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Ultrasound Diagnostic Shoulder Exam Part 2

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Dr. Antonio (Tony) Bouffard is an Musculoskeletal Radiologist from the Detroit Medical Center Sports Medicine Department and a Consultant Radiologist at the James Andrews Orthopedic and Sports Medicine Center in Michigan. Dr. Bouffard has published several chapters and articles in many peer-review journals and has lectured in over 32 different countries. He has appointments as Consultant Radiologist to NASA, the United States Olympic Committee as well as the James Andrews Orthopedics and Sports Medicine Center. This Webinar will focus on part 2 of the Ultrasound Diagnostic Shoulder Exam.

Publication Date

Tue, 09/11/2018 - 12:00

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- [Daniel] We've got a pretty lengthy presentation here.
Dr. Bouffard is extremely thorough, very accurate.
And everybody's in for a treat here.
I'm gonna go ahead and start the introduction.
Well, who we've got on the line, myself, Daniel Shelton,
I'm the MSK Development Director here.
It's on the site, but the star of the show today,
we have Tony Bouffard, or Antonio Bouffard,
he hails from Detroit.
He's at DMC currently, Detroit Medical Center.
He is deeply embedded with the Department of Orthopedics
and Sports Medicine.
It's a very unique situation
in that they have their own private world-renowned
MSK radiologist not only doing their reads,
but specializing in ultrasound there.
So they get beautiful image studies as well.
Dr. Bouffard, if you could, correct me if I'm wrong,
you've been doing this MSK ultrasound since 1988,
which is unheard of.
Is that correct? (Antonio laughs)
- That's correct.
I think musculoskeletal ultrasounds started in 1972,
but it's not until the, shall we call them
the orthopedic radiologists, like myself,
or some dedicated senologist, like Dr. Nazarian,
or Dr. Middleton, started concentrating
on the MSK ultrasound.
I would say 1988 is a fair year to say that
that's when we started,
along with Marnix van Holsbeeck
who's still at Henry Ford Hospital.
- [Daniel] Great.
It's impressive, its long deeply-rooted history.
Dr. Bouffard, you're one of the most published
people in MSK ultrasound that I've researched.
You've certainly been a crucial part of my training
getting into MSK ultrasound,
watching the DVDs from the AIUM.
You're very heavy and active in their participation
in all of their workshop.
Also you're a consultant in NASA.
I'm not sure if you could tell us a little bit about that.
- [Antonio] I think it's probably, I would call it,
the highlight of my career to be associated with
the National Aeronautic and Space Agency.
I hope all our audience knows that we have ultrasound units
in the International Space Station.
And so for the moon and Mars expeditions and exploration,
respectively, we actually are going to be carrying
ultrasound units.
So all our flight surgeons, who take care of the astronauts
and all our non-physician astronauts do know how
to use ultrasound.
And try to remember before and astronaut goes to space,
it's about two years and three years they're rehearsing
for their flight.
And they get hurt, and so we do have the astronaut
strength conditioning and we have other patients.
So we call them acers
and they use a lot of musculoskeletal ultrasound.
So, for me, it's extremely exciting
to be associated with them
and knowing the fact that the portability
of ultrasound is helpful.
In addition, try to remember, we're trying to do
video streaming with our astronauts, not only in space,
but also while they train here on Earth.
- [Daniel] That's exciting stuff.
And you're also gonna be working
with the PGA very soon, I believe.
Is that a pending project?
Or is that something that can be affirmed?
- [Antonio] Starting this month, we'll be training
their sonographers.
Most of 'em, I think, are gonna be a physician,
sorry, a physical therapist.
And, of course, the doctors involved at that hospital.
And so we're gonna launch that part for the PGA.
So we went from teaching our sonographers
in the hospital to teaching the athletic trainers
over at the United States Olympics Committee.
And so far they're doing so well in Sochi.
And then we went to NASA and now we're going to the PGA.
So there's a lot of area to cover.
And I'm glad that you're joining us this Saturday
to really appreciate the fact of how widespread
musculoskeletal ultrasound is.
- [Daniel] Thank you.
Thank you, again, for joining us.
And I think now would be a good time.
We'll go ahead and get started with that first slide.
Thank you, again, Tony, Dr. Bouffard,
it's an honor to have you hear working and teaching
with these fine folks that joined us here.
So I'm gonna go mute my phone
and hand everything over to you.
- [Antonio] Thank you very much, Daniel.
And welcome, everybody, thank you for sharing
part of your Saturday and weekend with me.
I think I'd like you to know
that this is the first webinar I'm giving.
I've given a lot of lectures.
And so this is very exciting for me.
I can't wait to see the feedback from you
and also from Daniel on how well things went this afternoon.
And this is going to be, as you could see, part two
of the Shoulder Ultrasound Diagnosis.
We're going to be looking at the posterior
and superior structures.
First, I'd like to thank Sonosite
for organizing this webinar.
It's gonna be the first time in my life of doing one.
And, second, I'd like to thank Daniel for preparing
the entire presentation.
So for what we need to know,
I think this is going to be a very complete examination.
But, please, do not be shy, get in touch with us.
Maybe we could do like a feedback training
where you can visualize exactly what we're trying to say.
Let's begin by taking a look, as usual,
when you look at musculoskeletal ultrasound sonography,
we're going to take a peek at the anatomy.
And in doing so, let's quickly review
the supraspinatus tendon.
That's going to be very important,
because you know that the rotator cuff is conjoined tendon.
Although, arbitrarily, for example,
we separate the supraspinatus from the infraspinatus
and even from the teres minor.
They really are quite individual tendons that decussate,
they merge, like they merge one into each other.
So it's going to be very important to review, again,
the supraspinatus.
We are going to verbalize a short review
of the subacromial subdeltoid bursa.
But for today we're now going to jump
onto the posterior area.
I'm going to look at the infraspinatus,
the teres minor, and then we're going to
try to remember that that suprascapular notch
is going to be an important avenue
where in the nerves and arteries go through.
We're going to point the course of the
of the suprascapular nerve.
But we're also going to concentrate
on the posterior superior labrum.
Musculoskeletal ultrasound can only show two quadrants
of the labrum of the shoulder.
That is the anterior posterior quadrant
and also the anterior inferior,
excuse me, I said anterior posterior,
actually posterior superior labrum,
and the anterior inferior labrum where the
Bankart injury is.
But that's for another time.
Today, you're also going to be touching a bit of the
rotator cuff interval, which is going to play a huge part
in the stability of the long bicipital tendon
or the long end of the biceps tendon.
You know the acromioclavicular joint
is often forgotten and it's really in proximity
of the rotator cuff so that many times
it can mimic rotator cuff disease.
In passing,
we're gonna talk about the coracohumeral ligament,
the superior glenohumeral ligament.
And I'll only verbalize and show the location
of the coracohumeral ligament.
And so with that, let's go ahead and take a peek
at the lateral shoulder anatomy review
by looking at the supraspinatus and how it merges
with the infraspinatus.
So let's take a look at the lateral shoulder anatomy.
You all know that the supraspinatus is going to come out
from this outlet.
As a matter of fact, on radiographs,
we do have what we call the subacromial outlet
of the supraspinatus.
So the supraspinatus is going to be in the direction
of the anterior facet.
And then the infraspinatus coming from the
infraspinatus fossa is going to be on the middle facet.
The middle facet, as you can see here.
And, of course, lastly, you'll see that there's
one more facet known as the inferior facet
for the teres minor.
So the infraspinatus actually is a larger
tendon donator than the supraspinatus,
and so you'll feature very much
in this posterior shoulder talk.
The acromion process is a bony acoustic landmark for us
when we visualize it as imagers,
but even, more importantly,
now try to remember that we're going to be taking
the changes that occur in the acromion,
not only for arthritic changes,
but also the enthesophytes or the osteophytes
that it creates.
Last, but not least, one more time,
the greater tuberosity has three facets,
which you kind of have to rehearse
and remember it's going to play a part
when you localize and triangulate
the rotator cuff here in your practice.
So from here, let's go ahead and get a little bit more
of an anatomic view.
Here you see the work of Daniel Shelton
wherein he's giving you is 3D reconstruction
of the shoulder.
Let's begin on your right-hand side,
where you see the coracoid process
and then you see a little bit of the short-head,
long-head combination of the bicipital tendon.
It's well within the bicipital groove,
or most of you might call it the intertubercular sulcus,
and as you go head into the leading edge
of the supraspinatus, notice that it's going to insert
on the anterior most facet that which as shown.
Now, very important here is the junction
between the infraspinatus and the supraspinatus.
Many times, of course, we think that it's largely
supraspinatus insertion, but please note
that over two-thirds of it is going to be
the infraspinatus.
So, therefore, as we proceed now on the left-hand image,
you again note the long bicipital tendon
within bicipital groove,
the leading edge of the supraspinatus,
the footprint, or rim, of the supraspinatus,
combined with the infraspinatus.
Note, again, that it's actually a conjoined tendon,
and, of course, it's in contiguity with this teres minor,
it's a little bit more posterior.
And so this is the whole review
that we're going to take a look at.
Let's look at the insertion
of the major rotator cuff tendons.
Here in the anterior facet, colored in blue,
is going to be the insertion of most of the supraspinatus,
followed by a yellow colored facet,
which is the middle facet of the infraspinatus.
Although, try to remember, this is just arbitrary separation
in those individuals,
because a lot of the supraspinatus is going to tuck itself
underneath the supraspinatus.
Often forgotten is the teres minor, but, I think,
some aside Daniel Shelton prepared an excellent presentation
on how important this anatomy is going to be.
And that's the green part of the facet.
So you have anterior facet, supraspinatus arbitrarily,
middle facet infraspinatus arbitrarily,
and then you've got the inferior facet for the teres minor.
The bicipital groove is an excellent marker
wherein we could separate what is going to be subscapularis
from the supraspinatus.
So that's going to be a very important area
which we'll review as the bicipital interval.
Here now you could see an excellent presentation
for some short axis view.
This is going to be the equivalent
of your sagittal MRI view, as you could see.
Let's begin with the blue colored convexity
of the proximal humerus.
Here you could see the subscapularis,
the long bicipital tendon and the leading edge
of the supraspinatus.
The interval between the leading edge of the supraspinatus
and the superior margin of subscapularis,
it's going to be known as the rotator cuff interval.
That's where you have the outlet
of the long bicipital tendon.
Notice that the blue colored convexity
upward of the humerus is where you have the midsubstance
or musculotendinous junction of the supraspinatus.
So, again, arbitrarily, you got the supraspinatus
infraspinatus combination.
And do not forget the subacromial subdeltoid bursa.
Note that at this slice, very high in the proximal area,
you'll see not only the subchondral plate,
but also you'll see the articular hyaline cartilage.
Now let's go to the yellow type of short axis view.
And you can see a further definition
of what is the anterior facet from the posterior facet.
You'll see almost pyramidal apex...
Pyramidal apex type of bony acoustic landmark
and definitively they're now over the greater tuberosity.
And so this is why you have a little bit of thinning
as you approach the tip of he supraspinatus infraspinatus.
And now you're going to see the hypoechoic stripe
of the pieces of the greater tuberosity.
Don't forget, again, you're still seeing part
of the rotator cuff interval.
Let's go to the very tip, to the very insertion,
the edge, of the greater tuberosity, in purple.
And, actually marginated here,
you could see the purple area.
And now you get to see the anterior and posterior facet,
almost limiting what could be a rotator cuff tear
if you're not very careful.
So this is why you make a sweet from the achromial level,
also known as proximal, over the humeral head.
And you make a sweep to the midsubstance
for the anatomic neck, and finally,
