1. Intro to Musculoskeletal Ultrasound of the Shoulder
John Hill, DO
Tim Mazzola, MD
University of Colorado
Office Based Sports Medicine
Saturday, May 17, 2014

2. Disclosure Statement Newton Shoes: Physician Advisory Board
MuscleSound: Physician advisor for software development to determine muscle glycogen content.

3. Objectives
Discuss the normal ultrasound appearance of the shoulder and the individual structures
Describe the AIUM standard shoulder exam
Discuss the uses of dynamic imaging

4. The Standard Examination
Shoulder
The Standard Examination

5. Sonography of Shoulder
Complex structure containing
Muscles
Tendons
Bursa
Bone
Labrum
Fixed and Dynamic evaluations

6. Sonography of Shoulder
Physician Practice Guideline is established by AIUM & ACR for the Shoulder U/S
Biceps tendon
Subscapularis tendon
Supraspinatus tendon
Infraspinatus tendon
Teres minor
Dynamic evaluation

7. Sonography of Shoulder
Examination of:
Joint effusions
Bursa effusions
Comparison of contralateral side
Evaluate for:
Bursal thickening
Loose bodies
Tendon calcification
Muscle & bone abnormalities

8. Biceps Tendon- Short Axis
Transverse
Normal transverse
Normal Notch view

9. Biceps Tendon- Short Axis
Transverse
Chronic Tendinopathy
Acute Tendinopathy

10. Biceps Tendon - Long Axis
Normal Biceps LA
Normal Long Axis

11. Biceps Tendon - Long Axis
Chronic Tendinopathy
Fluid in tendon sheath
Long Axis
Acute Tendinopathy

12. Long Head of Biceps Tendon
Normal internal/external motion
Normal long axis appearance

13. Is there subluxation of the Long Head of Biceps Tendon?

14. Subscapularis Tendon
Instruct patient to place their arm in full EXTERNAL rotation
Sagittal view (Short axis)
Short Axis view of Subscap
Short Axis Subscap

15. Subscapularis Tendon
Instruct patient to place their arm in full EXTERNAL rotation
Transverse view (Long axis)
Long Axis view of Subscap
Long Axis Subscap

16. Subscapularis Tendon
Instruct patient to place their arm in full EXTERNAL rotation
Transverse view (Long axis)
Sagittal view (Short axis)
Short Axis view of Subscap
Long Axis Subscap

17. Supraspinatus Tendon
Instruct patient to place their arm in INTERNAL rotation
Place hand in back pocket
(Long axis)45 degrees Coronal/ Sagittal
SST WNL
SST Normal Long Axis view

18. Supraspinatus Tendon
Instruct patient to place their arm in INTERNAL rotation
Place hand in back pocket
(Short axis) 90 degrees Rotation of long axis
SST, internal shoulder rotation SA view
SST Short Axis WNL

19. Supraspinatus Tendon
Instruct patient to place their arm in INTERNAL rotation
Place hand in back pocket
(Long axis)45 degrees Coronal/ Sagittal
(Short axis) 90 degrees Rotation of long axis
SST WNL
SST with Tendinopathy

20. Supraspinatus Tendon-Long Axis
Subacromial Bursa GT
Supraspinatous, birds beak view (insertion)

21. Supraspinatus Tendon-Short Axis
WNL
SAB

22. Dynamic Motion Good Humeral Head Depression
Rotten Humeral Head Depression
Poor Posture, Weak Scapula Stability

23. Infraspinatus Tendon
Instruct patient to place their arm in full INTERNAL rotation
Place hand in back pocket
Similar to Supraspinatus, but moved posteriorly
(Long axis)45 degrees Coronal/ Sagittal
(Short axis) 90 degrees Rotation of long axis

24. Infraspinatus Tendon
Instruct patient to place their arm in full INTERNAL rotation
Place hand in back pocket
Similar to Supraspinatus, but moved posteriorly
(Long axis)45 degrees Coronal/ Sagittal
Long Axis appearance of IST
Normal appearance of IST

25. Teres Minor Tendon
Instruct patient to place their arm in full INTERNAL rotation
Place hand in back pocket
Similar to Infraspinatus, but moved Inferiorly
(Long axis)45 degrees Coronal/ Sagittal
(Short axis) 90 degrees Rotation of long axis

26. Teres Minor Tendon
Instruct patient to place their arm in full INTERNAL rotation
Place hand in back pocket
Similar to Infraspinatus, but moved Inferiorly
(Long axis)45 degrees Coronal/ Sagittal
Normal Long Axis of Teres minor

27. Teres Minor Tendon
Instruct patient to place their arm in full INTERNAL rotation
Place hand in back pocket
Similar to Infraspinatus, but moved Inferiorly
(Short axis) 90 degrees Rotation of long axis
Normal Short Axis of Teres minor

28. Contralateral Comparison Long Axis Views
Left SST is WNL
Right SST Thickened chronic Tendinopathy

29. AC Joint
AC Joint

30. AC Joint
AC Joint
If the person is very thin, you might need standoff/interface disc

31. AC Joint Arthritic Changes but no effusion
Less evidence of DJD, but effusion present

32. Summary
Many structures in the shoulder are superficial and can be examine accurately with MSK ultrasound
Diagnostic Ultrasound should incorporated static and dynamic image
If you examine many normal shoulders, then you will soon be able to pick-up even subtle changes