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