to the greater tuberosity level.
And as you make a sweep, you'll notice the
tendon volume change as it thins out,
because you're approaching the very tip
or the very lateral insertion
of the footprint of the supraspinatus.
So, again, most of us will think about the first
two sonometers, at the supraspinatus,
and many of us will even divide for the anterior
from the posterior segment of the supraspinatus.
So this is very important.
But, of course, you all know that in ultrasound,
we not only look at things in one plane,
but now you also have to look at it on 90 degrees.
And, therefore, what we're going to do now
is we're going to take a look at everything
in long axis view.
In long axis view, the same thing.
Before we do that, let's go ahead and rehearse
what is the long bicipital tendon.
The long bicipital tendon
is within the rotator cuff interval.
And we already talked about
what makes the rotator cuff interval.
The rotator cuff interval
is where the outlet of the long bicipital tendon is.
And here, for example, you'll note first,
you see the speckled pattern echo signature
of a tendon in short axis view.
And then it's within an interval, or a space,
where you have the leading edge of the supraspinatus
and you have the superior margin of the subscapularis.
Usually, we've been thinking that this is about
a sonometer wide and any change in that diameter
or measurement might hint that there is a chunk
of supraspinatus missing or a piece of subscapularis
that's been affected.
Now within the rotator cuff interval,
you'll set the lateral ward,
okay, Carlo Martinelli likes to call it the lateral ward.
I like to think of it as the lateral limb
of the coracohumeral ligament,
emerging itself into the supraspinatus.
Then you have the middle ward type of
coracohumeral ligament, which you could see.
And that, along with a capsule,
all the coracohumeral ligament and the capsule
make a reflection pulley around the long bicipital tendon.
In addition, you get to see a piece
of the superior glenohumeral ligament
in the rotator cuff interval.
So these are the things that we could see.
And notice, again, you have the anterior facet
from the middle facet.
And so arbitrarily now we're going to divide
what is supposed to be the supraspinatus
from the infraspinatus.
And you note that it's a conjoined tendon.
And the other thing is you look at the volume,
the thickness of this tendon,
that means you're high up, very high up over
the humeral head.
And, therefore,
what you'll be seeing at that slide selection
is the bony acoustic landmark of this high level echo
representing the subchondral plate
and then a hypoechoic cleft representing
now the articular hyaline cartilage.
So this is going to play an important part
in your dictations and your assessment,
because now you're going to tell people
exactly what is going to be supraspinatus-esentric
and what's going to be infraspinatus-esentric defects.
So, as promised now, from short axis,
let's take a look at things on long axis.
And one more time,
this was provided to us nicely color coded.
First, if you look at the 3D reconstruction in blue,
we're going to have over the long bicipital tendon
and the bicipital groove.
And so this is the outlet of the long bicipital tendon.
And that's going to be very important,
because most of your are going to relate
the distance of a defect in relation
to the long bicipital tendon.
So once you've seen that part,
you gingerly slide posterolateral
and now you're here to the yellow slice.
The yellow slice we're in the anterior segment
of the supraspinatus, and, of course, the anterior facet
of the greater tuberosity.
Here you see the classical parrot beak appearance
of the supraspinatus with its fibrillar echopattern,
convexity upward of the tendon
and the subacromial subdeltoid bursa itself.
As we go from the tendon down to the equal
midsubstance area, you now identify the subchondral plate
of the proximal humerus.
You identify the anatomic neck
of the greater tuberosity.
And then you're going to see the ledge
of the greater tuberosity.
Note that over the ledge of the greater tuberosity
is another hypoechoic stripe
just like the hypoechoic stripe
of the articular hyaline cartilage.
But this time that's where the insertion
of the tendon is and that is the enthesis
which is made up of fibrocartilage.
So from the long bicipital tendon,
we went to the anterior portion of the anterior facet
of the greater tuberosity, or the anterior segment
of the supraspinatus.
Now we're going to scoot towards the posterior segment.
So now we're approaching the middle facet.
As we approach the middle facet of the greater tuberosity,
or a combination, the junction
of the supraspinatus with the infraspinatus,
notice that the tendon is now a little bit more elongated.
You don't have that hook appearance of a parrot beak
when we're looking at the anterior segment
of the supraspinatus and it's a little bit longer.
But, on more time, I'll emphasize,
there are hypoechoic stripes representing
the footprint of the supraspinatus,
which is the fibrocartilage enthesis
of the greater tuberosity.
And another hypoechoic stripe which represent
the articular hyaline cartilage of the proximal humerus.
So very nicely in static images, of course,
you'll see different slices as we go from
anterior going to postural lateral.
So you make entire sweeps
and that's going to be very important.
In order to have said that we've covered the entire
stent of the supraspinatus in these individuals.
So as we do that now, just a quick review
of what we were talking about in long axis
when we're taking a look at the supraspinatus tendon.
Let's begin again with a bony acoustic landmark
of the greater tuberosity.
And above that will be that hypoechoic stripe representing
the enthesis, which is made up of fibrocartilage.
Then as we go a little bit towards the anatomic neck,
you'll se the reflection on the under surface of a tendon.
But once we hit the proximal head of the humerus,
now you'll see this hypoechoic stripe represented in blue,
which is the articular hyaline cartilage.
From there, we're going to look at the footprint proper
of the tendon, we're going to the midsubstance
off the tendon.
And as we approach to the medial aspect,
you'll see the interdigitating
musculotendinous junction of a tendon.
Note, again, that you had different types
of bony acoustic landmark.
First, you had the subchondral plate
under a cartilage, which is articular hyaline cartilage.
Second, you have a enthesis, which is the ledge
of the greater tuberosity.
And the last bony acoustic landmark
is going to be the lateral deltoid shelf,
that's tibia cortex.
But the rest we'll call them boney landmarks,
or these bony acoustic landmarks on ultrasound.
Let's look at the supraspinatus in its different layers.
And now you can take a look.
Of course, again, these are because
you have the merging of tendons.
That's why we kinda gonna see some separations amongst them.
Let's begin again with the bony acoustic landmark
of the greater tuberosity.
You'll notice that footprint will involve
a bursal aspect, an intratendinous,
also known as intrasubstance aspect,
and finally the articular layer.
The articular layer, of course,
is where most of you are going to see, very commonly,
the tears that do occur.
In cadavers, however, we've noticed that
most of the tears we see are intratendinous.
So from the bony acoustic landmark,
you get the fibrillar pattern of the echosignature
of the tendon going from the footprint
to the midsubstance, otherwise known as middle-third,
to the muscular tendinous junction.
As we proceed up now, therefore,
now you're going to be catching
the subacromial subdeltoid bursa.
Remember that the bursa is an imperceptible space,
it's a virtual space, and therefore if it's normal,
it's going to be a little bit merging
with all the other structures.
However, you'll also appreciate the fact
that with the resolution of ultrasound units today,
you could almost always pick up that,
you know, you could separate what's going to be the bursa
from tendon proper.
So let's proceed now and take a look
at the posterior shoulder,
now that we've rehearsed what the tendons
are going to look like.
The bony acoustic structures you're gonna look at
are going to be the scapular spine.
But remember that the scapular spine has a base to it.
And the base of the scapular spine will become
very evident to you as you join the fossa
of the infraspinatus, 'cause that's where you have
spinoglenoid notch.
Then as you go around,
you're gonna have the acromion process.
Remember that that's going to be very important
because we could see normal variant of acromiale.
So don't forget that you have to go around
the entire acromion process in order to pick up
that normal variant.
Then you've got this scapular body.
Of course, you have the supraspinatus fossa
and you have the infraspinatus, or infraspinus fossa,
if you wish.
We already rehearsed time and time again,
about not seen here the anterior facet,
but now you could clearly see the middle
inferior facet of the greater tuberosity.
I'm glad when Daniel prepared the slide
that he separated one for spinoglenoid notch
from the spinoglenoid groove.
Because here, clearly, you could see as the scapular spine
joins the body of the scapula,
this is a notch much like the scapular notch superiorly.
The spinoglenoid notch, but as we go around the neck
of the glenoid itself, that is the spinoglenoid groove.
And it's all one contiguous valley
and extends from the scapular notch
to the spinoglenoid notch to the spinoglenoid groove,
'cause that is the course of the
scapular nerve and neurovascular bundle.
Very importantly now,
we're going to look at the posterior glenoid labrum.
And so you look and identify for the bony acoustic landmark
of the glenoid itself.
And once you see the socket of the glenoid,
then there's going to be a washer-like fibrocartilage
structure representing the labrum.
The posterior glenoid tubercle
is where they take off of the triceps
latissimus dorsi and teres minor are going to be.
And so that's going to be important.
When you're looking at the posterior shoulder,
it's not uncommon that you'll identify the medial border
of the scapula, but also the scapular inferior angle,
which most of us will use as a takeoff point
when we look at the posterior glenohumeral tubercle.
From there, let's now put some soft tissue
color structures on the bony acoustic landmark.
The scapular spine, as you could see, but remember that
it has a base which forms the spinoglenoid notch.
The acromion process, which goes entirely around
to the front for the acromioclavicular joint.
The scapular body proper, mostly made up of
the infraspinatus, unless you're taking a peek
at the supraspinatus fossa.
Then you go over to the greater tuberosity.
You look for the convexity of the humerus,
the anatomic neck, and you identify the middle facet,
mostly from the infraspinatus insertion.
And then (mumbles) better said.
And then you also can catch the posterior area,
which is going to be the inferior facet,
donated mostly for the teres minor.
As you proceed now, remember that we're going to separate
was the spinoglenoid notch from the spinoglenoid groove.
That's important, because you could have a
suprascapular ganglion that's strictly affecting the groove
or the spinoglenoid notch,
or even more superior ally, scapular notch.
And then now take a look at the drawing
that we have for the fibrocartilage, number seven,
which is the posterior glenoid labrum.
We're very good with ultrasound when we look at the
superior, posterior, superior glenoid labrum.
A little more difficult when we're looking at
the mid and inferior area.
But I think if you position the patient correctly
then what's going to happen
is that you're gonna have an excellent acoustic window,
wherein you could see most of the posterior portion
of the glenoid labrum.
We're going to take a look at the posterior glenoid tubercle
for the takeoff of the teres minor, and also
for the insertion triceps as we'll show you shortly.
And we can go and proceed now
and take a peek at the next slide,
which are the two important tendons
in the posterior rotator cuff area.
The largest of all is the infraspinatus inserting on
the middle facet, and of course,
its partner, the teres minor.
Often we could see changes of muscle atrophy
and infiltration of the infraspinatus,
using the teres minor as your control.
And in fractures of the proximal humerus,
especially in adolescent and kiddies,
we do take a look at the teres minor tendon.
So notice the relationship now.
So you have a little bit more superior
infraspinatus tendon.
And it's made up of a bipennate type of muscle.
But you have a smaller, almost unipennate,
teres minor tendon inserting on the inferior facet
of the posterior greater tuberosity.
And so we proceed from there.
Let's dedicate ourselves to the infraspinatus tendon.
Here you could see the probe in transverse
across the posterior part of the patient.
And now you're going to see that we can see
the infraspinatus throughout its entirety.
But notice that we have to make a sweep.
Now how do you locate the infraspinatus tendon?
Very simple, you look for the fibrillar echo signature.
But it's not uncommon for us now
to look for the glenohumeral joint.
We do that by taking a peek
at the vertex of the shoulder
and the posterior axillary fold.
