How To: Supraspinatus Tendon Exam

00:00:38,837 What this does is free up the supraspinatus 13 00:00:38,837 --> 00:00:40,478 so it's not obscured, 14 00:00:40,478 --> 00:00:43,509 but I can clearly visualize the tendon efficiently. 15 00:00:43,509 --> 00:00:44,784 There are two views we're going to look at the 16 00:00:44,784 --> 00:00:46,359 supraspinatus tendon. 17 00:00:46,359 --> 00:00:49,085 First, where we see most pathology will be 18 00:00:49,085 --> 00:00:50,925 in cross-section. 19 00:00:50,925 --> 00:00:52,297 And with this technique, 20 00:00:52,297 --> 00:00:55,261 we keep the notch of the probe faced upwards 21 00:00:55,261 --> 00:00:57,837 and we're going to angle the probe 22 00:00:57,837 --> 00:00:59,727 diagonally down towards the navel, 23 00:00:59,727 --> 00:01:01,394 or the belly button. 24 00:01:02,560 --> 00:01:05,477 Maintaining contact on the patient, 25 00:01:06,670 --> 00:01:09,617 I visualize the supraspinatus tendon 26 00:01:09,617 --> 00:01:11,033 and it's fibers. 27 00:01:11,033 --> 00:01:14,306 And I'm going to examine the supraspinatus tendon 28 00:01:14,306 --> 00:01:15,348 in both directions, 29 00:01:15,348 --> 00:01:17,625 to clearly rule out any pathology. 30 00:01:17,625 --> 00:01:21,679 I'm gently maintaining contact and rocking the probe, 31 00:01:21,679 --> 00:01:24,941 side to side, following the length of the fibers. 32 00:01:24,941 --> 00:01:26,663 On top of the tendon here, 33 00:01:26,663 --> 00:01:29,524 we notice a little black, thin line, 34 00:01:29,524 --> 00:01:32,597 which is the subacromial subdeltoid bursa. 35 00:01:32,597 --> 00:01:34,771 In patients with shoulder abnormalities, 36 00:01:34,771 --> 00:01:36,576 this bursa fills with fluid 37 00:01:36,576 --> 00:01:39,589 and is often the target of one of our injections. 38 00:01:39,589 --> 00:01:42,578 Next, I prefer to look at what's called 39 00:01:42,578 --> 00:01:45,063 the rotator cuff interval. 40 00:01:45,063 --> 00:01:47,546 And to do this, I maintain the same position 41 00:01:47,546 --> 00:01:50,206 that I'm currently in. 42 00:01:50,206 --> 00:01:52,888 And I'm going to slowly move the probe 43 00:01:52,888 --> 00:01:55,305 medially towards the patient. 44 00:02:01,043 --> 00:02:04,492 This will allow me to visualize the bicep tendon 45 00:02:04,492 --> 00:02:07,279 as well as the subscapularis tendon. 46 00:02:07,279 --> 00:02:08,729 On the left of the screen is the 47 00:02:08,729 --> 00:02:10,205 supraspinatus tendon. 48 00:02:10,205 --> 00:02:12,074 Next, there's the bicep tendon 49 00:02:12,074 --> 00:02:15,229 which is the white circular structure seen. 50 00:02:15,229 --> 00:02:17,181 And just adjacent on the right to that, 51 00:02:17,181 --> 00:02:19,509 is the subscapularis tendon. 52 00:02:19,509 --> 00:02:21,541 In patients with tears, 53 00:02:21,541 --> 00:02:23,874 we measure the interval between 54 00:02:23,874 --> 00:02:25,849 the supraspinatus tendon as well as 55 00:02:25,849 --> 00:02:27,932 the subscapularis tendon. 56 00:02:29,421 --> 00:02:31,366 If there's increased distance between the two, 57 00:02:31,366 --> 00:02:34,282 it's suggestive of a tear. 58 00:02:34,282 --> 00:02:36,733 Lastly, we're going to look at the supraspinatus 59 00:02:36,733 --> 00:02:39,845 tendon in it's longitudinal view. 60 00:02:39,845 --> 00:02:41,554 I place the notch of the probe facing 61 00:02:41,554 --> 00:02:43,397 towards the patient's ear, 62 00:02:43,397 --> 00:02:45,975 which is an easy to remember landmark. 63 00:02:45,975 --> 00:02:48,253 Maintaining contact with my hand, 64 00:02:48,253 --> 00:02:50,727 on the patient's shoulder, with the probe angled 65 00:02:50,727 --> 00:02:53,110 up towards the patient's ear, 66 00:02:53,110 --> 00:02:54,983 we can see the rotator cuff, 67 00:02:54,983 --> 00:02:56,374 in what's commonly referred to as 68 00:02:56,374 --> 00:02:58,110 a bird-beak type image, 69 00:02:58,110 --> 00:02:59,506 clearly seeing the fibers of the 70 00:02:59,506 --> 00:03:01,197 supraspinatus tendon, which are healthy 71 00:03:01,197 --> 00:03:02,530 in this patient. 72 00:03:04,725 --> 00:03:07,238 In abnormal cases, we may see partial tearing, 73 00:03:07,238 --> 00:03:08,757 blackness within the tendon, 74 00:03:08,757 --> 00:03:10,389 as well as thickening, 75 00:03:10,389 --> 00:03:14,502 or tendonosis with chronic poor blood flow 76 00:03:14,502 --> 00:03:15,585 in a patient. 77 00:03:16,534 --> 00:03:18,727 What we're going to do is follow the 78 00:03:18,727 --> 00:03:21,394 length of the tendon, on one end 79 00:03:22,279 --> 00:03:25,034 where it attaches at the bird beak, 80 00:03:25,034 --> 00:03:27,264 as well as through the opposite end, 81 00:03:27,264 --> 00:03:29,163 looking at the fibers and continuity 82 00:03:29,163 --> 00:03:31,568 to see if there's any abnormalities. 83 00:03:31,568 --> 00:03:33,322 Additionally, one pearl to be aware of 84 00:03:33,322 --> 00:03:35,905 is a concept called anisotropy. 85 00:03:36,957 --> 00:03:39,328 And what may appear to be an abnormality, 86 00:03:39,328 --> 00:03:41,127 or a partial tear, where you can see a 87 00:03:41,127 --> 00:03:44,039 hypoechoic or black signal within a tendon, 88 00:03:44,039 --> 00:03:45,519 that may suggest a tear, 89 00:03:45,519 --> 00:03:47,398 was really just a result of your probe 90 00:03:47,398 --> 00:03:49,398 not being perpendicular to the structure 91 00:03:49,398 --> 00:03:50,695 you're viewing. 92 00:03:50,695 --> 00:03:53,753 An example of that would be a blackness here 93 00:03:53,753 --> 00:03:56,203 in the tendon, that you can see on the bottom 94 00:03:56,203 --> 00:03:58,998 aspect of the tendon as it inserts on the bone. 95 00:03:58,998 --> 00:04:02,165 But by rocking the probe side to side, 96 00:04:04,011 --> 00:04:05,858 I remove the blackness and realize 97 00:04:05,858 --> 00:04:07,691 that it was anisotric. 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