Transcript
- Let me be the first to welcome you
to the Sonosite webinar on diagnostic shoulder exams,
specifically for the lateral shoulder.
Before we begin, please be advised all attendees are muted,
and you may type your questions
into the Q&A box in the toolbar
located at the bottom or the side of your screen.
I will conduct that Q&A session at the end
of the presentation and demonstration.
And this webinar will be recorded
and archived for future reference.
So with us today is Daniel Shelton.
Daniel Shelton is the director
of musculoskeletal market development
for Fujifilm Sonosite.
Daniel spent 16 years as a dedicated musculoskeletal,
excuse me, musculoskeletal sonographer,
and 10 of those years have been here at Sonosite.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point-of-care ultrasound.
So Daniel, I'll go ahead
and turn it over to you and we can get started.
- All right, thank you, Chris, for that introduction.
I want to welcome everybody again,
this is the lateral shoulder.
This is a running part of our four-part series.
This is part two.
If you did not catch the anterior shoulder,
I encourage you to go back through our webinar library
and get caught up on the anterior shoulder
and the associated artifacts
with musculoskeletal ultrasound
such as anisotropic artifact or angle artifact.
We'll discuss a little bit of that here,
but it was more in depth in the first
of the four-part series.
So with that said, a little bit of background
about what we're going to be talking about today.
There's a lot going on in the lateral shoulder
and we're going to cover these slides really quickly
and then we're going to spend the majority of our time
on the live demo
and then hopefully a heavy amount of time
on the Q&A with your questions,
and maybe anything that you want clarified in the live demo
would be best addressed in the Q&A.
So have those questions ready,
have them typed out in the chat portal
or the Q&A portal for Chris to address.
He'll tally those up
and we'll run 'em through in the Q&A portion.
But you're going to see a lot of diagrams,
you're going to see a lot of anatomy,
ultrasound images depicted in here.
I'm not going to read from the slides.
I'm going to breeze through these slides
as quickly as I know how to.
But just know that this is recorded
and you can go back through the recording and use these
and pause these videos as a diagram for you to scan along.
I encourage that you go through these slides,
you hit the pause button,
and you try to achieve the scanning targets
that are discussed in each slide.
And that will help be a very nice scan along.
So let's go ahead without any further ado.
And you'll notice I have an anatomy image
up here depicted already.
And this is the shoulder, not an anatomical position.
This is the modified Crass position
and it's very important to scanning the lateral shoulder.
And the anatomical position
were slightly externally rotated,
and you'll see that the greater tuberosity
would typically be sitting out here laterally
underneath the acromion for the most part.
So what we have to do
to bring out these cuff structures
like the supraspinatus and infraspinatus
away from the acromion
is we have to rotate the shoulder this way
and we just tell people
to either place their palm in their back pocket.
The real key here is to not let there be
much of a gap between the elbow and the rib cage.
So what we're doing is, a couple of things,
and we'll do this in the live demonstration,
is we've taken the greater tuberosity
from a lateral superficial structure,
okay, to this anterior and deeper structure.
And we did that by internally rotating
then dragging the elbow back posteriorly,
which is not super evident here.
So when we rotate the model,
both anatomical model and the photograph,
we see how far back this elbow goes.
If your patient's not able to do that, it's okay.
Start in a fairly neutral,
just arm slightly internally rotated
and pull the elbow back maybe to the outside of their thigh
and just see what kind of range of motion
you can get away with.
But look at the stretching
that's occurred on the supraspinatus anteriorly.
The infraspinatus follows as it overlaps
the supraspinatus by a third.
Teres minor follows much more inferiorly,
and we'll talk about those especially in the live scan.
But there is a twisting anteriorly
and a dropping of the greater tuberosity inferiorly.
So we've taken the greater tuberosity
from an anatomical position, which would face us here,
and we've wrapped it anteriorly and dropped it inferiorly.
And that's going to dramatically change
where our transducer would be located.
If you looked at a traditional anatomy diagram,
I think you would assume
that your transducer would be placed
very lateral for a rotator cuff exam.
And just know from a patient positioning standpoint,
any surface landmarks have now changed
from where we put our probe.
So we're not going to be focused
on the lateral anatomical shoulder,
we're looking at lateral structures,
but we're going to have the probe very anterior.
Anytime I'm evaluating major tendons,
I start in a short axis.
So we're going to go straight
into the short axis transducer placement
for the supraspinatus, which is here.
And we can see this rounded oval of the supraspinatus.
It's cut in half.
This is your sagittal MRI equivalent.
Here's the coracoid process as a landmark.
So the medial side of the transducer screen,
right is the patient's medial side
just under the fingers of this photo,
and that's where the coracoid's going to be.
And then what you're going to do
is just windshield-wiper over
until you see the humeral head typically.
And if the humeral head is not sharp and crisp,
the rest of these structures
are not going to look very good either.
Here's that familiar biceps tendon.
If you do not see the biceps tendon,
don't move forward with this exam.