Imagine a virtual line between those two points.
And we put it at the upper and middle thirds,
and you'll fall not only to the infraspinatus tendon,
but also the glenohumeral joint.
In actuality, it's the same point that the arthroscopist
is going to put his posterior portal
for shoulder arthroscopy.
So it's identical, except that as imagers
we're going to use topographic landmarks,
rather than palpate the glenohumeral joint,
other than palpate the coracoid process.
But you could see the line of direction,
the trajectory of the probe in looking at the infraspinatus.
Remember that we have to make an entire sweet.
So as we proceed, therefore,
this is what you're going to see as you sweep
from posterior to anterior, anterior to posterior.
First, the grayscale imaging.
You have the bony glenoid socket.
You have the ball or convexity of the humerus
and then you have the glenohumeral joint line.
Above the bony glenoid socket,
you have in short axis view a triangular hypoechoic line
representing the fibrocartilage.
Now you get to see the posterior middle facet
of the greater tuberosity and the insertion and footprint
of the infraspinatus.
This is the infraspinatus tendon from footprint
to midsubstance or musculotendinous junction.
You could see the fibrillar echo signature
into the pennate, bipennate structure of the muscle.
And as you go from the lateral aspect
to the medial aspect, now you begin to catch
the spinoglenoid groove.
Let's go over to the colored rendition.
Again, the bony acoustic landmark
of the posterior glenoid labrum nicely seen.
Then you have the ball of the convexity of the humerus,
also seen on the grayscale.
Then you have the joint, now this is very important.
That's where your target is
and that's where you're going to try to put your needle in.
But also very imperceptible now is the capsule.
And here you could see the drawing of the capsule
in white line drawing, clearly stating
that it is adherent or very closely adapted
to the humerus and glenoid socket.
Then you have the echo signature
of the infraspinatus tendon.
And as you go a little bit more medially,
you see the spinoglenoid groove and notch
with the neurovascular bundle.
And almost a short axis view you see on top
of the infraspinatus is the posterior segment
or posterior third of the deltoid muscle.
But in yellow you have the subcutaneous panniculus or fat,
and finally skin.
So as you proceed from there now,
you remember that we are going to scan from
posterior to anterior.
So when you go to the anterior portion,
you get to see further the footprint
of the infraspinatus.
Note that you see the muscular tendinous junction,
interdigitating hypocoiled muscle,
with the fibrillar echo hyperechoic signature
of the infraspinatus inserting on the enthesis
of the middle facet of the greater tuberosity.
Above that you have the posterior third segment.
Excuse me, it's jumping here for me.
You have the anterior third,
posterior segment of the deltoid muscle.
And, of course, the middle segment of the deltoid muscle.
Note that the fascia of muscle can be pitfall.
It is very dense and therefore it'll cast
a posterior acoustic shadow
which can therefore mimic tendinopathy
in the subadjacent tendon.
More about that when we look at the other image.
So as you go from posterior to anterior
then you're supposed to see the musculotendinous junction,
midsubstance, and finally the footprint.
And if you compare it to the image above that you'll see
not only the loss of the echogenicity
of the fibrillar pattern,
but take a look at the size of the tendon.
So therefore we know this is diffused tendinopathy
or tendinosis.
So echogenicity is going to be very, very important.
Echogenicity is going to be very, very important.
So those are the things that we have to take
and be careful for first, echogenicity, size and contour.
Contour because this used to be very, very straight.
Now the contour because it's a little bit more hooked,
mimicking a supraspinatus.
But we know that's infraspinatus, of the size,
therefore this is tendinopathy.
I don't have an example.
And I'm glad Daniel has this
because you notice that we're doing a internal
and external rotation of the forearm and hand.
And when you do that now, you have the glenoid socket,
you have the convexity of the humerus.
And guess what?
The echo signature fibrillar pattern of the
infraspinatus as it goes through its footprint
is now interrupted with this hypoechogenicity
sharply marginated.
If you compare that to a mirror image,
contralateral part, notice the preserve echo signature.
So the affected part will be a change in echogenicity,
a change in size, and now you can delineate
exactly the medial lateral extent
of the sharply marginated defected
against the height.
And that's important because over here, for example,
we can say that this occupies 50% of the tendon volume.
And so that will help the individual.
Note, too, that when you have tendinopathy
you have bony irregularity.
So bony irregularity is going to accompany the changes
of tendinopathy.
And that's the area that you want to check
the minute you see bony irregularity
because there may be a tendon disease.
And then from here, let me show you some examples
of that muscular septum.
Look at the posterior acoustic shadowing, its cross state.
Look at the posterior acoustic shadowing, see?
So a lot of that might mimic, of course, tendinopathy.
You have to be careful with that.
So, again, one more time, remember
interruption of the fibrillar pattern of the echo signature,
tendinopathy usually is accompanied by bony irregularity
in comparison to the unaffected site.
Here you see the glenoid socket,
the ball of the humerus,
the joint line, the of course labrum
in an intact infraspinatus in comparison
to the cleavage that you've appreciated
on the abnormal infraspinatus.
Proceeding therefore some more,
let's look at glenohumeral effusion.
If you listen to a radiologist colleague,
like Louis Van Schmidt, they'll tell you
that it's on the external rotation.
As you do an external rotation of the arm,
I'm looking for my cursor right now.
See if I can find it.
There we go.
As you go to external rotation,
you'll notice that you can pick up more of the
glenohumeral effusion.
And so on external rotation,
this is what you're going to see.
You're going to see a little bit of buckling
of the capsule, which we showed you earlier.
And then you'll catch small amount
of normal physiological fluid in between
the bony acoustic landmark of the humerus
in subjacent to the fibrillar pattern of the infraspinatus.
Note, again, at a triangular fibrocartilage
and the socket of the bony glenoid.
So when we look at glenohumeral effusion,
identify the bony socket of the glenoid.
Identify the convexity and ball of the humeral head.
And you can see the joint line.
And when you do an external rotation,
this is what's going to happen.
You're going to ball and balloon out the capsule
showing you this unechoic fluid.
But don't stop there, okay?
Because what we wanna do now today is we want to
make sure that you characterize the effusions,
their synovitis is their loose body.
So here you see the bony socket,
the ball of the humerus, the glenoid and the effusion.
From there, let's now proceed and see
what is happening to the other structures
in the posterior area.
We're going to take a look at the infraspinatus
from what we're looking at,
the long axis of the infraspinatus into short axis.
We're going to look at the medial aspect,
the midsubstance aspect and almost at the joint line.
So line number one is showing you the infraspinatus
as we take a peek at it on short axis.
What used to be a tenate structure of muscle
on long axis, on short axis now shows us
a starry night pattern.
Then as we move to the midsubstance,
we go from the infraspinatus, a little bit more
off the central tendon.
Central tendon, and then as we go towards the joint line,
number three, we'll see most of the tendon.
Let's look at it on real time.
And let's begin again by taking a peak, let's pause.
And then let's drag the image back all the way.
This is a left shoulder,
so you're seeing the bony glenoid socket,
the head of the humerus, and then the fibrocartilage.
The infraspinatus is fibrillar in pattern
with a pennate structure.
As we launch this one now you'll see that
we're going to go from long axis to short axis.
And so when you turn the probe 90 degrees,
in this case, left shoulder, you turn it clockwise,
you go short axis.
So here, for example, is plane number one,
because we're looking at the musculotendinous junction,
a smaller central tendon, and as we proceed,
now we're going to go to cut number two.
And, finally, we're going to end up in cut number three,
which is very, very close to the humerus.
And this is what we see most of the time.
We see the infraspinatus, and guess what?
The acromial process.
You get to the subacromial subdeltoid bursa.
So you see the tendon and then the muscle around it,
and, of course, the insertion.
Very important to always determine the insertion
in those individuals.
So remember that musculoskeletal imaging requires
that we see things in our (drowned by cut out audio) of use.
And we'll proceed from there and take a look
at the teres minor.
The teres minor is below the infraspinatus.
Notice that infraspinatus is almost horizontal transverse,
while the infraspinatus is going to be horizontal oblique.
When you do that, then you can identify first
on short axis.
Here you see the infraspinatus in its fossa.
Then you see the inferior angle or tubercle of the scapula.
This is the central tendon of the infraspinatus.
As we jump over, you'll see a second fascicle of muscle
representing the teres minor.
So identify the bony acoustic landmark of the fossa
for the infraspinatus,
the tip or inferior angle of the scalpula.
And then, finally, you'll see the teres minor.
A little bit of the triceps long head now,
excuse me, we forgot to change this diagonal sort.
Long head is being in show in this area.
As we proceed now a little bit more
towards the lateral aspect to see the insertion
of the teres minor, now you get to see a lot larger
than the infraspinatus.
And you see the central tendon going very, very well.
And now we begin to see the tendon of the triceps long head
in the area.
So, again, a typographical error calling it short head.
This is what most of us really wanna see.
We wanna see the transition between what is
the infraspinatus and conjoined area
with the teres minor.
And you'll see a mostly hyperechoic tendon
of the infraspinatus, and a mixed muscle tendon
junction of the teres minor.
This is why it's called minor.
And so very well to the inferior facet
of the greater tuberosity.
And so from there, remember that we have to angle
oblique downwards and you only get a glimpse
of the glenoid socket and the labrum.
And you see a huge source,
slimmer tendon than the infraspinatus
of course in long axis and almost a unipennate structure.
On short axis, one more time,
notice that we're showing the teres minor
and the central tendon.
Incidentally, I'd like to point to you
that as we approach the teres minor
and you look below the teres minor, you see
the quadrant lateral space.
Some of us, like Dr. Theresa one,
want to take a look at that
because that's where the axillary there might exist.
So when you go on short axis from medial,
as you approach the qudrilateral area,
you might see the neurovascular bundle
underneath the teres minor on short axis.
So as we proceed now,
let's go up to the spinal glenoid notch.
We already talked about it at length
going from the scapular notch to the spinoglenoid notch
into the spinoglenoid groove.
As you scan, you have to move from the glenohumeral joint
to the medial aspect of the spinoglenoid groove.
So this is what we're going to see.
Here, you see the lateral aspect for the glenoid socket,
humerus and the joint line, the infraspinatus.
Note that as you move from the lateral part,
or external part of the shoulder,
you get into this dip,
and that is going to be the spinoglenoid groove.
If you were to move up a little bit more
then you see the notch.
And that is where the neurovascular bundle is.
Note, again, that you can see pulsations
that you can catch.
In addition, please recognize
that when you do internal/external rotation,
you dilate, you dilate things.
And, of course, that might mimic a cyst,
be careful with that.
So that is a normal variant on dynamic imaging.
As we proceed now let's finish by taking a look
at the superior shoulder anatomy
in the last three minutes.
You'll see the mid clavicle going to the distal clavicle
and the acromioclavicular joint,
acromioclavicular joint.
Then you have the acromion process,
that entire thing that you have to look at.
Not shown, it's going to be the acromioclavicular ligament.
I'd like to take one minute
to show you that the scapular notch.
And you see the scapular notch connection to the
spinoglenoid notch and then finally
to the spinoglenoid groove.
And now you can imagine that scapular nerve
from the brachial plexus is going to the scapular notch
to the spinoglenoid groove, and in, sorry,
spinoglenoid notch and into the spinoglenoid groove.
Now we're going to go and take a look at the
acromioclavicular joint.
I've already told that.
This is often because of its proximity to the rotator cuff
it may mimic rotator cuff disease.
And so let's take a peak at it.
You put your probe at the vertex of the shoulder
