<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>