We need to see the biceps tendon, if it's there,
if they're postoperative and had a tenodesis
or something like that, keep that in mind.
But we're really looking for the biceps
because its next lateral landmark
here is the supraspinatus.
There are other structures that we'll talk about
towards the end of the slides
between the biceps and the supraspinatus.
But for now, let's focus on this leading edge
of the supraspinatus.
That's where all the pathology happens, for the most part.
Infraspinatus won't be so heavy this slide deck,
but we will discuss it a little bit.
But we've cut the rotator cuff in half
and we're looking down the fibers
as a sagittal MRI equivalent.
Now, let's colorize these structures,
and I've got part of the transducer on the coracoid
and the other part of the transducer
on the acromion process.
And this makes up our transducer placement
for the proximal supraspinatus.
So this is where the musculotendinous junction is,
and we can see the central tendon of the supraspinatus
and the muscle fibers following
of the very proximal edge
of what we consider to be something to look at.
But here's your coracoacromial ligament.
If it's dipping or sagging, we've got volume loss,
and that's something to look for here.
This is also a good position to do wagging of the elbow
for any adhesions that may occur
in the subacromial bursa to that coracoacromial ligament.
And we can look at that in the live scan.
Again, leading edge of the supraspinatus
is our focus for these slides.
We'll get to the rest of the interval structures shortly,
but supraspinatus and biceps tendon relationship
is really important.
It will not change
as we fan this transducer
distally down the greater tuberosity,
and we're going to look for the shape
of this humeral head to change.
So unless you have a rounded humeral head,
I don't want you to advance the transducer.
Okay, so we've advanced the transducer
to this new white location here.
You can see this big dot,
just like in our last set of slides,
and in the wrist is going to represent
the left side of the screen.
This thumb orientation marker in the transducer
is the left side of the screen.
So here we have the humeral head. It's nice and bright.
Supraspinatus has this big oval leading edge appearance.
And we're really just going to be focusing
right here on the leading edge
of the supraspinatus and transverse.
Here's that biceps tendon for reference.
As we fan distally, that's where a lot of things change.
And as we go distally, we leave the,
I'm going to go back to the humeral head,
let's look at these changes.
We have the humeral head, which is rounded.
We've not hit the greater tuberosity yet.
And I see the articular hyaline cartilage here,
and it's also capped here in blue in the illustration.
But as I go further distal
and drag the transducer,
relatively speaking, towards the floor
because of the arm's rotation,
watch the shape of the humeral head change.
Cortical landmarks are number one in MSK
because soft tissue changes so frequently.
And that's what we're here to look at.
Follow your bony landmark first.
And what I'm going to do after I find a nice sharp cortex
is I'm just panning, dragging, like a paintbrush,
the transducer distally
towards that ball shape of the shoulder.
And we end up with this apex here,
this bony peak of the anterior
and the middle facets at a greater tuberosity.
Here's the biceps tendon for a reference.
It's not so prominent here because it's anisotropic.
It has the angle artifact.
It's not the focus of our exam right now.
We're really focusing on making sure
we don't have any anisotropy
or angle artifact across the footprint
of the supraspinatus tendon primarily.
Infraspinatus tendon will be
kind of a collateral concern at this point,
but we're really focusing on these fibers here.
You can see this dark rim here.
We want to wag and tilt the transducer
and try to get rid of this anisotropic artifact.
Also, compression is very useful here.
If you suspect a tear, apply transducer pressure
and see if you can't get the subacromial surface
to collapse into the supraspinatus.
It's at this point that the supraspinatus
actually has a very unique relationship
with the infraspinatus.
And I'm going to go with the next slide to illustrate that.
So here we are.
This is a 3D CT on the greater tuberosity facets
under the acromion process.
And we're really focusing here
on the anterior facet of the greater tuberosity,
the superior facet, I should say.
At that superior facet surface,
we have primarily supraspinatus.
We will have about 1/3 of the tendon fibers
of the infraspinatus
overlap the supraspinatus at this point.
And you just want to sweep and scan approximately distally,
approximately distally, until you see this relationship.
And as we scan more proximally,
you'll actually see this diagonal line
show up between the infraspinatus and supraspinatus.
And we're going to show that in the live demo.
We want to maintain this relationship
to the biceps as much as we can.
But that relationship leaves a little bit
as we're in the interval
and we start to see this gapping
between the biceps and supraspinatus.
And we'll talk about the interval
after the main supraspinatus slides,
but just be aware of this cortical landmark,
this apex of the greater tuberosity,
sometimes called the anterior facet or superior facet,
as illustrated here by Dr. Jon Jacobson,
and the "Fundamentals of Musculoskeletal Ultrasound" book,
it's in its third edition.
I encourage everybody to give that a read.
It's the best handheld reference, non-hardback,
easy to travel with.
It's a great read. It's not your typical radiology book.
I think you'll enjoy it.
So, this is a great illustration.
