
<p begin="00:04:13.320" end="00:04:14.590" style="s2">would be a better</p>
<p begin="00:04:14.590" end="00:04:17.170" style="s2">landmark</p>
<p begin="00:04:17.170" end="00:04:20.220" style="s2">subtle interest substance carrying is<br />often harder to identify</p>
<p begin="00:04:22.470" end="00:04:26.460" style="s2">there is a hyper collect where over the<br />summer Camille bursa called Perry</p>
<p begin="00:04:26.460" end="00:04:27.380" style="s2">personal Sat</p>
<p begin="00:04:27.380" end="00:04:30.960" style="s2">and indicating layer that is the actual<br />bursal void</p>
<p begin="00:04:30.960" end="00:04:35.270" style="s2">followed by the supraspinatus tendon<br />itself area of interest here</p>
<p begin="00:04:35.270" end="00:04:38.630" style="s2">is the Dept or the concave and what<br />would normally be</p>
<p begin="00:04:38.630" end="00:04:41.630" style="s2">declined backs appearing mursal layer</p>
<p begin="00:04:44.530" end="00:04:49.000" style="s2">in long axis is normally contact<br />Trinkaus may actually be flattened</p>
<p begin="00:04:49.000" end="00:04:52.070" style="s2">instead of rounded as we see here again<br />take care</p>
<p begin="00:04:52.620" end="00:04:56.860" style="s2">to scan through the entire cast to avoid<br />any false positives</p>
<p begin="00:04:56.860" end="00:05:00.010" style="s2">as we have us demonstrated here as a<br />falsely</p>
<p begin="00:05:00.010" end="00:05:01.140" style="s2">mall cop and blue</p>

<p begin="00:00:03.880" end="00:00:07.029" style="s2">this is a brief introduction to super<br />spin a dispatch ology</p>
<p begin="00:00:10.240" end="00:00:12.980" style="s2">we will begin by describing the bony<br />anatomy</p>
<p begin="00:00:12.980" end="00:00:16.470" style="s2">covered by the articular hailing<br />cartilage shown here</p>
<p begin="00:00:16.470" end="00:00:18.140" style="s2">in blue</p>
<p begin="00:00:18.140" end="00:00:22.580" style="s2">illustrated here is too long head of the<br />biceps tendon passing through the bicep</p>
<p begin="00:00:22.580" end="00:00:26.240" style="s2">ru to insert at the superior going on</p>
<p begin="00:00:26.240" end="00:00:29.650" style="s2">labor</p>
<p begin="00:00:29.650" end="00:00:32.520" style="s2">illustrated next is the supraspinatus<br />tendon</p>
<p begin="00:00:32.520" end="00:00:36.640" style="s2">as attach is to the greater tuberosity<br />at interior</p>
<p begin="00:00:36.640" end="00:00:39.860" style="s2">portion posteriorly the interest in a<br />distant</p>
<p begin="00:00:39.860" end="00:00:43.160" style="s2">wraps around the posterior surface the<br />humeral head</p>
<p begin="00:00:43.690" end="00:00:48.020" style="s2">to attach to the remainder the greater<br />tuberosity is lateral</p>
<p begin="00:00:48.020" end="00:00:51.020" style="s2">and post your your margins</p>
<p begin="00:00:51.820" end="00:00:55.590" style="s2">as the interest Benitez tendon attaches<br />to the post your your aspect of the</p>
<p begin="00:00:55.590" end="00:00:56.880" style="s2">greater tuberosity</p>
<p begin="00:00:56.880" end="00:01:02.330" style="s2">take note in about one-third Pittston<br />anti burst share an insertion point with</p>
<p begin="00:01:02.330" end="00:01:03.730" style="s2">two super spin eight assists</p>
<p begin="00:01:03.730" end="00:01:07.020" style="s2">post your your one-third its tendon as<br />well</p>
<p begin="00:01:07.020" end="00:01:10.050" style="s2">due to the oblique nature</p>
<p begin="00:01:10.050" end="00:01:14.690" style="s2">the interest in a dis is insertion<br />relative to the supraspinatus insertion</p>