and identify the bony landmark with the acromion
with a clavicle and we get to see the joint.
This is what it looks like on black and white.
So you have the acromioclavicular joint.
Then you have the superior acromial ligament.
Notice that Daniel put a mound of gel,
differential gel in order to catch the entire joint.
And well within that, you could see the subarticular plate.
And of course the synovial capsule
and finally the fibrocartilage disk,
which you may see it in adolescence,
but by the time most of us are adults
it kinda dissipates and disappears.
So that's the area you would take a look at.
What are the things that could affect,
a acromioclavicular joint
that's remote from rotator cuff disease?
Well, you already know where to put the probe,
you know what it looks like normal on long axis view.
Now if you take a look at this now, in comparison,
look at the level of acromion clavicle.
But here you could see that the distal clavicle
is elevated superiorly so you have
at least a grade two subluxation.
Also note, well what's impact fibrillar pattern
of the superior ac, or acromioclavicular ligament
is now interrupted for a partial tear.
It's not uncommon to how sometimes
you'll see a huge fluid collection with internal speckles
representing loose hydroxy appetite calcium formation.
So those are the things that can happen
that is exclusively acromioclavicular disease.
You remember where to put the probe
and what it looks like on normal.
What if you have this?
Above the acromioclavicular joint
is a collection of predominately hypoechoic,
somewhat mixed echogenicity for a ganglion cyst,
but beautifully shown on on dynamic imaging.
Acromioclavicular joint, acromioclavicular ganglion cyst.
Differential diagnosis should include
a geyser sign because of a full thickness rotator cuff tear
or adventitial bursitis in chronic
acromioclavicular osteoarthrosis.
So those would be the two differentials.
Note, again, the exquisite resolution we get
knowing what's going to be fluid
from what's going to be thickened wall
and therefore if we have to sample this anteriorly,
we can catch it correctly.
For acromioclavicular joint, a compressions study,
or a cross chest maneuver.
We have the patient just bring his affected hand
to the unaffected shoulder.
And so what you're doing is you're translating
on the shoulder.
And so compression is going to be important.
So remember that ultrasound is dynamic.
Always take advantage of it.
And then, of course, we could do the separation study
where a patient usually will hold
maybe more like 15 ponds weight
rather than the usual 10 pounds shown here.
So you know where to put the probe,
acromioclavicular joint line, here's the acromial ligament
in drawing, we're not gonna show it in ultrasound.
So when we do that, my mouse is jumping, excuse me.
So first you have a neutral.
Look at the difference space here.
You know that irregularity represented osteoarthrosis
and of course, the subarticular area,
look at the joint effusion and the detritus inside it.
When you do a cross-chest compression maneuver,
notice how the joint line closes, how the effusion bumps up
and more floaters that you can appreciate
and the intermediate echos representing
chronic synovitis.
What about the second one?
We're going to now distract the shoulder.
And so now in neutral, now try to appreciate
the distance between the two.
And when we distract it, look how it opens up showing you
clearly large joint effusion.
And so from there, let's take a look at it
strictly just on distracting the shoulder.
Glands are translucent.
This is your neutral area.
And then when you put weight, about 15 pounds,
look how you open up and clearly show what's inside it.
You can really see the bursal aspect of the rotator cuff.
And when you do a cross-chest maneuver,
again, you can appreciate the closing of this joint.
So with that, therefore,
I think let's finish by taking a look at
something which is acute versus chronic.
You remember what the normal grayscale looks like,
you remember where to park your probe.
If something is acute you'll have hemarthrosis,
very much fluid.
That's why you get good through transmission
on echoic fluid in somebody with some osteocytes.
But when you have chronicity now, you distract,
you separate it, but now you also have
the chronic fibrosis and synovitis in this individual.
So I hope we've covered everything that we need
to look at the posterior shoulder,
especially the infraspinatus.
And do not forget the glenohumeral joint.
And last, but not least, of course,
the acromioclavicular joint, which is the only
superior structure that we'll look at
in the superior scanning of the shoulder
with musculoskeletal ultrasound.
We have about 10 minutes for questions and answers.
And so I'm gonna wait for Daniel to show me the questions.
And then we'll try to cover as much as we can.
And after the webinar, I'll be more than happy
to answer your emails.
Daniel and I will try to get in touch with you
if we run out of time.
Please, hand in your shoulders,
(laughs) hand in not the shoulders,
hand in your questions, please.
- [Daniel] (laughs) give me your shoulders, please.
That's great.
Thank you, Dr. Bouffard.
Outstanding, great job, as usual.
I'm gonna start with the first five questions
that I've entered because they are diagnostic in nature.
If we have time at the end of the webinar,
basically I'll start answer the miscellaneous ones
such as procedural guidance,
certification related questions, things like that.
So the first one is,
and I really appreciate this first question,
"MRI or ultrasound?
"Which one have you been..."
And I wanna expand on their, their question
was pretty short, MRI or ultrasound
for shoulder diagnostics,
and I think also something to expand on that are
what are the limitations of ultrasound
and what are the limitations of MRI?
- [Antonio] This is how we work it out.
In the two institutions that I work with,
The Henry Ford Hospital and right now
The Detroit Medical Center.
When it comes to rotator cuff disease,
so you're looking at tendons all the way
to the muscular tendinous junction, we use ultrasound.
And not only for rotator cuff disease,
but usually it's treating a painful shoulder.
So we always start with ultrasound.
Now when you look at the labrum,
something interarticular then you must think of MRI.
So that's the way to look at it.
If it's a painful shoulder, screen it with ultrasound.
If it's rotator cuff, diagnose it with ultrasound.
My orthopedic sports medicine surgeons
they will rely on ultrasound rather than MR.
There was a time wherein we recalled a massive
retracted tear, they'll ask for an MR
to see where the proximal stump was.
But nowadays we can still kinda create,
if you look at my cursor,
an acoustic window behind the acromion underneath.
And therefore we could see how far retracted
some of those tendons are.
And when it comes to the labrum,
if you look at my arrow again,
you must concentrate with MR rather than ultrasound.
- [Daniel] Okay, great.
And, let's see, surgical outcome tracking.
Do you guys utilize ultrasound to track surgical outcomes?
- [Antonio] Well, we have not done it in our institution,
but if you follow, for example, Dr. Robbie Cohen
and Bruce Miller at the University of Michigan,
they looked at their outcomes by taking a look at
post-op rotator cuff disease by taking a look at it
with ultrasound.
And they noted that within the first three months
that's where you get most of your re-ruptures.
I think outcomes are fantastic, I believe,
because I know for a fact that in our institution,
when we have some asymptomatic rotator cuff tears,
or maybe mildly symptomatic,
we might treat them conservatively rather than surgically.
And I think it's a great project to be done.
But nothing that I can quote from the literature right now,
using ultrasound to determine the outcome
of rotator cuff disease.
Next question. - Okay,
how about certification?
Do you have to be certified for diagnostic ultrasound?
There's probably more--
- [Antonio] That's more for,
yeah, yeah, more for you to answer, Daniel, of course.
I mean, I think, look, this is what's gonna happen, right?
They're gonna say, "Well, how good are you in ultrasound?"
So if you're certified, let's say you take the RMSK,
or let's say you have a masters
in musculoskeletal ultrasound,
then they'll have to respect you as an expert.
Pass the exams of the RDMS, ARDMS, which is RMSK
registered musculoskeletal sonographer in medical...
That would be medical diagnostician.
And so, yeah, see, I believe you should be certified.
But it's not necessary.
And so whether you are an imager, like a sonologist,
sonographer, radiologist, the non-radiologist physicians
usually take the RDMS test.
Now they can take the RMSK test.
The non-sonographer radiologist technologist
like athletic trainers, physical therapists,
also request that they take the RMSK,
or a master's degree in musculoskeletal ultrasound .
- [Daniel] Great.
Next question is, "Do you take an ultrasound diagnosis
"straight to surgery?
"Or are more diagnostic exams required?"
- [Antonio] The orthopedic sports surgeons
in our institution have taken, at Henry Ford,
have taken them straight to surgery after ultrasound
and the same thing at The Detroit Medical Center
bypassing MR, if that was your question, yes.
We diagnose it by ultrasound. (Daniel drowned by Antonio)
On the other hand, we had people like with MR
that exaggerated because of the signal intensity
and the signal averaging, that's like an artifact
that exaggerates the abnormality in MR.
We kinda saved those patients, at least the patients
going to surgery, by looking with ultrasound,
because we would see things like,
you know, it's a footprint tear,
it's not a deep partial thickness tear.
So those are the things that also helps us in our practice.
- [Daniel] Okay, and I think you already answered
the next question back,
about two questions ago about the labrum.
So that was the next question I had written down.
And limitations of the labrum.
And I guess would that be posterior window only?
Do you use ultrasound to diagnose labral tears?
- [Antonio] No, we don't.
We do use ultrasounds looking at the resultant
tear or labral cyst that occur on the labrum.
But, please, do not be discouraged.
I know for a fact that the posterior superior,
posterior superior labrum is where you can catch
most of the slap lesions.
And this is a posterior image here with my arrow,
but you can also see the Bankart lesions
by putting the patient.
And if you watch me on your screen,
you put your hand behind you.
And this is called a abduction external rotation.
And then you can put the probe in here
to look for a Bankart.
And if the patient has effusion, it'll be perfect
because then you could really catch a torn labrum,
or maybe even a bony chip of the Bankart.
I'll take the next question, Daniel.
- [Daniel] Great.
I think that about does it for our time.
And, let's see, one more, hold on, we have one.
Okay, I'm gonna address one of the questions offline
because it has to do with biologics and
(drowned by audio cutting out).
It has a specific stance on biologics,
so we can't really tie our name to it.
So I'll go to the next one.
"Where do you place the probe
"when you do a ultrasound guided bursal injection
"and we'll say in a maybe interarticular injection."
And I'll also preface that by saying we do have our prior
webinars on that.
I apologize they're not posted to the web, yet.
So I could email that.
So we've already addressed that in webinar,
unfortunately it's not posted.
So I do...
I do apologize for that.
- [Antonio] We could take a quick look at the image
that you prepared and let's take a look at
usually this image here would be great.
So this is a short axis view.
You go from the acromion to the greater tuberosity,
go back to the acromial level.
And here you can see the convexity of the tendon.
And here you see the subacromial subdeltoid bursa.
So we usually inject by approaching it externally,
if you look at the model now.
So the needle would be from this start going into
the subacromial subdeltoid bursa.
And you could see the bevel and the whole works
in those individuals.
Okay?
- [Daniel] Okay, great.
And Dr. Bouffard, do you have anything to add to this group?
Any words of wisdom?
- [Antonio] The words of wisdom
is for the posterior shoulder.
Remember that they usually look at the glenohumeral joint
for our injections.
And so if you take a look again one more time,
you identify the joint line of the bony glenoid socket,
and the convexity of the humerus.
And you can approach
from a lateral medial approach trajectory
where you can just clip the tip of the fibrocartilage
of the glenoid labrum.
Or you could also approach from a medial to lateral.
Or now you could see that I could just cap
and I could just pierce the capsule in order
to do my injection or my aspiration in those individuals.
I think part one was excellent,
where you covered the anterior shoulder
and lateral shoulder.
And then the part two completes it.
And most of the examination
should be done in about 10 minutes
to 15 minutes, maximum,
and, therefore, if you really wanted to be
a musculoskeletal physician,
somebody who takes care of the musculoskeletal system,
you have to know musculoskeletal ultrasound.
And also I wanna thank everybody
for spending part of their Saturday and weekend with me.