It's just depicting that point with all the other stuff,
just decluttered like the interval
and the deltoid and its septations and things.
It's just really simplified.
So I enjoy that illustration a lot.
And then overlying all of these structures,
we have the subacromial subdeltoid bursa and its layers
and there are many layers.
Going to long axis now,
we've rotated the probe 90 degrees
to a longitudinal plane to the supraspinatus.
This is a coronal body plane.
And then we're going to be panning
the probe lateral and medial.
We're looking at the humeral head to be rounded
and the greater tuberosity to have
this kind of parrot's beak.
As I mentioned, the difference
between the subscapularis and the supraspinatus is cortical.
Landmark that I discussed last week
at the anterior shoulder demo,
was that a subscapularis, while it looks very similar,
has a very flat beak.
So it's a bird's beak.
This is a parrot's beak, it has a hooked bill.
If you want to get nerdy
about how you remember these things,
that's one way to do it.
But it also identifies the actual footprint
of the predominant supraspinatus.
Here's some angle artifact.
We would tilt the probe and get that feathered out.
It's anisotropic artifact.
And I think if we just aim the beam back into the footprint,
you'd see that clear right up.
Let's go into how to scan that.
Start at where the round ball
of the shoulder meets the chest wall.
There's this divot,
and what you're not seeing back here is my fingers
are placed firmly in that divot of the shoulder
where the chest wall meets the remainder
of this ball shape of the shoulder.
Set your transducer right on the outer ball shape.
But what you want to do is just fan
that transducer towards the fingers.
And as you do that, you're going to come across
this very deep humeral head.
And the humeral head's going to have this irregular contour,
but it should be smooth.
You're going to see this arc shape with the fibers in it.
That's the biceps tendon proximally
that we scan on the anterior shoulder.
That is our landmark because in long axis,
this biceps tendon is parallel
to the supraspinatus tendon laterally.
So as we pan this transducer laterally,
we will immediately see the supraspinatus.
So until we see the biceps tendon anteriorly,
you will not be confident
that you've evaluated the anterior margin
of the supraspinatus.
It's that that has the most pathology.
And if you're not seeing this
and you're not able to get this arc shape
of the biceps tendon, take a look at your patient's elbow,
we'll do this in the live scan,
but if it's wagged too far out like a chicken wing,
you're not going to get it.
You need to bring the elbow towards the spine
and that will bring and externally rotate out
this rotator cuff interval, which is where the biceps is,
and we will get this landmark really nicely.
So after that, we're going to pan the transducer
about a centimeter lateral,
and you'll see that the bony landmark
has changed dramatically,
more like that MRI contour slide that we looked at.
So here we are, just lateral, we're on the very peak
of that ball shape of the skin surface,
if you can palpate that on your patient.
We have the rounded humeral head and greater tuberosity.
Greater tuberosity is in profile
and it's got this nice curve to it, like a ski jump,
versus laterally, as we pan more and more laterally,
you'll see it flatten out.
If it flattens out like this, just be aware,
most of these fibers are actually infraspinatus
coming in from the posterior margin,
and be aware of any contour changes
of the greater tuberosity.
So there's a big difference in going from here to here
and how that is shaped,
because as we see this greater tuberosity flatten out,
it means you've gone so far posterior,
you're leaving the fibers
of the predominant supraspinatus,
and right in here,
which should be illustrated, but it's not,
you start to see this overlapping wedge
of anisotropic artifacts sometimes.
Don't confuse that for a tear
or pathology, that's infraspinatus.
So let's move even further
anterior from the supraspinatus.
So here we just got done evaluating this tendon
in both short axis and long axis.
And let's find out what those parts were
that were surrounding the biceps tendon.
From the coracoid process,
we have this overlying ligament
that has many, many fibers going many different directions.
Some go over the biceps groove,
some go under the supraspinatus,
some go over the supraspinatus,
and that's the coracohumeral ligament.
This acts as a stabilizing sling for the biceps.
So it's not all up to the biceps groove
to keep it from dislocating into the subscap.
A lot of the strength,
in fact, more often relies on this coracohumeral ligament
in conjunction with the transverse humeral ligament,
which is here.
It's very broad and is more of an extension
of the anterior subscapularis fibers.
So anterior subscapularis, which we evaluated last week,
shares fibers and jumps over the biceps groove
to create mostly that transverse humeral ligament,
which blends in with the coracohumeral ligament.
And these ligaments are the things
that stabilize the biceps.
So other things that may be pain generators
or sources of instability in the shoulder
and various other things to look for.
Don't forget about these ligaments surrounding the biceps.
So we're going to climb,
oh, actually we're going to slice this
and get more of a cross-sectional view
of what we're looking at.
So we just got done evaluating the anterior supraspinatus
and it's surrounding like a yin-yang
and like a hammock on each side bordering the biceps.
The biceps pierces between this relationship
of that superior glenohumeral ligament,
which is acting like a hammock.