<p begin="00:01:14.690" end="00:01:16.150" style="s2">to the greater tuberosity</p>
<p begin="00:01:16.150" end="00:01:20.100" style="s2">special care should be taken while<br />scanning through this section</p>
<p begin="00:01:20.100" end="00:01:23.100" style="s2">to avoid false-positive tears</p>
<p begin="00:01:24.109" end="00:01:27.759" style="s2">in developing these lateral rotator cuff<br />structures will be D</p>
<p begin="00:01:27.759" end="00:01:30.759" style="s2">subacromial sub deltoid versa</p>
<p begin="00:01:31.930" end="00:01:35.360" style="s2">this illustration shows a cross-section<br />the supraspinatus</p>
<p begin="00:01:35.360" end="00:01:38.360" style="s2">proximal to its insertion the greater<br />tuberosity</p>
<p begin="00:01:39.829" end="00:01:42.950" style="s2">primary focus this video will be the<br />relationship</p>
<p begin="00:01:42.950" end="00:01:46.140" style="s2">on the supraspinatus tendon with the<br />bicep tendon edits</p>
<p begin="00:01:46.140" end="00:01:49.110" style="s2">intercapital our segment</p>
<p begin="00:01:49.110" end="00:01:53.020" style="s2">this is the corresponding image the<br />supraspinatus tendon in cross-section</p>
<p begin="00:01:54.869" end="00:01:58.710" style="s2">highlighted here is the funeral at<br />proximal to the supraspinatus insertion</p>
<p begin="00:01:58.710" end="00:02:02.010" style="s2">the black gram is the articular<br />cartilage</p>
<p begin="00:02:02.010" end="00:02:05.190" style="s2">the lateral deltoid muscle run and cross<br />section as well</p>
<p begin="00:02:05.190" end="00:02:08.570" style="s2">at this level</p>
<p begin="00:02:08.570" end="00:02:12.350" style="s2">the interior super spin a distant is<br />well socialized while the posterior</p>
<p begin="00:02:12.350" end="00:02:14.470" style="s2">supraspinatus tendon is less</p>
<p begin="00:02:14.470" end="00:02:17.860" style="s2">identifiable due to its merger with the<br />interest in Ames</p>
<p begin="00:02:17.860" end="00:02:21.950" style="s2">highlighted in this image is the bicep<br />tendon also in cross-section with the</p>
<p begin="00:02:21.950" end="00:02:23.230" style="s2">supraspinatus tendon</p>
<p begin="00:02:23.230" end="00:02:26.120" style="s2">anterior margin</p>
<p begin="00:02:26.120" end="00:02:29.030" style="s2">from the transverse or cross-section<br />image we will now</p>
<p begin="00:02:29.030" end="00:02:33.840" style="s2">switch to the long axis more saddle cut<br />the supraspinatus tendon</p>
<p begin="00:02:33.840" end="00:02:36.840" style="s2">at the interior margin a greater<br />tuberosity</p>
<p begin="00:02:39.170" end="00:02:43.310" style="s2">here's the corresponding long axis<br />section the supraspinatus tendon</p>
<p begin="00:02:43.310" end="00:02:47.450" style="s2">as in search to greater tuberosity<br />highlighted here is the humeral head</p>
<p begin="00:02:47.450" end="00:02:52.500" style="s2">in greater tuberosity in profile it is<br />not uncommon to see a long axis deltoid</p>
<p begin="00:02:52.500" end="00:02:53.069" style="s2">muscle</p>
<p begin="00:02:53.069" end="00:02:58.319" style="s2">in relation to the long axis the<br />supraspinatus tendon highlighted in the</p>
<p begin="00:02:58.319" end="00:02:59.180" style="s2">next image</p>
<p begin="00:02:59.180" end="00:03:03.010" style="s2">is the long axis the supraspinatus<br />tendon as it answers to the greater</p>
<p begin="00:03:03.010" end="00:03:05.260" style="s2">tuberosity</p>
<p begin="00:03:05.260" end="00:03:08.260" style="s2">super spin anus pathological images</p>
