<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>

<p begin="00:00:09.612" end="00:00:12.755" style="s2">- Next we're going to examine<br />the infraspinatus tendon,</p>
<p begin="00:00:12.755" end="00:00:15.965" style="s2">as well as the glenohumeral<br />joint and labrum.</p>
<p begin="00:00:15.965" end="00:00:16.828" style="s2">We look at these together</p>
<p begin="00:00:16.828" end="00:00:19.011" style="s2">because they're in the same window.</p>
<p begin="00:00:19.011" end="00:00:21.627" style="s2">So what I like to do is<br />stand behind the patient,</p>
<p begin="00:00:21.627" end="00:00:26.507" style="s2">in this study, and use the<br />patient's scapular border</p>
<p begin="00:00:26.507" end="00:00:28.705" style="s2">as a landmark and follow their scapula</p>
<p begin="00:00:28.705" end="00:00:31.555" style="s2">across to the acromion that you'll feel.</p>
<p begin="00:00:31.555" end="00:00:34.660" style="s2">To allow the physician to<br />easily identify the structures,</p>
<p begin="00:00:34.660" end="00:00:36.775" style="s2">we recommend that you have the patient</p>
<p begin="00:00:36.775" end="00:00:37.919" style="s2">take their right hand,</p>
<p begin="00:00:37.919" end="00:00:39.384" style="s2">if we're examining the right shoulder,</p>
<p begin="00:00:39.384" end="00:00:42.823" style="s2">and reach across to the opposite shoulder.</p>
<p begin="00:00:42.823" end="00:00:46.199" style="s2">And I place the probe,<br />again facing medially</p>
<p begin="00:00:46.199" end="00:00:50.199" style="s2">towards the patient,<br />always maintaining contact.</p>
<p begin="00:00:52.264" end="00:00:53.895" style="s2">What we're able to do with ultrasound,</p>
<p begin="00:00:53.895" end="00:00:56.680" style="s2">if some of the images appear<br />a bit dark from shadowing</p>
<p begin="00:00:56.680" end="00:00:59.663" style="s2">we can adjust with a feature called gain.</p>
<p begin="00:00:59.663" end="00:01:03.024" style="s2">And there's a control on the<br />bottom of my ultrasound machine</p>
<p begin="00:01:03.024" end="00:01:05.775" style="s2">that will allow me to<br />brighten the lower aspect</p>
<p begin="00:01:05.775" end="00:01:07.791" style="s2">of the patient's shoulder.</p>
<p begin="00:01:07.791" end="00:01:10.199" style="s2">So I'm just going to<br />increase my depth here,</p>
<p begin="00:01:10.199" end="00:01:12.680" style="s2">next I'm visualizing the tendon fibers</p>
<p begin="00:01:12.680" end="00:01:16.688" style="s2">of the infraspinatus in a fibular pattern,</p>
<p begin="00:01:16.688" end="00:01:19.527" style="s2">looking for any abnormalities.</p>
<p begin="00:01:19.527" end="00:01:21.815" style="s2">Oftentimes if I'm suspecting a problem</p>
<p begin="00:01:21.815" end="00:01:23.575" style="s2">with the infraspinatus tendon,</p>
<p begin="00:01:23.575" end="00:01:27.064" style="s2">I'll request the patient to<br />externally rotate their arm.</p>
<p begin="00:01:27.064" end="00:01:30.320" style="s2">I'm going to have you slowly<br />push here, with your palm up.</p>
<p begin="00:01:30.320" end="00:01:33.653" style="s2">Just push your arm out, against my hand.</p>
<p begin="00:01:44.224" end="00:01:45.416" style="s2">So next we're gonna visualize</p>
<p begin="00:01:45.416" end="00:01:47.695" style="s2">the patient's glenohumeral joint,</p>
<p begin="00:01:47.695" end="00:01:49.847" style="s2">as well as their posterior labrum.</p>
<p begin="00:01:49.847" end="00:01:52.903" style="s2">In many patients we can<br />see their posterior labrum</p>
<p begin="00:01:52.903" end="00:01:55.432" style="s2">if they have a thin body habitus.</p>
<p begin="00:01:55.432" end="00:01:57.327" style="s2">And what we're looking for here</p>
<p begin="00:01:57.327" end="00:02:00.111" style="s2">is the posterior labrum that we can see,</p>
<p begin="00:02:00.111" end="00:02:01.671" style="s2">as a triangular pattern</p>
<p begin="00:02:01.671" end="00:02:05.007" style="s2">at the inferior aspect of the screen,</p>
<p begin="00:02:05.007" end="00:02:09.344" style="s2">as well as some cartilage<br />at the glenohumeral joint.</p>
<p begin="00:02:09.344" end="00:02:13.511" style="s2">This is the site of many<br />intra-articular injections.</p>