And the coracohumeral ligament,
which is subtracted quite a bit of transparency here,
but it is acting as this big broad bridge
up and over the biceps.
And they taper together along with the joint capsule
to wrap around the biceps.
And that's what keeps the biceps intraarticular,
is this joint capsule sling that is a part of this complex.
So when you do a biceps tendon injection
that's too proximal,
you're going to end up dumping it into the joint.
And that's why you want to go distal
in the biceps groove
when you do a biceps sheath injection
so that the remainder of your injection
does not end up in the joint.
If you have a large joint effusion
of the glenohumeral joint,
it's right here at this window
that it will outpour into the bicep sheath.
So if you see a huge effusion in the bicep sheath,
you can almost 100%,
I think it's 90-something percent by Jacobson,
rely on there being some sort of rotator cuff tear
that let fluid out into that articulation of the biceps.
Let's take a look at how that image is.
So here we have the biceps tendon
as this oval over the humeral head that is pretty rounded.
It's irregular in shape
because the biceps groove is kind of tapering away
and we're about to hit the humeral head laterally.
But the CHL and the SGHL
are, like, the sling around the biceps.
And we'll focus on that in the live demo.
But the graphics are here for your future reference
so that we don't spend too much time.
One more thing before we go to the live demo.
We have the subacromial subdeltoid bursal interface
and we'll be doing this predominantly in the live demo,
but just know, in a modified Crass position,
you can still see these layers really nicely.
So this is all supraspinatus primarily from here to here,
right where my mouse is starting and stopping.
And then we have these other little soft tissue layers,
and there are a lot there.
I think there's something like seven layers
when you get to the peritenon of the supraspinatus,
that peribursal fat,
the actual interface
where the two structures are gliding on each other
of the subacromial bursal potential space.
And then you have the subacromial fat
of the subdeltoid fascia.
And then you have the peritenon
and subdeltoid fascia of the deltoid.
So there's a lot of layers here to get your needle lost.
So we're going to apply some dynamic maneuvering
to make the interface of this
as clear and easy to see as possible.
And then when you go in
to do your abduction maneuvers for impingement,
it's going to be a relatively anatomical plane.
And that's why we see the acromion here
and we see the greater tuberosity so close in relation
is that we're not going to stay in the modified Crass position.
We're going to go to anatomical position, relatively speaking,
and we're going to abduct and watch this glide.
But look at the teardrop, look at the dependent recess
of the subacromial subdeltoid bursa laterally,
that peribursal fat, that white interface
of the subdeltoid fascias, it's these layers that combine
that have this redundant fold
over the greater tuberosity laterally
and create this really nice pouch
for free fluid to exist.
And when we internally and externally rotate, abduct,
and internally rotate and strain,
like the modified Crass position,
this big redundant recess unfolds
and allows us to have that range of motion.
But it also fills with free fluid
in the case of either bursitis
or if you have some sort of cuff tear
that goes from articular to bursal surface.
And we'll talk about that in the live scan.
But it's just a couple words
about the subacromial bursa and its interface
and I think it's just better depicted in the live scanning.
So what I'm going to do is go ahead
and get set up for the live demonstration
and kick it over to that.
After the live demo,
it will be time to answer your questions.
So have those ready.
I know the slides were really fast,
but we're going to try to predominantly spend
the rest of the time in live scan
so that those points can be driven home
with a more dynamic study.
Don't forget to use these slides for future guidance
on what those tissue layers are.
One second while I switch over.
So just like on the anterior shoulder,
we started with the patient facing the machine,
I was standing behind the patient.
That's really how I like to scan shoulders
'cause I get to rest my palm up here.
And the majority of all your pathology will take place
within roughly one inch of the acromion anyway,
so we're not traveling far away from the acromion,
and that's why I like to rest my hand up there.
So I'll be selecting
the linear 15 megahertz transducer on the Sonosite PX.
I've got my system where I want it to be,
I've tilted things where I would like it to be,
and all my controls are facing me nicely here.
I'm going to keep the left side of the screen
to the patient's right or lateral here.
And to start out with the supraspinatus exam,
just in case your patient is not able to do
the full modified Crass,
I like to just take a spot peek first
before we start stretching them into various positions.
So I'm just going to start with the probe over the acromion
and out lateral,
and here in this view,
you're going to see a lot of things
such as the subacromial bursa,
you're going to be seeing the full volume
of the supraspinatus in many cases,
and it's just not necessary to go ahead
and stretch the tendon
and do any damage to something
that may just be hanging on by a thread.
So what I see already is very nice is,
let me pull my arrow out,
I see full volume of the rotator cuff.
I'm going to bring my depth a little bit more shallow.
And I see a nice smooth greater tuberosity.
So proceeding forward is probably not super risky
with doing a modified Crass position.
So I've done just kind of this quick survey of volume
and I'll go short axis as well
and just make sure that we're not suspecting
any big major tear.
We're going to be looking for subtle pathology here,
in this case, a normal exam.
Here's our biceps here as our anterior landmark,
and then here we have our anterior supraspinatus.