<p begin="00:03:09.150" end="00:03:12.799" style="s2">this image demonstrates an interior<br />full-thickness tears well as a</p>
<p begin="00:03:12.799" end="00:03:16.299" style="s2">personal surface mid segment tear the<br />supraspinatus tendon</p>
<p begin="00:03:18.700" end="00:03:23.070" style="s2">here we have multiple terror citing no<br />volume loss identified</p>
<p begin="00:03:23.070" end="00:03:26.070" style="s2">in the transverse image</p>
<p begin="00:03:26.890" end="00:03:29.719" style="s2">here we have interior articular surface<br />tearing</p>
<p begin="00:03:29.719" end="00:03:33.290" style="s2">demonstrating by in los as Hypoluxo like<br />absence</p>
<p begin="00:03:33.290" end="00:03:35.700" style="s2">tendon fibers</p>
<p begin="00:03:35.700" end="00:03:38.430" style="s2">he rehashed post-operative retailer</p>
<p begin="00:03:38.430" end="00:03:42.030" style="s2">the interior super spin a distended<br />locating the exact site</p>
<p begin="00:03:42.030" end="00:03:46.530" style="s2">this terror is difficult as the bicep<br />tendon is not in its normally situated</p>
<p begin="00:03:46.530" end="00:03:51.390" style="s2">by typical group scanning from the<br />indeed biceps group posteriorly</p>
<p begin="00:03:51.390" end="00:03:55.970" style="s2">will reveal arced first in best landmark<br />the lateral greater tuberosity in</p>
<p begin="00:03:55.970" end="00:03:56.629" style="s2">profile</p>
<p begin="00:03:56.629" end="00:04:01.290" style="s2">scanning to post early may reveal<br />falsely normal rotator cuff as</p>
<p begin="00:04:01.290" end="00:04:03.690" style="s2">demonstrated in blue</p>
<p begin="00:04:03.690" end="00:04:07.900" style="s2">here's a corresponding normal rotator<br />cuff with the normally situated bicep</p>
<p begin="00:04:07.900" end="00:04:09.330" style="s2">tendon highlighted in blue</p>
<p begin="00:04:09.330" end="00:04:13.320" style="s2">where the dislocated is in red in this<br />case a long axis greater tuberosity</p>
<p begin="00:04:13.320" end="00:04:14.590" style="s2">would be a better</p>
<p begin="00:04:14.590" end="00:04:17.170" style="s2">landmark</p>
<p begin="00:04:17.170" end="00:04:20.220" style="s2">subtle interest substance carrying is<br />often harder to identify</p>
<p begin="00:04:22.470" end="00:04:26.460" style="s2">there is a hyper collect where over the<br />summer Camille bursa called Perry</p>
<p begin="00:04:26.460" end="00:04:27.380" style="s2">personal Sat</p>
<p begin="00:04:27.380" end="00:04:30.960" style="s2">and indicating layer that is the actual<br />bursal void</p>
<p begin="00:04:30.960" end="00:04:35.270" style="s2">followed by the supraspinatus tendon<br />itself area of interest here</p>
<p begin="00:04:35.270" end="00:04:38.630" style="s2">is the Dept or the concave and what<br />would normally be</p>
<p begin="00:04:38.630" end="00:04:41.630" style="s2">declined backs appearing mursal layer</p>
<p begin="00:04:44.530" end="00:04:49.000" style="s2">in long axis is normally contact<br />Trinkaus may actually be flattened</p>
<p begin="00:04:49.000" end="00:04:52.070" style="s2">instead of rounded as we see here again<br />take care</p>
<p begin="00:04:52.620" end="00:04:56.860" style="s2">to scan through the entire cast to avoid<br />any false positives</p>
<p begin="00:04:56.860" end="00:05:00.010" style="s2">as we have us demonstrated here as a<br />falsely</p>
<p begin="00:05:00.010" end="00:05:01.140" style="s2">mall cop and blue</p>

<p begin="00:00:10.011" end="00:00:12.732" style="s2">- Today we're going to<br />examine the shoulder.</p>