Brightcove ID

5768936512001

https://youtu.be/WzkiVfEg3qw

Ultrasound Diagnostic Shoulder Exam Part 1

Read more about Ultrasound Diagnostic Shoulder Exam Part 1

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Dr. Benjamin DuBois, MD is a board-certified and fellowship-trained orthopaedic surgeon who devotes 100% of his practice to the treatment of shoulder disorders. Dr. DuBois has expert training in shoulder surgery, and has extensive experience in shoulder replacements, rotator cuff disorders, and arthroscopic shoulder surgery. He is trained in state of the art techniques including the reverse ball and socket shoulder replacement and performs in-office shoulder ultrasound for the immediate diagnosis of rotator cuff disorders. This Webinar focuses on Diagnostic Shoulder Ultrasound Part 1. Additional information about Dr. Benjamin DuBois can be found on his website sandiegoshoulderdoc.com

Publication Date

Tue, 09/11/2018 - 12:00

Media Library Type

Other Videos

Subtitles

- [Ben] Surgeon and shoulder specialist
in the San Diego area, and I've been in practice
for about nine years here, since about 2004.
I actually got involved with musculoskeletal
'cause I first learned how to do it in 2003 and 2004
when I was doing my shoulder surgery fellowship
with Dr. Rick Mattsen at University of Washington.
That's where I did all my training,
residency, and fellowship in.
My experience was a little bit different
than your experience.
There wasn't anything fancy like this
back then for guys like me.
Basically, I just taught myself originally how to do this,
and this was around the time when the first generation
of affordable laptop ultrasounds became available.
So I basically just lugged the thing
around my fellows clinic and asked my patients
whether I would be able to scan their shoulder.
So I actually learned how to do the diagnostic aspect
of this first, years before I actually using it to do
the ultrasound-guided injections.
Now in my practice, I would say it's probably 70-30
for injections versus diagnostic.
Diagnostic exams I do still utilize ultrasound for.
I use it quite a bit
for my post-operative rotator cuff repairs.
I do a lot of rotator cuff repairs,
and as you guys are probably aware, trying to look
at a post-operative rotator cuff integrity
after surgery with an MRI can be very challenging
because of the artifact,
whereas in ultrasound, there's no artifacts.
I use it a lot for that.
And so, that's kind of where I'm at now.
I've been teaching these courses for several years,
probably going back to six or seven years
I've been putting on seminars and teaching courses.
And so I would recommend, if you're just getting started
out, I think at this point it's a little bit easier
to learn how to do some of the injections first
before you start really getting confident
in your ability to do diagnostics.
Doing diagnostics takes a while,
because there's two aspects.
One, we have to know how to physically do the exam,
you know, hold the probe appropriately,
find the structures that you wanna look at.
That's half of it.
The other half of it is interpreting what you see.
So a lot of people who don't have much experience
with ultrasound, the first time they look at this stuff,
you really don't even know what you're looking at.
So that takes some time, usually a few months
or maybe a hundred exams to really get good at it.
So today, we're not going to cover everything.
Like Dan said, we've only got a finite amount of time.
So the first part of the shoulder exam
that we like to talk about is looking
at the anterior structures and the lateral structures.
And this is usually where most of the pathology
is going to be in the shoulder.
Typically, when I'm seeing a patient in the office,
it's one of just a few different diagnosis.
Number one's a rotator cuff tear.
Number two is bicipital tenosynovitis.
You know, there's some other things we can see.
But the main pathology you're gonna see on ultrasound
is typically in the subscap, biceps,
and supraspinatus range.
And so today, talking about the rotator cuffs,
we're gonna focus
on the subscapularis and the supraspinatus,
and then the non-rotator cuff soft tissue structures
are the biceps, the biceps groove,
the transverse humeral ligament, the bursa,
and briefly on the coracobrachialis
and the short head of the biceps.
So, focusing on the anterior shoulder,
I always start the exam in the anterior shoulder.
The things that we're interested here is the biceps groove.
That's usually what I look at first.
I'll hold a probe transverse
right over the bicipital groove,
rotating the patient's arm starting at about neutral
to try to center the biceps
in the center of my ultrasound screen.
So I'd like to see the biceps first.
I can see the transverse humeral ligament overlying that.
The subscap is gonna be just medial to that,
where it inserts into the lesser tuberosity.
You can follow the biceps tendon down the arm distally
until you reach the musculotendinous junction,
but typically, the pathology that you're gonna see
is gonna be up in the tendinous portion
of the biceps tendon.
So, let's start on the biceps.
Now, you can see in the upper-left part of the screen,
you're going to be holding the probe transverse
or parallel with the floor,
directly overlying the anterior shoulder.
And so the goal is to get that biceps groove
and the biceps tendon centered on the screen.
So, you see here in that middle ultrasound image
on the left, that's exactly what we wanna see.
Superficial is skin.
Going deeper is a little bit of fat.
Deeper to that in the red is the anterior deltoid muscle,
and then deep do that,
you're gonna get a bright cortical line.
That's the cortex of the anterior humerus,
and you're gonna get a groove in the bone,
which you can see clearly on the left in the two images.
And inside there,
you're gonna have the biceps tendon itself.
And there's something called anisotropy
that a lot of you are probably aware of.
You wanna make sure that your probe
is perpendicular to the biceps tendon.
Go ahead, next.
So, this is just kind of a zoomed in version
of what we just saw.
So you're gonna see skin at the top.
I think we've got...
Someone's not muted.
I hear a little kid out there somewhere.
I don't know if you guys can hear that.
So if you're not muted, if you don't mind muting your phone,
'cause I'm getting something coming from somewhere.
So the anterior shoulder, you can see skin at the top.
Yellow's a little bit of fat, subcu tissue.
The red's the anterior deltoid,
and then getting a little bit deeper,
you're gonna see a white line
going across the anterior humerus.
That's the transverse humeral ligament.
And so basically, that's the ceiling of the bicep sheath
where the biceps tendon's gonna run.
And so that's gonna contain
the fluid of the bicipital sheath.
The biceps tendon appears as either a circle or an oval,
depending on whether there's pathology involved with it.
And so, it's normal to have a little bit of fluid,
which is gonna show up being dark
surrounding the biceps tendon.
There's a normal physiological amount of fluid
that surrounds the biceps tendon, because the sheath
communicates with the shoulder joint itself.
So you're gonna get synovial fluid coming from the joint
pumping down this sheath and surrounding the biceps tendon.
There is an ascending branch of the circumflex
humeral artery, which, if you turn on your Power Doppler,
you may see pumping in there.
But it's something I don't really pay much attention to
unless I were to do an ultrasound-guided injection,
where I don't want to stick the tip of my needle into it.
Next.
Medial, you're gonna see what we call the conjoint tendon,
which is the coracobrachialis
and the short head of the biceps.
And if you go distal to the tip of the coracoid process,
these are gonna be muscular structures.
And so if you put your probe over tip of the coracoid
and go distal, you're just gonna run into a bulk
of muscle there, which is the conglomeration
of the coracobrachialis and the short head of the biceps.
Next slide.
After you're satisfied with your transverse view,
you're gonna turn the probe gently 90 degrees
to where the probe is now vertical.
And so it's basically perpendicular to the floor.
The best way to do this is to once again
center the biceps over the center of the screen
and then turn the probe slowly.
And as you do this, you're turning the image
from an axial type of image to a sagittal type of image.
So now it's as if we're looking
at the shoulder from the side.
So it's the equivalent of a sagittal image on an MRI.
And so in the lower part of the screen,
what you're gonna see at the top of that image
is skin, a little but of subcu fat,
the anterior deltoid going deeper,
and then you're gonna see the biceps tendon itself,
the fibers of it running proximal to distal,
which is where the green structure is,
and this part of the tendon is usually just tendinous.
If you kept going distal,
you're gonna run into the musculotendinous junction,
which is not shown here,
but this is typically where the pathology is
and typically, if you're gonna see an effusion
around the biceps, this is where you're gonna see it.
So I think that this is probably the hardest image to get
on a shoulder ultrasound,
because it's a thin structure,
and your probe beam coming out of the probe
is a pretty thin beam.
And so you've gotta get two thin structures
perfectly parallel to one another,
and that can be a little bit of a challenge.
So if you can get this good image like we see
in the left lower part of the screen,
you're doing pretty good.
Next image.
So, this is now a zoomed-in version.
The yellow at the top is superficial.
The top of the screen is superficial;
the bottom screen is deep.
So the top, you're gonna just see the skin,
a little bit of fat.
The red is the anterior deltoid,
and going deep to that, in between the second
bottom blue line which is the cortex of the humerus
and the top light blue line,
which is the outer sheath of the bicep sheath,
in between is the biceps tendon.
And you can see a little bit of bursal tissue
just superficial to it
if you get closer up towards the shoulder joint itself,
but here, we're a little bit distal,
so you may not see a lot of bursal space.
So, moving along the subscap.
This is the second structure
of the anterior shoulder that we're really interested in.
Once again, you're gonna go back holding your probe
transverse or parallel to the floor.
The best way to visualize a subscap is to either have
the patient externally rotate their arm
or you passively externally rotate it for them.
The reason for that is as the patient's sitting there
with their arm internally rotated,
the subscapularis insertion is gonna be medially rotated
so much, you won't actually be able
to see the subscap at all.
It's rotated out of your field of view.
So you wanna externally rotate the arm.
And as you do that, you're delivering the lesser tuberosity
into the field of view,
what you see in the bottom part of the screen,
and then you're going to see the subscapularis appear,
which, on the top part of the screen,
you can see that green area there.
That's the thickness of the subscapularis as it's inserting
in its broad insertion on the lesser tuberosity.
And so this is a pretty thick tendon,
and one that we don't typically see a ton of pathology in,
unless there's a couple situations.
One's a massive rotator cuff tear,
where someone's already torn their infraspinatus
and supraspinatus and the subscap is next to go.
There are situations where we have
isolated subscap ruptures and biceps dislocation.
Those are not that common.
I've probably seen five or six of them in nine years.
Isolated subscap ruptures are just not all that common.
Next slide.
So, over on the right is the video clip
of that motion that we're talking about.
If you initially start with the arm neutrally rotated,
you're gonna see the biceps in the center of the screen.
As you externally rotate,
you're gonna see that subscapularis appearing
out from underneath the coracoid tip,
which is the dense, white structure
on the very right part of the screen.
So the subscap's kind of hidden in there
until you externally rotate the arm,
and you'll see as it comes out from underneath there,
you get a really good view of the insertion of the subscap.
Next slide.
Taking just a bit of a delay here.
Be patient with us while the bandwidth here catches up.
There we go.
So, you're gonna go from a transverse view now
to a sagittal view.
And so, as you rotate the probe
from being parallel to the floor to being perpendicular
to the floor, you're basically turning this image
from an axial type of cut equivalent on an MRI
to a sagittal type of cut.
And so this is one of the challenges
of diagnostic ultrasound is depending on how
you position the probe, that's really telling you
what type of view you're gonna get.
Really, if you boil it down,
there's only three views you're gonna get.
It's just like an MRI.
You're gonna get an axial view, a sagittal view,
or a coronal view.
So if you can keep that in your mind
that it's gonna be one of the three, unless you rotated
your probe halfway in between two of them,
it's gonna be one of those three.
So that's an easy way to kind of simplify it.
Go back to what you're familiar with,
which is, for most of us, looking at MRIs.
You're gonna get the same views on ultrasound, only you're
in charge of the positioning of the probe to get there.
So what we have now is as if we're looking
at the shoulder from the side.
And so over on the left,
proximal would be to the left.
Distal would be to the right.
In the green are there are these bundles of collagen
fibers of the subscap kind of running right at you
before they attach to the lesser tuberosity.
So the probe is actually medial to the lesser tuberosity.
So you're kind of in that tendinous bulk of the subscap.
That's what it looks like.
So at the very left part, that green,
that's gonna be the upper border of the subscapularis.
Next slide.
So, moving onto the lateral shoulder,
this is usually where the money is.
I spend most of my time in my exam here
looking at the supraspinatus and infraspinatus.
But this is where most of the stuff
that we're doing in the office is gonna be focused on.
We're looking at supraspinatus tendon,
the bursal area.
You can look at the greater tuberosity
for calcitic tendonitis in this area,
and it'll touch on a little bit of the infraspinatus.
Next slide.
So the basic anatomy here.
Starting at the biceps anteriorly,
that's just another little key here.
If you ever get lost on shoulder ultrasound,
which, as you're starting out, it's very easy to do.
You get lost on where exactly you are
and what exactly you're looking at.
If you can go back and find the biceps tendon,
that'll really let you reorient yourself to where you are.
Because if you can clearly see the biceps,
you know that you're just anterior to the supraspinatus,
where most tears are gonna occur,
and you're just posterior to where the subscap is running.
And so you're in the area called the rotator cuff interval.
So if I ever get lost,
or when I'm teaching other people how to do this,
they get lost, I go, go find the biceps.
Once you re-orient yourself,
you can kind of hit the reset button.
So, what we're really focused on here
is the rotator cuff insertion of the supraspinatus
and the bursal structures that are surrounding it.
So the tuberosity, most of the time,
when I start my exam, I'm gonna be starting
my supraspinatus view very far anterior.
So I'm actually gonna be starting right over the biceps.
'Cause if I know that I can see the biceps,
once again, I know that I'm just anterior to where most
of the tears of the supraspinatus are gonna occur.
So, if I start at the biceps and then start sliding
or scrolling my hand posterior and bringing the probe
back just a little bit,
we're going to end up over that little blue area there,
which is the anterior insertion of the supraspinatus,
which is where most of the pathology occurs.
As you keep sliding around the back,
you're going to get more to the middle and posterior
aspect of the supraspinatus and then into the infraspinatus.
And we're not really going
to the back of the shoulder today.
That's for the February webinar.
Next.
So once again, you're gonna be able to get
either a sagittal view of the supraspinatus