So before you just look at the book or watch the video
and decide that all your patients have to be stretched
into that maximum level of modified Crass
and putting any stress on the tendon,
just keep in mind you can see a whole lot of anatomy
just without stressing your patient's positioning.
So I'm going to add a bit more gel here.
And with that gel standoff, it's going to allow me
to do a nice subacromial view without collapsing the bursa.
So while I'm here and not stressing the patient,
let's just do a quick subacromial exam.
And what I'm going to have our patient do
is just slowly internally and externally rotate
and wag the elbow a little bit.
There we go.
And then what I'm looking at is this bursal interface.
You can see the hypoechoic mine between those two layers
of peribursal fat, subdeltoid fascia here, superficially,
peritenon and peribursal fat at the supraspinatus.
And then zooming in is a good idea when doing these,
unless you have a higher-frequency transducer,
which we can get to after we do the basic exam.
And I'm just going to go ahead and zoom in on these layers
and then we'll do
just very subtle internal and external rotation
and watch those layers show themselves.
So in a normal subacromial subdeltoid bursa,
we should just see this very, very thin line.
And then if you're just eyeballing
how thick should a subacromial bursa be,
let's just relax.
I'm going to come up here to the hyaline cartilage
of the humeral head here,
and I should be able to eyeball
that the subacromial bursa is not thicker
than the articular hyaline cartilage.
If it starts to get any thicker,
it's time to pull the calipers out and measure
whether or not you have a suspected subacromial bursitis.
And there's a lot of published findings on that thickness,
and just use your clinical impression.
Does it compress?
Is it a fused or is it just synovitis?
Put your color-powered Doppler on and see if it's inflamed
or maybe something else is going on in the bursa.
So that's one way to do a subacromial evaluation
with internal and external rotation.
I'm going to hit 2D to escape my zoom,
and now I'm going to go long axis to the supraspinatus
and we'll do the subacromial impingement.
So if you've ever been frustrated by this view,
find your AC joint first,
which we'll get to here in two more webinars,
and go laterally on the acromion process here.
From this point right here,
what I just want you to do is point the lateral side
of the probe anterior while pivoting
and keeping the proximal side of the probe on the acromion.
So I'm just going to windshield wiper anteriorly,
keeping those two structures in view.
We're relatively internally rotated in a neutral plane.
And the reason I say that is our patient's hand
is in her lap
and we're not out here in anatomical position.
So when we're in anatomical position
and the palm is forward,
the greater tuberosity is extremely lateral
and we see what we see in the anatomy books.
But right now,
we're seeing our patient's positions internally rotated.
That's really important
when it comes to doing any rotator cuff
or any shoulder exam, is which position is the arm in?
And now I'm going to have our patient not only just abduct,
but abduct a little bit anteriorly,
and we're going to be watching that greater tuberosity
glide and clear the acromion process.
Now, one tip while scanning this,
if you've ever been frustrated by doing this
as they abduct, notice the deltoid is starting to contract.
And when the deltoid contracts, it can bump your transducer.
So you'll notice all the weight of my probe
is right here on the acromion,
and I'm relatively floating the lateral side
of the probe out here,
letting the rest of the arm come up to the transducer.
But I can see this interface nicely.
While that provides
a really nice consistent scanning surface,
it also helps me know with confidence
that I'm not collapsing the bursal interface
with the weight of my transducer.
So I can come out here laterally, just relax,
and I can get a beautiful subacromial shot,
but I fell off the acromion
and now I'm collapsing any bursitis I may have,
or if it's simply effused, you're going to miss that.
And if our patient abducts again,
go ahead and abduct,
that deltoid contraction is going to bump my transducer
sometimes off axis
and it makes it very hard to scan.
So those are my scanning tips
for a subdeltoid bursal view there.
In the Q&A portal,
if you have questions about injections
and where that needle should go,
save those for the Q&A at the end.
So from that subacromial exam
and that non-invasive rotator cuff sweep,
it's time to go ahead and stretch the rotator cuff tendon
of the supraspinatus.
And what I'm going to have our patient do
is go into the modified Crass,
which is the palm in the back pocket.
If your stool doesn't have a backrest, that's a plus.
If they do, sometimes they just have to scoot
to the front of the stool.
But if your patient's comfortable in this position,
it's going to be just fine.
Actually, I'm going to have you scoot up just a touch.
There we go.
And the reason for that
is we're going to be moving the elbow just a little bit
and we want that free room back here.
In modified Crass,
it's really important not to chicken wing out here.
If you can get an arm through here, that's bad.
If you can come up here and see
that that gap has closed quite a bit,
it's going to bring the rotator cuff structures lateral.
And when we're internally rotated,
when we chicken wing out like that,
the cuff structures go in
and under the coracoid process,
so I'm not able to see them.
So you have to externally rotate
the shoulder in this position.
Most people like to just go ahead
and plop the probe on to long axis
and just get right to the point.