<p begin="00:00:12.732" end="00:00:15.420" style="s2">There are multiple protocols<br />available for the shoulder,</p>
<p begin="00:00:15.420" end="00:00:17.859" style="s2">however I've found some<br />simplified techniques</p>
<p begin="00:00:17.859" end="00:00:20.246" style="s2">and I think what's most important is</p>
<p begin="00:00:20.246" end="00:00:22.034" style="s2">to maintain a consistent protocol</p>
<p begin="00:00:22.034" end="00:00:23.825" style="s2">and repetitively go over it and over it</p>
<p begin="00:00:23.825" end="00:00:26.716" style="s2">until you're comfortable<br />with what exam works for you.</p>
<p begin="00:00:26.716" end="00:00:29.474" style="s2">In looking at the shoulder, I<br />recommend that the patient's</p>
<p begin="00:00:29.474" end="00:00:31.301" style="s2">in the seated position.</p>
<p begin="00:00:31.301" end="00:00:34.226" style="s2">I prefer to stand behind the<br />patient so that I can look</p>
<p begin="00:00:34.226" end="00:00:36.676" style="s2">at the screen, which is in front of me</p>
<p begin="00:00:36.676" end="00:00:40.572" style="s2">at approximately a 2<br />o'clock window for me so</p>
<p begin="00:00:40.572" end="00:00:42.879" style="s2">that the patient and myself<br />can both look at the screen</p>
<p begin="00:00:42.879" end="00:00:45.242" style="s2">an interact and educate the patient while</p>
<p begin="00:00:45.242" end="00:00:47.103" style="s2">I'm doing the scan.</p>
<p begin="00:00:47.103" end="00:00:48.370" style="s2">In examining the shoulder,</p>
<p begin="00:00:48.370" end="00:00:50.207" style="s2">there are some important<br />principles to follow.</p>
<p begin="00:00:50.207" end="00:00:53.130" style="s2">First of all, when holding the transducer,</p>
<p begin="00:00:53.130" end="00:00:56.656" style="s2">it's easiest to have the<br />notch of the transducer</p>
<p begin="00:00:56.656" end="00:00:59.875" style="s2">always facing upwards or<br />cephalad on the patient.</p>
<p begin="00:00:59.875" end="00:01:02.803" style="s2">That will always be your<br />lighthouse so to speak</p>
<p begin="00:01:02.803" end="00:01:05.888" style="s2">of exactly where you are, so I<br />always keep the notch upward,</p>
<p begin="00:01:05.888" end="00:01:08.234" style="s2">as well as looking at the<br />upper left hand corner</p>
<p begin="00:01:08.234" end="00:01:12.265" style="s2">of the screen to making sure<br />I know exactly where I am.</p>
<p begin="00:01:12.265" end="00:01:14.020" style="s2">I'm going to using a linear transducer</p>
<p begin="00:01:14.020" end="00:01:16.130" style="s2">and this is a high frequency probe,</p>
<p begin="00:01:16.130" end="00:01:18.232" style="s2">which allows us the optimal resolution</p>
<p begin="00:01:18.232" end="00:01:20.033" style="s2">in musculoskeletal imaging.</p>
<p begin="00:01:20.033" end="00:01:21.860" style="s2">With examination of the shoulder,</p>
<p begin="00:01:21.860" end="00:01:23.764" style="s2">I prefer the musculoskeletal setup.</p>
<p begin="00:01:23.764" end="00:01:26.767" style="s2">I press the exam button<br />and I check to make sure</p>
<p begin="00:01:26.767" end="00:01:29.740" style="s2">that I'm on the musculoskeletal<br />setting and press select.</p>
<p begin="00:01:29.740" end="00:01:33.431" style="s2">Next it's important to know<br />what depth you'd like to do</p>
<p begin="00:01:33.431" end="00:01:35.743" style="s2">for the exam and here for starters,</p>
<p begin="00:01:35.743" end="00:01:40.296" style="s2">I'm going to begin at 3.3,<br />which is noted on the screen.</p>