or a coronal view of the supraspinatus.
And so we're staring out here with the sagittal view.
So the sagittal view is the equivalent of as if
you're looking at the shoulder from the side,
so viewing from lateral to medial.
So, if you look at where these little lines are,
the blue line, the yellow line, and the purple line,
the blue line is you are more medial to the insertion
of the supraspinatus, so you're actually gonna be
over the top of the humeral head.
So that upper blue box right there is giving you
a sagittal equivalent, and once again, focus on the biceps.
Where's the biceps?
It's that little circular structure that says BT.
And so if you see that, you know that just to the left
of that is the anterior aspect of the supraspinatus,
which is the thickness between the dense line,
which is the cortex of the humeral head,
and there's a second, less-dense white line
which represents the outer surface
of the supraspinatus and the subdeltoid fasciae.
And so that's a pretty healthy,
thick-appearing supraspinatus.
And as you start to go more posterior with your view,
you're going to get into the infraspinatus.
Now, the yellow box is if you were to bring your hand
and the probe a little more lateral.
And as you bring the probe more lateral,
now you're gonna be actually over the anatomic footprint
of where the tendon's attaching,
and it's normal for this tendon to start to thin out
or peter out at this point in time,
because you're reaching kind of the lateral terminal limit
of where the tendon exists.
And so it's normal to kind of have this thing
peter out until you get to the purple box,
which is now, you see, no tendon.
Basically you're just over the very lateral aspect
of the greater tuberosity,
where there is no rotator cuff insertion anymore.
You're lateral to where the limit of the insertion is.
Next slide.
So, now we're switching
from the sagittal view to a coronal view.
This is where I spend most of my time in my exam.
So one of the keys here, well, you don't have the video,
but you're gonna reposition the patient's arm,
because if the patient's just sitting here
resting with their arm in their lap, a lot
of the supraspinatus is actually underneath the acromion.
And your ultrasound waves are not going to go
through the bone of the acromion.
So you need to deliver out
the insertion of the supraspinatus
out from underneath the acromion.
So, what I'll have the patient do is essentially
put their hand on their hip or their upper thigh
and then bring their elbow kind of back.
So what that's doing is extending their arm,
allowing that insertion of the supraspinatus
to be delivered out from underneath the acromion.
And so once again,
I always start in the very anterior aspect here.
So I'm holding my probe parallel
to the way the fibers are running in the supraspinatus.
So this is gonna give me a nice coronal view.
So the blue line over to the right
is where I would typically start,
which is just very far anterior.
In the blue box at the top of the screen,
this is what it looks like.
You're actually over the biceps tendon.
So if you see a little bit of biceps,
and it's hard to see on just one static image,
but you'll see a difference if you're doing this live.
You know the difference between what the biceps looks like
and what the supraspinatus looks like.
If you get it over the biceps, you know you're good,
because you're gonna be just anterior to the supraspinatus,
and then I'll start to slide the probe
slowly posteriorly, and as I do that,
I'm gonna hit that area that's represented by the yellow.
And so this is a perfect coronal view of the supraspinatus.
And so, to the left of the screen is lateral,
or the outside part of the shoulder.
To the right of the screen is gonna be medial
towards the head where that little blue dot is.
That's medial.
And so, we see a very good image here
of skin, fat, anterior deltoid, and then down below,
the yellow line is the cortical bone
of the humeral head and the greater tuberosity,
and just superficial to that
is the insertion of the supraspinatus.
So that whole thick structure just superficial
that we've got the mouse over, that's the supraspinatus.
And so this is where most of the pathology
you're gonna experience, you're gonna see it right here.
And you can see that broad insertion of it
all the way along what we call the anatomic footprint.
The bottom box is when you keep bringing your probe
posteriorly, and you'll notice, the architecture
of the anatomy of the tuberosity
of the tendon itself start to change.
So, you get this flattening out of the greater tuberosity.
You get kind of a thinning out of some of the supraspinatus,
and then once you get back into the infraspinatus,
it'll change even more.
Next slide.
So, people always,
a lot of people think that the bursal space
is this big old space that's filled up with all this stuff.
And under normal circumstances, that's not true.
There's barely anything in there.
And so an ultrasound, the vast majority of the time,
unless you're dealing with someone
with a big subacromial fluid collection,
you're really not going to see much of a space.
It's more of a potential space.
Think of it like a deflated balloon.
Most times I do ultrasounds, I'm gonna see
deltoids basically touching the supraspinatus.
And so, you're not gonna see the giant space.
And people wonder why, you know, it can be difficult to get
a needle in there when you're doing a subacromial injection.
The reason is there's usually not much in there.
And so, this blue area here
is just representing the bursal space,
which really, it's, we call it the subacromial space,
but it's much more than that.
It goes way anterior, way posterior,
medial, and so, it's more of an area
that kind of circumferentially surrounds
the humeral head and the rotator cuff.
And then it all communicates with itself.
Next slide.
So, over on the right,
once again, we've got this color-coded deal here
where superficial is gonna be the top of the screen,
and that's gonna be yellow,
which is just a little bit of subcu tissue, fat.
The red's gonna be deltoid,
and let's skip the bursa for a second.
Going deeper to that, in the green is going to be
the supraspinatus tendon, and then bone.
Over to the left in the actual ultrasound image,
what you see here is skin, fat, deltoid,
supraspinatus, and you're gonna see,
where that little white star thingy is,
that represents the subacromial space.
So there's this little dark rim that is separating
the outer surface of the supraspinatus
and the undersurface of the deltoid, which is
a dense fasciae called the subdeltoid fasciae.
Those are the double white lines you see right there.
In between, there's this little dark area.
That's the subacromial space.
And most of the time,
it's gonna look something just like that.
There's not a lot of fluid in it.
There's not a lot of space in there.
It's more of a potential space.
Next.
So, as we turn from the coronal image
which we just had to the sagittal image,
which is turning your probe 90 degrees,
you're gonna get there on the bottom left,
that image.
So if you look to the color-coded diagram
again on the right, same thing.
Little bit of skin, little bit of fat,
deltoid, and then you're gonna get the supraspinatus
where it's labeled there just posterior to the biceps.
Once again, if you focus on where the biceps is,
you can see it very easily on the image on the left.
Just posterior to that is gonna be the supraspinatus tendon,
anterior middle, and getting back
into the posterior aspect of it.
Now, just to the right of the biceps,
sometimes you can see it very clearly,
a lot of times you can't,
is gonna be the upper border of the subscapularis.
So, really, what you're looking at there
is the rotator cuff interval area.
Next.
So, this is a diagram of the insertion of the supraspinatus.
And so most of the time,
when we're looking at the supraspinatus,
you're going to be dealing with the tendinous portion of it.
Really, we don't get much of the muscle of it at all
with ultrasound.
That tendon comes across,
it's draped over the top of the humeral head,
and it attaches to this thing called the anatomic footprint,
which is a very broad area on the greater tuberosity.
And so when I'm doing rotator cuff repairs,
during surgery, this is exactly where the tendon
has torn away from, where our mouse is there.
Tendon tears away from the bone, and it retracts.
Next.
We try to break up the tendon into a couple different areas.
The bursal surface is the outer surface.
So if I'm doing a surgery and you hear about people
doing subacromial decompressions and bursectomies,
my arthroscopic camera would be
just on the outer surface of that bursal surface.
So I'd be looking down, kind of a bird's-eye view from above
at that bursal surface of the tendon.
The articular surface,
which is the joint-sided surface,
is something that if I had a camera
inside the glenohumeral joint,
that's where I would see that insertion,
on the undersurface of the supraspinatus.
Then in between is an intrasubstance area,
which is oftentimes,
it's not visible when we do an arthroscopy.
So you can have an intrasubstance type of tear
and not actually be able to see it
during arthroscopic surgery
because it's kind of hidden from both bursal surface view
and the articular surface view.
So now we're gonna move onto a little bit of pathology.
Start on the biceps.
So, biceps, we see a lot of pathology in the biceps.
Most of the things that you're going to see
are going to either be biceps tendinosis,
which will represent itself as just being
kind of a thickened, abnormal-appearing biceps tendon.
You can get tenosynovitis,
in which you're going to get a thickened,
inflamed tendon with a lot of surrounding effusion.
You can get a tear of the tendon,
either a partial tear or a full tear.
Over on the left of the screen,
if you're noticing here, we've got our probe vertical,
which is gonna give us a sagittal or a lateral type of view.
There is our familiar image on the bottom left,
which is the sagittal view.
So the patient's head would be to the left.
Their feet would be to the right.
It's as if we're looking from the side.
And that's a pretty normal-appearing biceps.
You don't see a lot of fluid or anything like that.
It doesn't look torn.
You can actually see the collagen fibers of the biceps
running left and right.
So it's a pretty nice looking biceps.
Over to the right there,
you've got a situation where there's a significant amount
of fluid in the sheath.
And so that black area represents fluid.
And so remember, this takes some getting used to.
On MRI, a lot of fluid shows up as being white.
So when you have an MRI,
and there's a big effusion, it's white.
Ultrasound's the opposite.
It's black, or it's dark.
And so that right there
is a lot of fluid in the bicep sheath
that that biceps tendon's kind of swimming around in.
So, if I were to do an ultrasound-guided injection
of someone's biceps sheath for tenosynovitis,
if I see that image right there, my target is that fluid.
I wanna put the tip of my needle right in that fluid.
Next slide.
You can also get some calcium formation
in the biceps sheath.
Oftentimes, you'll actually see this on x-ray.
They'll have a few little calcium deposits
that are directly anterior.
Sometimes you won't see 'em
unless you did an axillary lateral x-ray view.
This is different than calcitic tendonitis
of the supraspinatus.
And oftentimes, what this represents is, you know,
someone will have arthritis of their shoulder joint,
and sometimes it can get some little bone spurs
that have fractured off,
and they get pumped down this sheath,
and they can accumulate right surrounding the biceps tendon.
So that's what it can look like
just kind of massive calcium deposits,
just superficial to the biceps tendon.
Next.
So now what we've done is we've flipped our probe
to be parallel to the floor again,
which is gonna give us that axial view.
It's the axial equivalent of an MRI.
Upper right part of the screen,
you're gonna see that image where we can see
a little biceps tendon kind of floating in a sea of fluid.
So, that is in effusion of the biceps.
Now, I got one thing to say about that.
Don't assume automatically 'cause you see an effusion
around the biceps tendon that the problem
is all because of the biceps tendon.
Remember, the sheath communicates with the joint itself.
And so I see this quite commonly in people
who have osteoarthritis of the shoulder,
and if I ultrasound them,
their biceps actually doesn't look all that bad,
but they've to this big effusion.
It's because they've got a big joint effusion
because of the arthritis that's getting
hydraulically pumped down this sheath.
And so, it may be a combination of both.
It may be a biceps and arthritis, but you'll see this
quite commonly in people with glenohumeral arthritis.
Synovitis, if you turn on your Power Doppler,
which is a feature on your machine,
oftentimes you can see this enhancement, and these vessels
really, really on fire in the biceps sheath.
And that would be a good candidate for an injection
into the biceps sheath under ultrasound guidance.
Next slide.
So, ultrasound, I think ultrasound's superior to MRI
to really look carefully at the pathology of biceps.
You get a lot better image quality.
I mean, if you look carefully at MRIs on the axial view,
the biceps barely shows up.
I mean, it's just this little black dot.
I mean, you can barely see it oftentimes,
whereas an ultrasound,
you really get fine detail.
I mean, you can actually see the split tears in the tendon.
So you'll see two,
basically two separate bundles of the biceps,
and that's represented by some of that joint fluid
kind of seeping in between into the tears.
So you'll get this kind of double circle
with a darkness in between, and that darkness
is the fluid that's creeping into the tear.
Next slide.
So moving along to some biceps instability.
I can tell you right now,
when someone has a dislocation of their biceps,
it's not subtle.
These things typically are mega-dislocated medially.
I mean, they're completely out of the groove,
like you see here on that MRI image.
So this is an axial cut on an MRI,
so looking down from above.
The humeral head is the the right.
The glenoid is to the left.
And that oval, flattened oval right there
that we've got the cursor over,
that is the long head of the biceps.
That belongs in the biceps groove,
which you notice is completely empty.
And typically how these occur is someone's got
a massive rotator cuff tear,
either a combination of the supraspinatus, infraspinatus,
subscap tearing, and then they immediately dislocate
their biceps, or this can be an isolated subscap tear
with a medial dislocation of the biceps.
In my practice, it's most commonly the latter,
or the former.
It's usually just a massive tear.
And so on your ultrasound image on the left,
you have an empty biceps groove to the right,
and then you'll have this white oval,
which is essentially completely dislocated medially
over the lesser tuberosity,
incarcerated into the joint space.
And so that's what you're gonna see.
To the right of the screen,
you can have situations where the biceps tendon
is not frankly dislocated,
but maybe there's a split tear of it proximately,
or it's subluxed, like you see at the bottom of the screen
where it's kind of up and over the rim
of the lesser tuberosity, but you can tell
that it's not frankly sitting in the biceps groove.
This may represent a partial tear of the subscap
as well as some medial instability of the biceps,
but typically these patients are gonna have pain anteriorly.
That's where their symptoms are gonna be,
and usually, they've got a history of trauma.
If someone comes to see you and you've got a weird-looking
biceps on ultrasound but they've got no history of trauma,
it makes you wonder what's really going on,
because these things just don't dislocate by themselves.
It usually takes some pretty significant trauma.
So, this is just to give an example
of some post-operative biceps.
So, if you were to try to do an MRI of the biceps tendon
after biceps tenodesis or something involving the biceps,
you won't be able to see anything.
Here, you can actually see the anchors that are in the bone.
So the lower left, that little area
which looks like little concentric ridges,
that's actually a suture anchor that's down inside the bone.
That's what it looks like.