Well, that's fun. That's okay.
We're here to learn the scanning techniques
of how to do this fairly thorough.
And I'm going to go short axis first.
So remember the anatomy diagram,
we pulled the structure anteriorly and inferiorly.
I'm going to take this slice
right here across the anterior humeral head,
putting the medial side of the probe
towards the chest wall,
almost touching it completely.
In fact, in this case I am.
I'm going to bring my depth down just a touch
so that I can see that biceps.
I'm going to check the gain on our webinar
and soften that up just a touch real quick
before we really get going.
There we go.
I kind of like that for what's being broadcasted.
Let's bring our arrow back up
and start pointing some things out.
If I'm fanning the medial side of the probe
over to coracoid, it's this big prominence here,
I'm going to fall off into the biceps tendon here.
So I've located the biceps anteriorly,
and then as I move laterally, I can see the anterior margin
of the supraspinatus that we identified earlier here.
Really nice.
And then I'm going to keep traveling posteriorly
until I see that tapering edge
between the musculotendinous junction
and the infraspinatus,
which will be this diagonal little line right here
between the two over the articular hyaline cartilage level.
As we go out more distally,
follow the anterior part of the supraspinatus only
and make sure you keep the biceps tendon in view.
Okay, so we're going to follow the biceps
and the anterior margin of the supraspinatus first.
Remember, the cortex needs to be nice and bright
for this view.
I need to see articular hyaline cartilage also.
And what I'm going to do is just pull the probe
almost towards the floor obliquely,
and I need to see the cortex change shape.
See the tendon, the overlying tendons
also changing direction.
And I need to drop the handle of the probe,
drop the handle of the probe.
And I'm just walking down the humerus greater tuberosity.
Did you see the transducer tilt as I pivoted distally?
So let's do that again.
We're going to go to the articular hyaline cartilage level.
I'm going to go distal, you'll see the tendon disappear.
I need to drop the handle back into the tendon,
go distal, see the tendon disappear,
drop the handle, back into the tendon.
You're going to keep walking that down.
We did something really similar in the carpal tunnel webinar
when it came to all
the anisotropic connected tissue artifacts
that we had within the tunnel.
Here's our biceps anteriorly to make sure
that we're not losing our spot, our lighthouse.
And then you can see that anterior
or superior facet right here as it's called,
of the greater tuberosity,
that bony apex we saw in the anatomical diagram.
And you can see the infraspinatus back here
jumping over about 1/3
of the supraspinatus's posterior margin here.
So we're going to sweep up and down that footprint right here,
and we're going to just be evaluating
that leafy feathery edge of the supraspinatus
and using sometimes anisotropic artifact to our advantage.
Healthy tendon will turn dark, okay?
Old scars, old dense collagen,
backfill of scar will not turn dark
and it will remain echogenic as you sweep the probe through.
So what I'm doing is I'm just kind of panning
through the tendon,
and as you see me cause the anisotropic artifact,
I'm just tilting the transducer
back and forth through the artifact,
making sure that whole tendon fills
and the whole tendon gets dark.
I'm going distally again, making sure the whole tendon fills
and the whole tendon gets dark.
And I'm going distally all the way to the very edge
to make sure the whole thing is remaining nice
and, well, anisotropic where it helps us.
Maintaining our anterior biceps here,
going through the interval.
That would be me scanning
through a short axis supraspinatus.
Now, what I'm going to do is come back
to the articular hyaline level here.
I'm going to tuck my transducer towards the chest wall
and I have the biceps tendon
here in the middle of the image.
And I'm going to spin the probe, I'm going to put the left side
of the screen towards the floor or the patient's right,
and what this does is just keeps us in line
with a traditional MRI.
I know not everybody on the call today is reading MRIs
or trying to keep things correlate to an MR.
But I'm going to keep that there for consistency
with some of our other material.
So look how anterior and medial I am,
almost laying the transducer
up against that chest crease, okay?
And I'm maintaining a 90-degree perpendicularity
to the biceps tendon.
And then you can see the back half
of what would be the humeral head.
Now, I'm going to follow this arc of the bicep.
So this is distal, and you can use the anisotropic artifact
and see that familiar structure that we looked at last week.
Check it out.
Biceps tendon, climbing intraarticular here.
Okay, so there's an intraarticular biceps
as it's traveling down, and some people we can actually see
it tapering into that superior glenoid,
typical with the the superior labrum.
But we're not going to focus on that just now.
Let's follow the biceps as our landmark.
Okay, so now I'm going to take
this orientation here laterally.
And I'm going to drag the transducer laterally
because in it's in this,
like we talked about in the PowerPoint,
the biceps runs parallel with the supraspinatus.
Okay, so I'm just going to drag the transducer laterally,
about a centimeter really is all.
And there I can see the supraspinatus,
just like we saw on the slides.
Another scanning pearl here is if you're in a true long axis
to the supraspinatus, your superficial fibers here,
the deltoid, the anterior deltoid,
will also be in long axis.