<p begin="00:01:40.296" end="00:01:43.922" style="s2">I can move up or down and<br />the closer to the surface</p>
<p begin="00:01:43.922" end="00:01:48.089" style="s2">of the skin, the better clarity<br />and resolution I'll have.</p>

<p begin="00:00:09.561" end="00:00:12.559" style="s2">- Next, I'm going to examine<br />the subscapularis tendon.</p>
<p begin="00:00:12.559" end="00:00:16.130" style="s2">I start with the patient<br />again with his palm up</p>
<p begin="00:00:16.130" end="00:00:19.226" style="s2">at the bicep tendon in<br />the cross-sectional view</p>
<p begin="00:00:19.226" end="00:00:22.797" style="s2">with my hand on the patient's shoulder,</p>
<p begin="00:00:22.797" end="00:00:25.299" style="s2">identify the bicep tendon.</p>
<p begin="00:00:25.299" end="00:00:27.624" style="s2">Next I'm going to have the<br />patient slowly externally</p>
<p begin="00:00:27.624" end="00:00:29.874" style="s2">rotate his arm to the side.</p>
<p begin="00:00:31.365" end="00:00:34.448" style="s2">What this does is opens up<br />the subscapularis tendon</p>
<p begin="00:00:34.448" end="00:00:36.531" style="s2">so we can clearly see it.</p>
<p begin="00:00:38.449" end="00:00:40.047" style="s2">Oftentimes, I'll have the patient resist</p>
<p begin="00:00:40.047" end="00:00:42.832" style="s2">against my hand in internal rotation</p>
<p begin="00:00:42.832" end="00:00:44.840" style="s2">to detect any pathology.</p>
<p begin="00:00:44.840" end="00:00:45.921" style="s2">Push against my hand.</p>
<p begin="00:00:45.921" end="00:00:47.616" style="s2">Good, relax.</p>
<p begin="00:00:47.616" end="00:00:48.449" style="s2">And again.</p>
<p begin="00:00:49.362" end="00:00:50.195" style="s2">Relax.</p>

<p begin="00:00:09.449" end="00:00:10.456" style="s2">- Lastly we're going to look at the</p>
<p begin="00:00:10.456" end="00:00:12.193" style="s2">supraspinatus tendon.</p>
<p begin="00:00:12.193" end="00:00:13.697" style="s2">I prefer to look at this last because</p>
<p begin="00:00:13.697" end="00:00:17.126" style="s2">this is the area that we<br />see most abnormalities.</p>
<p begin="00:00:17.126" end="00:00:20.777" style="s2">Now to make this examination<br />as time efficient</p>
<p begin="00:00:20.777" end="00:00:21.910" style="s2">as possible,</p>
<p begin="00:00:21.910" end="00:00:23.758" style="s2">what I will do, is have the patient</p>
<p begin="00:00:23.758" end="00:00:25.508" style="s2">take their right arm,</p>
<p begin="00:00:26.695" end="00:00:30.037" style="s2">and slowly put it back<br />behind their back pocket,</p>
<p begin="00:00:30.037" end="00:00:32.978" style="s2">while keeping their elbow inward.</p>
<p begin="00:00:32.978" end="00:00:36.406" style="s2">This is termed, "The<br />Modified Crass Technique."</p>
<p begin="00:00:36.406" end="00:00:38.837" style="s2">What this does is free<br />up the supraspinatus</p>
<p begin="00:00:38.837" end="00:00:40.478" style="s2">so it's not obscured,</p>
<p begin="00:00:40.478" end="00:00:43.509" style="s2">but I can clearly visualize<br />the tendon efficiently.</p>
<p begin="00:00:43.509" end="00:00:44.784" style="s2">There are two views we're<br />going to look at the</p>
<p begin="00:00:44.784" end="00:00:46.359" style="s2">supraspinatus tendon.</p>
<p begin="00:00:46.359" end="00:00:49.085" style="s2">First, where we see most pathology will be</p>
<p begin="00:00:49.085" end="00:00:50.925" style="s2">in cross-section.</p>
<p begin="00:00:50.925" end="00:00:52.297" style="s2">And with this technique,</p>
<p begin="00:00:52.297" end="00:00:55.261" style="s2">we keep the notch of<br />the probe faced upwards</p>