You'll see a hole in the cortex,
and you'll some little structure down below.
These things are like big metal or plastic screws
is essentially what they are.
Suture can show up being either like a white dot,
if it's running right at you
or in the lower part of the screen,
you'll see this white thing right there.
That suture as it's leaving one hole and grabbing ahold
of the tendon.
So these suture that we use during surgery
are non-absorbable typically,
and they're nice, thick kind of a nylon type of suture.
They're gonna be in there forever,
and they really show up on ultrasound well.
Next slide.
So I think we've got a couple of video clips here.
So on the left, we've got the Power Doppler box turned on.
And this is a post-operative case where you can just
really see the things that are revved up in there.
You're gonna see a lot of pulsing of the arteries
surrounding the biceps.
On the right side of the screen,
you're going to see a large effusion surrounding the biceps.
So that's more now like a sagittal view on the right.
You can see the biceps just superficial to the cortex
of the humerus running down the arm,
and it's surrounded by a lot of fluid,
which is a darkness,
and there's a nice little trick you can do
which is compression.
So you can actually, with your probe,
push down on the skin,
not super hard, but a little bit,
and what that does,
it'll compress that area of effusion.
So sometimes you can't really tell what you're looking at.
You're going, gosh, is that fluid or is that not fluid?
You do a little compression test, and it'll
kind of squeeze some of that fluid out of your way.
And so, very, very common, if I were to ultrasound all
my patients how have had recent surgery within, you know,
a month, they all have effusion.
They all have fluid in their subacromial space.
They all have fluid surrounding their biceps.
It's all part of the normal healing process.
So if you're seeing patients in your office
that are three weeks after a shoulder surgery,
arthroscopic or open or whatever,
and you see a bunch of fluid in there,
that's pretty normal.
I mean, most people have that for, you know,
four to six weeks after surgery, sometimes even longer.
Next slide.
We're experiencing just a little delay here.
Thanks for your patience.
Okay, so, looking at the subscap again.
So remember our anterior shoulder anatomy.
If you've got your probe transverse,
it's gonna give the equivalent of an axial view.
So over on the left side of the screen,
just to reorient yourself, biceps groove to the left,
you're gonna have your subscap tendon
inserting into the lesser tuberosity
kind of in the middle part of the screen,
and to the very right, it's going to be
that conjoint tendon area, which is the short head
of the biceps and the coracobrachialis.
So, if you look at the bottom of the screen,
that is the equivalent actual ultrasound image.
So you can see some thickness to the subscap.
Now a lot of people will have some calcification
of their subscapularis.
What that is gonna appear is like over here
on the right side of the screen,
you see little dots, and those dots represent
little calcifications of the subscap.
Just clinically speaking,
I don't...
These don't tend to be very symptomatic,
compared to a large calcium deposit of the supraspinatus,
which, those patients, they're hurting bad.
They come into your office,
and they are hurting really bad,
whereas I've got a lot of x-rays and done ultrasounds
in a ton of patients who have a little bit of this,
which is just a little,
you know, calcification of the subscap.
That's usually not their problem, though.
That's usually clinically not why they're there.
It's just kind of an incidental finding oftentimes.
But it can be significant
if they have a supraspinatus calcium deposit,
and this may represent calcium that's already erupted
out of that and it's kind of lodged itself
in this subacromial or subdeltoid space,
just anterior to the subscap.
Next.
So, once again here,
we're looking at some post-operative pictures.
And not a lot of artifact.
That's the nice thing about ultrasound.
You're actually viewing a subscap
that's been surgically repaired,
and this becomes particularly helpful for me.
I do a lot of shoulder replacements.
And if you have a subscap rupture
after a shoulder replacement,
that could be a problem.
And so sometimes, you have a patient who comes in
maybe four to six weeks after surgery.
Maybe they fell.
Maybe they overdid it.
You're concerned about the integrity of the subscapularis.
You can easily put your probe on there,
and if I see this,
I'm happy, because what I see is
a nice, thick subscapularis attached
to the lesser tuberosity with some suture material,
which are those little white dots that you see
in the subscapularis kind of holding things together.
And so this, this, if I saw this on a patient,
I would be, I wouldn't be worried,
because I can see that the subscapularis is still intact,
the thickness of it is still intact,
and those sutures are exactly where I put them.
And there's not a big surrounding fluid collection.
So if you were to completely rupture off your subscap
relatively acutely,
you're going to see a big joint fluid extravasation
out through a hole accumulating superficial
to the subscap in between the deltoid,
and I don't see that.
So this would be, this would be very reassuring,
to see this image.
Next.
Subacromial bursitis.
I showed the subacromial bursal area before.
That image at the top that we have have the cursor on,
that's kind of representing where that potential space
of subacromial fluid is.
And so if you're doing an injection for subacromial bursitis
or a little partial rotator cuff tear or whatever,
maybe you did a diagnostic lidocaine injection
to see if the pain's coming from here,
really, the tip of your needle can go anywhere
along that entire area.
You can go lateral.
You can go a little medial.
You can actually go pretty medial with this.
It doesn't really matter.
As long as the tip of your needle
is getting in that subacromial space, you're good.
You can even go anterior, posterior.
So this stuff all generally communicates with itself,
unless there's some dense adhesions in there,
and in that case, you may not get
complete communication of all the areas.
And so, we'll see situations with mild bursitis,
which is down at the lower left part of the screen.
And so we see a little dark area,
it looks like a little dark oval.
That is fluid in the subacromial space.
So yep, right down there.
So that's a little bit of fluid.
If I were injecting this patient, I would stop right there.
I see my target.
I'm gonna hit my target.
Because I know if I can get my needle into that fluid,
that fluid is the subacromial and subdeltoid space.
So I would stop right there,
I would put my needle right in that,
and I would start injecting.
In the middle of screen, once again, you've got a little bit
of mild bursitis, where you're gonna see a little dark area
right where that cursor is,
which is just superficial to the supraspinatus tendon,
just deep to the deltoid.
And so once again, if I saw that,
that's my target to stick my needle in.
To the right of the screen is gonna be
a little more significant, where medially here
you'll see a big fluid collection there.
And so in that situation, once again,
I'm hitting that with my needle.
Next slide.
So, some rotator cuff pathology.
This is the most common thing
that we're gonna see is tough tears.
And this is really, for the most part,
I'd say probably 75% of why I'm doing shoulder ultrasounds,
is to look at the rotator cuff for tears.
So we see our normal anatomy at the top.
We've seen that slide a couple of times, that image.
At the bottom of the screen, what you kind of see here
is you can see a little dark area,
which represents and intrasubstance tear.
So this little dark area.
Now, there's something called anisotropy,
which is, it's kind of like an artifact on ultrasound
where if your probe's not perfectly positioned,
you may get an area of false hypoechoic area.
You can make anisotropy go away by moving your probe around.
You can't make a tear go away.
And of that's the key.
If you're viewing a tear on orthogonal views,
both sagittal and coronal, you cannot make it go away
like you would if you had an isotropy,
it probably is a tear.
And so that's a small intrasubstance tear.
The middle part of the screen shows a full thickness tear,
where you're actually doing to get a full defect
in the tendon.
So the supraspinatus would pull away
from the greater tuberosity,
and there's going to be this dark void in between.
And that dark void is joint fluid.
Now, sometimes, you'll get some other stuff in that void.
It may be a little bit of bursal tissue, things like that.
And so it may not always be completely black,
because there could be some scar formed in there
or some bursal tissue formed in there.
As far as calcific tendonitis goes,
to the right of the screen, you're getting this little area
of hyperechoic area within the supraspinatus tendon.
That's a little bit of calcific tendonitis
of the supraspinatus there.
It doesn't look...
It's hard to tell whether that tendon
is completely torn or not,
or whether this is just calcific tendonitis,
but that's what calcium looks like on ultrasound.
Next slide.
So, let's start over to the left.
This is a sagittal view,
so it's as if we're looking at the shoulder from the side.
Once again, the BT represents biceps tendon.
You've got yourself oriented.
Just to the left of the biceps is the supraspinatus,
that view from the side.
And so that little video clip there are the bottom,
what you're seeing is there's a little dark void
kind of within the substance of the tendon.
That is gonna be either an intrasubstance tear,
or if you were to stick a scope in there, you may find
that that does communicate with an articular-sided tear.
It's not 100% clear on this, but that definitely represents
an intrasubstance tear of the tendon.
To the right, we've got a coronal view.
And so we've flipped our probe now to get a coronal view,
and what we're gonna see on the top,
the yellow box looks pretty normal.
At the bottom, as this thing scrolls through,
I think I might have a bandwidth issue, with how slow it is.
But you're gonna, right there, I can see there's a void
in the intra, it looks like an intrasubstance area
of the tendon where there's a hypoechoic area.
You'll see a little dark area
just adjacent to the greater tuberosity right there.
Next slide.
- [David] And just a second on the bandwidth.
Apologize.
- [Ben] Okay.
And so, now we're moving onto some more significant tears.
So typically, this probably represents
a full-thickness tear,
and it's coronal on the right,
and it's a sagittal on the left.
And so let's focus on the right for a second.
What we see is the insertion of the supraspinatus
but you've got this sizable area of fluid,
this hypoechoic area, which, if you just do a static image,
you look at it and you go, well,
maybe it's not a full thickness tear.
Maybe there's a few fibers hanging on by a thread.
But that's a very significant tear right there,
and there's something you can do with this compression,
where you can actually, if you're not sure
whether this is a tear or whether this represents
an isotropy, you can actually, once again,
use this compression test where you're pushing down gently
with your probe and it'll squeeze the deltoid down
into the supraspinatus,
and that fluid collection will go away
as it's kind of forcing the fluid out from there.
And so that would confirm that this is a tear,
because you can't really compress
the normal supraspinatus tendon.
It's not compressible.
It's like a big, thick burlap sack.
But when you've got a void and a tear in it,
you can compress that and make that tear collapse.
That's what we're gonna see there in that video.
Next slide.
So, I think that, in a nutshell, this slide
is really telling you to focus on this area.
And the reason I say that is because the vast majority
of shoulder pathology, soft tissue pathology
of the shoulder, is occurring right here,
in this anterior supraspinatus.
So, I'll spend, I'd say 75% of my exam on this area.
I mean, I'll look posterior.
I'll look a couple other places.
And if it looks normal on first glance, I move on,
because it's very unusual, for example,
to have an isolated tear of an infraspinatus
or a problem with your teres minor.
Those are, you know, I just don't see those in my practice.
What I do see all the time is a tear of the anterior
supraspinatus or a biceps problem in this vicinity.
So I'll spend a lot of time in this area.
Calcific tendonitis.
We'll see partial tears.
We'll see full thickness tears, and so just make sure
that you spend an adequate amount of time on this area here.
Next slide.
Very common to see cortical irregularities.
I don't spend a lot of time on this.
This is something that you'll see on an x-ray as well.
You know, you get an x-ray of someone's shoulder
who's 50 or above, and you're gonna see
a lot of these little cortical irregularities,
which represents just some chronic bony changes.
And it's not, you know, it doesn't always represent
a tear pathology.
It's just something to take note of where,
instead of some of these earlier images
where we had that perfect, clean cortical bone
of the tuberosity and the footprint,
here, you're gonna get kind of this funny-looking,
I always equate to being kind of like a mountain range,
very rugged looking,
like you're looking at the peaks of the mountains.
That's what it looks like to me.
Just a very rugged appearing bone.
And it doesn't necessarily mean
that this corresponds to pathology.
It's just something to take note of
and to be aware of.
This is what it looks like.
Next slide.
Calcific tendonitis, very easily identifiable on ultrasound.
If there's a, you know, first of all,
you're gonna see it on x-ray pretty well typically.
Sometimes, the patients are very early on
in the development of this.
It actually doesn't show up very well on the original x-ray,
'cause it really has completely calcified.
It's more like a motor oil type of consistency.
Only later as it completely calcifies
will it be visible on x-ray.
So, what we see here in the lower left
is just a lot of this probably
has already erupted out of the supraspinatus.
You get this big, giant collection of calcium
in the subdeltoid space.
Some of it's probably still within the supraspinatus,
but a lot of it's probably erupted out already.
And that's when people have tremendous amount of pain.
The story's always the same, you know, someone saying,
I was fine, and then I woke up Saturday morning,
and it's like someone shot me in the shoulder.
It really is that impressive.
I think over there on the right, David,
correct me if I'm wrong,
it looks like we've got about a 35-gauge needle
kind of into that area of calcium and injecting in there.
Is that what that represents?
- [David] Yes, and I think that particular position
was loosening it up
to come in with a larger needle and aspirate.
- [Ben] Got it.
So, that's what a calcium barbotage
to prep it would appear like.
You're sticking the tip of your needle,
probably injecting a bunch of lidocaine,
flooding that whole subacromial space
and actually putting some in there
to kind of numb things up.
Next slide.
- [David] There we go.
Hang tight.
- [Ben] So, these are just
kind of a hodgepodge of some pathology.
Normal's in your upper left box.
This is a sagittal view.
Lower left is gonna be, to me, I mean,
if I just look at this rotator cuff tendon,
I just go, man, this thing's a mess.
I mean, in areas, it looks completely torn.
In other areas, it looks very thickened and tendinotic.
This is just a complex degenerative tear, probably,
of the rotator cuff.
The center part here is a post-operative,
where we're gonna see that anchor down into the bone
and a lot of those white dots
that represents the suture in the tendon.
And then, if people who come in
who've got a large, chronic rotator cuff tear,
the image in the lower right, this is what it looks like.
So this is gonna be basically a bald head.
It's gonna be deltoid touching humeral head,
where there should be a big, thick supraspinatus
and infraspinatus tendon in this vicinity.
There is none.
You're basically seeing deltoid touching
cortical bone of the humerus,
and if you see that, you've got a big
retracted, probably chronic.