So take a look at that as just something
that you can do to check your work.
If you have nice long axis deltoid fibers in this position,
not all of the positions get you that,
but it's kind of a neat way to check your work here.
So we're going to follow the supraspinatus fibers distally
until the insert on the enthesis of the greater tuberosity.
Let's cause an anisotropic artifact.
So if I don't tilt the transducer at all, I get this wedge,
and this is not pathology, this is healthy tendon insertion.
See how the greater tuberosity is smooth?
If it were jagged, like somebody had taken a bite out of it,
if I saw a pull lesion,
I'd be really, really suspect of this dark area.
But it's smooth.
Not only is it smooth,
I don't see an overlying volume loss.
So this tendon is occupying this space.
If it stops occupying the space,
like if this tears and retracts back,
something has to fill that void.
And what fills that void
is the overlying subacromial subdeltoid bursa.
So when that happens, we get this big dip,
we no longer get this parrot beak-looking bill,
and we get this big flattened supraspinatus tendon,
and a lot of times the deltoid
will just sit on the greater tuberosity.
So this, I'm already suspecting to be artifact,
and watch me angle the transducer this way.
And when I angle the transducer back into the footprint,
you see all that tendon fill in.
And this is really important that you scan posteriorly
to the flattening of the greater tuberosity
and anteriorly to the curvature
of the anterior greater tuberosity
because that's where the tears happen.
And I'm going to check my work again,
as I went to the anterior greater tuberosity,
I'm going to watch the greater tuberosity fall.
And that's how you know you're going to enter
the biceps groove basically.
But I'm going to follow this part right here
where tuberosity meets humeral head,
and we should see that arc shape of the biceps
as I go more anterior there.
So there's our anterior marker, our reference point,
our lighthouse to make sure
that we've evaluated the anterior supraspinatus.
So we did short axis, we did long axis.
Make sure you're letting up on pressure
so that you're not collapsing any pathology.
That's also very important.
When I'm doing these
and I suspect a big tear or even a subtle tear,
if I see something that looks like it may collapse,
what I'm doing is I'm just going to let up pressure
and I can see where the gel was on the shoulder
or where it's not, because my probe was pressing down
and I put down a bead of gel right on that square.
And then I'm laying my finger
down underneath the transducer surface
to act as, like, a stilt
so that I can lay the probe into the gel first
and get this really, really pretty view
of the supraspinatus without compression.
So see how the deltoid is not compressed?
The subacromial subdeltoid bursa is not compressed.
And if I had any suspect of any tears here,
I would not be collapsing that useful pathology either.
So just a little scanning tip
that you can kind of pick up here and there.
That one has helped me a lot along the way.
Go ahead and relax.
I'm sure arm model's very happy to relax at that point.
That concludes that supraspinatus exam.
I'm just going to move to the rotator cuff interval now.
So I'm going to have our patient
just hang her arm out to the side
and the arm slightly externally rotated.
And then I'm going to place the transducer
at the acromion first.
And there where I see the acromion drop
off to the humeral head here,
I'm going to follow the biceps tendon.
So anterior slightly. There we go.
Now, when you see the biceps tendon is suspended
up in the air,
or not in the air, into this connective tissue,
use the anisotropic artifact to your advantage.
First we're going to zoom,
and because we have the convenience of 19 megahertz,
we're going to be checking out the rotator cuff interval
at a high frequency.
So I like where my zoom box is,
so I'm just going to hit zoom again.
That was easy.
Okay, so here I am,
I'm going to bring my arrow back up.
Here's the biceps tendon right in the interval,
and here we have the superior glenohumeral ligament,
just like the anatomy diagram showed.
Okay, we see subscap fibers way down here,
superior glenohumeral ligaments suspending the biceps
like a hammock,
tapering, there's some joint capsule in here
that we don't see.
And then here's the coracohumeral ligament complex.
And it's quite the large ligament.
Basically you can see with very little toggling
of the transducer,
I'm going to follow,
using this angle artifact to my advantage,
I'm going to follow this stripe above the biceps
to the anterior footprint of the supraspinatus here.
Okay, and then I'm also going to be following
some of those fibers to the superficial margin
of the supraspinatus too.
So these fibers really envelop
the anterior supraspinatus here, like a sling.
A lot of the underneath fibers
will even be traceable proximally to another structure
that's a little bit more detailed.
And we can cover in the Q&A,
but we won't cover now, or I'll get way off topic,
but back to the biceps
in the superior or the coracohumeral ligament.
That's pretty much it.
So once you fell off of the acromion,
look for that humeral head,
then look for the biceps tendon.
You're not going to see articular hyaline cartilage
under here very well.
And you're going to be seeing a ligamentous structure
and, like, I think this will looks like a yin-yang,
the sling around the biceps.
There's clearly this directionality
enveloping top and bottom of the biceps.
This is your rotator cuff interval.
So by definition, we have subscap here,
we have the superior glenohumeral ligament here.