<p begin="00:00:55.261" end="00:00:57.837" style="s2">and we're going to angle the probe</p>
<p begin="00:00:57.837" end="00:00:59.727" style="s2">diagonally down towards the navel,</p>
<p begin="00:00:59.727" end="00:01:01.394" style="s2">or the belly button.</p>
<p begin="00:01:02.560" end="00:01:05.477" style="s2">Maintaining contact on the patient,</p>
<p begin="00:01:06.670" end="00:01:09.617" style="s2">I visualize the supraspinatus tendon</p>
<p begin="00:01:09.617" end="00:01:11.033" style="s2">and it's fibers.</p>
<p begin="00:01:11.033" end="00:01:14.306" style="s2">And I'm going to examine<br />the supraspinatus tendon</p>
<p begin="00:01:14.306" end="00:01:15.348" style="s2">in both directions,</p>
<p begin="00:01:15.348" end="00:01:17.625" style="s2">to clearly rule out any pathology.</p>
<p begin="00:01:17.625" end="00:01:21.679" style="s2">I'm gently maintaining<br />contact and rocking the probe,</p>
<p begin="00:01:21.679" end="00:01:24.941" style="s2">side to side, following<br />the length of the fibers.</p>
<p begin="00:01:24.941" end="00:01:26.663" style="s2">On top of the tendon here,</p>
<p begin="00:01:26.663" end="00:01:29.524" style="s2">we notice a little black, thin line,</p>
<p begin="00:01:29.524" end="00:01:32.597" style="s2">which is the subacromial subdeltoid bursa.</p>
<p begin="00:01:32.597" end="00:01:34.771" style="s2">In patients with shoulder abnormalities,</p>
<p begin="00:01:34.771" end="00:01:36.576" style="s2">this bursa fills with fluid</p>
<p begin="00:01:36.576" end="00:01:39.589" style="s2">and is often the target<br />of one of our injections.</p>
<p begin="00:01:39.589" end="00:01:42.578" style="s2">Next, I prefer to look at what's called</p>
<p begin="00:01:42.578" end="00:01:45.063" style="s2">the rotator cuff interval.</p>
<p begin="00:01:45.063" end="00:01:47.546" style="s2">And to do this, I<br />maintain the same position</p>
<p begin="00:01:47.546" end="00:01:50.206" style="s2">that I'm currently in.</p>
<p begin="00:01:50.206" end="00:01:52.888" style="s2">And I'm going to slowly move the probe</p>
<p begin="00:01:52.888" end="00:01:55.305" style="s2">medially towards the patient.</p>
<p begin="00:02:01.043" end="00:02:04.492" style="s2">This will allow me to<br />visualize the bicep tendon</p>
<p begin="00:02:04.492" end="00:02:07.279" style="s2">as well as the subscapularis tendon.</p>
<p begin="00:02:07.279" end="00:02:08.729" style="s2">On the left of the screen is the</p>
<p begin="00:02:08.729" end="00:02:10.205" style="s2">supraspinatus tendon.</p>
<p begin="00:02:10.205" end="00:02:12.074" style="s2">Next, there's the bicep tendon</p>
<p begin="00:02:12.074" end="00:02:15.229" style="s2">which is the white<br />circular structure seen.</p>
<p begin="00:02:15.229" end="00:02:17.181" style="s2">And just adjacent on the right to that,</p>
<p begin="00:02:17.181" end="00:02:19.509" style="s2">is the subscapularis tendon.</p>
<p begin="00:02:19.509" end="00:02:21.541" style="s2">In patients with tears,</p>
<p begin="00:02:21.541" end="00:02:23.874" style="s2">we measure the interval between</p>
<p begin="00:02:23.874" end="00:02:25.849" style="s2">the supraspinatus tendon as well as</p>
<p begin="00:02:25.849" end="00:02:27.932" style="s2">the subscapularis tendon.</p>
<p begin="00:02:29.421" end="00:02:31.366" style="s2">If there's increased<br />distance between the two,</p>
<p begin="00:02:31.366" end="00:02:34.282" style="s2">it's suggestive of a tear.</p>
<p begin="00:02:34.282" end="00:02:36.733" style="s2">Lastly, we're going to<br />look at the supraspinatus</p>