Brightcove ID

5768921592001

https://youtu.be/mezZ0x5-D3s

Sonosite: 20 Years of Point-of-Care Ultrasound, Diku Mandavia, MD

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Sonosite's Chief Medical Officer, Diku Mandavia, explains what the early days of point-of-care ultrasound were like and how having a machine at the bedside changed the course of patient care.

Publication Date

Mon, 06/04/2018 - 12:00

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- If I reflect back in my career, in my training
at LA County Hospital in early '90s, you know, I was,
we were, frankly, overwhelmed with the trauma volume.
That was as the height of gang violence.
We needed technologies to assess these patients,
a large volume of them.
Ultrasound was a game changer.
But the environment itself was very challenging.
I distinctly remember one car accident victim
when we were thinking about doing a DPL,
I was able to take the transducer and look up
Morrison's pouch and find free fluid
and tell the entire team that it was internal bleeding.
The patient went to the operating room and survived.
And I remember seeing the first Sonosite device, and wow.
I mean, the Sonosite 180 is
a very different looking product.
I think it's incredible.
A lot of us look at this and say this is incredible.
We needed a device that wasn't intimidating
that could rapidly boot up and give us the answer.
Clinicians, many clinicians aren't looking for the image.
They're actually looking for that clinical answer
for the next decision point.
We were able to get those answers.
We were able to integrate this 180 into different areas
and that was the birth of really one company now
focusing on point-of-care ultrasound.
That was really what was missing.
I think that was an important part of the growth
of point-of-care ultrasound when you actually had
a company that was also going to be supportive
of those clinicians that were trying
to improve patient care.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=21BgM43j05A&p

Sonosite: This is Point-of-Care Ultrasound

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Sonosite: This is Point-of-Care Ultrasound

Publication Date

Fri, 05/25/2018 - 12:00

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- [Narrator] When time is of the essence,
you want an ultrasound you can count on.
We design our systems with clinician input
for intuitive controls, image optimization,
and extreme portability.
All so clinicians can provide outstanding care
to any patient anywhere, anytime.
(dramatic music)
We are Sonosite and this is point of care.

Brightcove ID

5508114785001

https://youtu.be/TYvoFQXaCps

Sonosite Veterinarian Testimonials: Dr. Richard Markell

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Sonosite Veterinarian Testimonials: Dr. Richard Markell

Publication Date

Fri, 05/11/2018 - 12:00

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(upbeat acoustic music)
- The Sonosite is remarkable in its ease of use.
It's really right out of the box, you get fantastic images.
Two weeks ago I had a group
accidentally spill a Coke on top of the machine
and it was no big deal.
With my old machine, I went through a motherboard
spilling water on it accidentally.
So the portability, the durability of the machine
and for me, most importantly, the quality of the image
is been a significant change in my use of ultrasounds.
To be able to have an almost instantaneous boot up,
and being able to look at every little
bump and lump that I can see in just a matter of seconds.
The number of cases that I can look at
has remarkably changed, I probably scan
20, 30 percent more horses because I can open the machine
and have an instant, quality image.
Its ease of use, different lighting,
the durability, and safety around the horses
has really changed the way I practice
and I know that the edge has made me a better doctor.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=IggX0X0YXTo

Sonosite Veterinarian Testimonials: Dr. Sammie Crosby

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Sonosite Veterinarian Testimonials: Dr. Sammie Crosby

Publication Date

Fri, 05/11/2018 - 12:00

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(bright music)
- I started out with Sonosite with an Mturbo,
used it for five years.
And then in the last year I traded up to an Edge2.
I like the Edge2 quite well.
It's got a bigger screen.
It has a better picture on it I believe.
The deal that Sonosite gave me for that was excellent.
The trade in on the Mturbo was good,
the value was great.
And technical support has been phenomenal ever since.
In fact, Natalie, the representative came up here today
and showed me a lot of things that
I didn't know about the Edge2
that were different than the MTurbo.
It was fantastic, she's always there on the phone,
and anytime I have a problem
I just have to call and she shows up,
or she calls back immediately.
As far as I'm concerned,
Sonosite's an excellent company,
and they make a great product.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=V_zQrY95BzE

Sonosite: This is Ultrasound Education

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Sonosite: This is Ultrasound Education

Publication Date

Wed, 04/18/2018 - 12:00

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- [Narrator] We believe in helping clinicians
use ultrasound with confidence,
whether it's through our SonoAccess mobile app,
Sonosite institute, or visual medicine workshops.
No other ultrasound manufacturer
has committed as many resources
to making sure clinicians have the right answers
at the point of care, and the confidence to act.
We are Sonosite, and this is education.
(soft music)

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=t-kLtXLU0jE

Sonosite: This is Ultrasound Reliability

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Sonosite: This is Ultrasound Reliability

Publication Date

Wed, 04/18/2018 - 12:00

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- [Narrator] Reliability.
To us it's the standard.
We run our machines through the toughest conditions.
(machine noises)
Dropped, frozen, shaken, baked, and shocked.
So they're built to deliver when you need them most.
With point of care ultrasound
down time isn't an option.
We are Sonosite and this is reliability.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=K3WgrpkbvHA

Sonosite: This is Ultrasound Durability

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Sonosite: This is Ultrasound Durability

Publication Date

Wed, 04/18/2018 - 12:00

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(dramatic music)
- [Announcer] With durability built
into every ultrasound system and transducer,
it's the details that matter,
from gathering diagnostics at extreme temperatures
to testing keyboard buttons over 190,000 times,
also our systems can survive a a three foot drop
and boot up within seconds.
We are Sonosite, and this is durability.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=VcuaaH_Fglc

Sonosite: This is Ultrasound Durability

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Sonosite: This is Ultrasound Durability

Publication Date

Wed, 04/18/2018 - 12:00

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Subtitles

(dramatic instrumental music)
- [Announcer] With durability built into
every ultrasound system and transducer,
it's the details that matter.
From gathering diagnostics at extreme temperatures
to testing keyboard buttons over 190,000 times.
Also, our systems can survive a three foot drop.
And boot up within seconds.
We are Sonosite,
and this is durability.

Brightcove ID

5508114785001

https://www.youtube.com/watch?v=VcuaaH_Fglc

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Ultrasound Diagnostic Shoulder Exam Part 2

Ultrasound Diagnostic Shoulder Exam Part 2

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Ultrasound Diagnostic Shoulder Exam Part 1

Sonosite: 20 Years of Point-of-Care Ultrasound, Diku Mandavia, MD

Sonosite: 20 Years of Point-of-Care Ultrasound, Diku Mandavia, MD

Sonosite: This is Point-of-Care Ultrasound

Sonosite: This is Point-of-Care Ultrasound

Sonosite Veterinarian Testimonials: Dr. Richard Markell

Sonosite Veterinarian Testimonials: Dr. Richard Markell

Sonosite Veterinarian Testimonials: Dr. Sammie Crosby

Sonosite Veterinarian Testimonials: Dr. Sammie Crosby

Sonosite: This is Ultrasound Education

Sonosite: This is Ultrasound Education

Sonosite: This is Ultrasound Reliability

Sonosite: This is Ultrasound Reliability

Sonosite: This is Ultrasound Durability

Sonosite: This is Ultrasound Durability

Sonosite: This is Ultrasound Durability

Sonosite: This is Ultrasound Durability

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