<p begin="00:02:36.733" end="00:02:39.845" style="s2">tendon in it's longitudinal view.</p>
<p begin="00:02:39.845" end="00:02:41.554" style="s2">I place the notch of the probe facing</p>
<p begin="00:02:41.554" end="00:02:43.397" style="s2">towards the patient's ear,</p>
<p begin="00:02:43.397" end="00:02:45.975" style="s2">which is an easy to remember landmark.</p>
<p begin="00:02:45.975" end="00:02:48.253" style="s2">Maintaining contact with my hand,</p>
<p begin="00:02:48.253" end="00:02:50.727" style="s2">on the patient's shoulder,<br />with the probe angled</p>
<p begin="00:02:50.727" end="00:02:53.110" style="s2">up towards the patient's ear,</p>
<p begin="00:02:53.110" end="00:02:54.983" style="s2">we can see the rotator cuff,</p>
<p begin="00:02:54.983" end="00:02:56.374" style="s2">in what's commonly referred to as</p>
<p begin="00:02:56.374" end="00:02:58.110" style="s2">a bird-beak type image,</p>
<p begin="00:02:58.110" end="00:02:59.506" style="s2">clearly seeing the fibers of the</p>
<p begin="00:02:59.506" end="00:03:01.197" style="s2">supraspinatus tendon, which are healthy</p>
<p begin="00:03:01.197" end="00:03:02.530" style="s2">in this patient.</p>
<p begin="00:03:04.725" end="00:03:07.238" style="s2">In abnormal cases, we<br />may see partial tearing,</p>
<p begin="00:03:07.238" end="00:03:08.757" style="s2">blackness within the tendon,</p>
<p begin="00:03:08.757" end="00:03:10.389" style="s2">as well as thickening,</p>
<p begin="00:03:10.389" end="00:03:14.502" style="s2">or tendonosis with chronic poor blood flow</p>
<p begin="00:03:14.502" end="00:03:15.585" style="s2">in a patient.</p>
<p begin="00:03:16.534" end="00:03:18.727" style="s2">What we're going to do is follow the</p>
<p begin="00:03:18.727" end="00:03:21.394" style="s2">length of the tendon, on one end</p>
<p begin="00:03:22.279" end="00:03:25.034" style="s2">where it attaches at the bird beak,</p>
<p begin="00:03:25.034" end="00:03:27.264" style="s2">as well as through the opposite end,</p>
<p begin="00:03:27.264" end="00:03:29.163" style="s2">looking at the fibers and continuity</p>
<p begin="00:03:29.163" end="00:03:31.568" style="s2">to see if there's any abnormalities.</p>
<p begin="00:03:31.568" end="00:03:33.322" style="s2">Additionally, one pearl to be aware of</p>
<p begin="00:03:33.322" end="00:03:35.905" style="s2">is a concept called anisotropy.</p>
<p begin="00:03:36.957" end="00:03:39.328" style="s2">And what may appear to be an abnormality,</p>
<p begin="00:03:39.328" end="00:03:41.127" style="s2">or a partial tear, where you can see a</p>
<p begin="00:03:41.127" end="00:03:44.039" style="s2">hypoechoic or black<br />signal within a tendon,</p>
<p begin="00:03:44.039" end="00:03:45.519" style="s2">that may suggest a tear,</p>
<p begin="00:03:45.519" end="00:03:47.398" style="s2">was really just a result of your probe</p>
<p begin="00:03:47.398" end="00:03:49.398" style="s2">not being perpendicular to the structure</p>
<p begin="00:03:49.398" end="00:03:50.695" style="s2">you're viewing.</p>
<p begin="00:03:50.695" end="00:03:53.753" style="s2">An example of that would<br />be a blackness here</p>
<p begin="00:03:53.753" end="00:03:56.203" style="s2">in the tendon, that you<br />can see on the bottom</p>
<p begin="00:03:56.203" end="00:03:58.998" style="s2">aspect of the tendon as<br />it inserts on the bone.</p>
<p begin="00:03:58.998" end="00:04:02.165" style="s2">But by rocking the probe side to side,</p>
<p begin="00:04:04.011" end="00:04:05.858" style="s2">I remove the blackness and realize</p>
<p begin="00:04:05.858" end="00:04:07.691" style="s2">that it was anisotric.</p>