And then we're going to see the sling of this complex,
of that coracohumeral ligament,
dragging over to the supraspinatus here.
And then if we see any anterior disruptions
on the supraspinatus, we're always going to be highly suspect
that this coracohumeral ligament may also be involved.
There's a few other dynamic maneuvers that we can do,
putting those ligaments into long axis
and internally and externally rotating
and stretching these ligaments.
But those are things that they need to correlate
with your clinical reason for why they're there.
And they don't really fall under the basic exam.
But hopefully this helps kind of demystify,
it did for me
when I learned about the rotator cuff interval,
when you zoom out,
I was always pretty good at getting this view,
the anterior supraspinatus,
I was always really good at getting the subscapularis,
and I was always really good at getting the biceps
to look really, really cool floating between the two.
But I knew there was just something here
and there was something here in my early days
of learning rotator cuff ultrasound.
I never identified it.
I knew there was a normal space here
and a normal space here of connective tissue
that I just, you know,
I was never taught super early on
that these were ligaments acting as a sling complex
ad that they actually are responsible
for a lot of the bicep stability in the groove
and it takes a lot of pressure
off that transverse humeral ligament, you know.
So from a a body mechanic standpoint,
this is really the structure responsible
for a lot of your biceps stability.
So with that, we've covered our supraspinatus in depth
and I feel like we've gone through the rotator cuff interval
and it's a little complex, pretty in depth,
and we also did some subacromial subdeltoid bursa scanning.
So I think at this point,
we could turn it over back to Chris
and if Chris could let me know if there's any questions
in the chat portal.
I think we'll go from there
and answer your questions live.
- Go ahead and put your questions and answer,
or the questions, in the Q&A box
at the bottom or the right side of the screen.
I'll go ahead and wait around for a little bit
and see if any of those come in.
- I said I would go into 19 megahertz
at the interval and I didn't.
So until we get some questions,
I'm going to play around at the L19-5
higher-frequency transducer in that rotator cuff interval.
- Yep, I'll go ahead and share that on our screen here.
Looks like you're up now.
- There we go.
So why not, right?
So just feel free to interject with questions,
but, you know,
I always say if your patient size permits a higher frequency
and you have a higher frequency, use the higher frequency.
Like, don't stick with the standard transducer
just because it's what you've always done.
You'd be really surprised
what you're able to see you turn that gai down.
Well, that's coming in hot.
I love Zoom.
But just to give you an idea of what we're seeing
at a little bit higher clarity here,
that superior glenohumeral ligament is now really big.
We can actually see more fibers
of the coracohumeral, I believe.
And then let's check out
this anisotropic artifact diving down
to the anterior greater tuberosity
that is still coracohumeral ligament.
So you'd be surprised how much of this
is actually suspending the supraspinatus up.
And we can see that because the beam
of a higher-frequency transducer is thinner,
it's a little bit more responsive
to an anisotropic artifact, right?
So this thin horizontal line
is actually holding up that supraspinatus tendon
a little bit,
and it's got another name,
it starts to get into the rotator cuff cable.
If we were to keep going proximally, let's go distally now,
and get into the biceps again,
I think we did this last week,
and look at that transverse humeral ligament now
and the fibers that you can see there.
So like I said,
if you have a higher-frequency transducer,
why not give it a shot?
And you'd just be amazed at how much you see.
You might find that one little pain generator
that's poking on a nerve
if it's a superficial little nerve or something like that.
In this case, in the rotator cuff,
the supraspinatus turns out really, really nice.
We'll do that modified Crass,
that 19 megahertz, because like I said, why not?
I mean, we have the 19 megahertz in hand
and why not fan across those
enthesis fibers all the way to the anterior shoulder?
I mean, this looks really nice.
I mean, you normally don't even see
lateral epicondyl fibers that big and pretty.
And here we are at a supraspinatus,
which is usually just a linear striated,
fairly heterogeneous group of fibers
because these fibers run in so many different directions.
I mean, how about relax
and maybe we'll play around
in some of the subacromial bursal layers
until maybe somebody wants to throw a question out there.
If not, I do understand everybody's time is very valuable.
We went over on time.
I've gone through all the core content for the day,
but if there's anything else that you wanted to see,
or maybe we can answer any questions
about the 19 megahertz transducer
or maybe the newly released Sonosite PX
that I'm scanning with,
we would be happy to discuss those here.
So I'm going to internally and externally rotate
the transducer, or sorry, the shoulder
and let's look at those bursal layers
superficial to the tendon,
because a lot of times these things can,
subacromial bursa, can kind of blend in
with the surrounding environment here, so.
- [Chris] We did get a question come in.
They ask, "How about the AC joint?"
- So we will have,
that webinar I believe is mid-June, is that right, Chris,
where we go over the superior shoulder?
- [Chris] Yes, I believe that's correct.
- I briefly covered it
on how to find your subacromial space,
which is still relevant here.
So here I am superiorly, I've got my finger hanging down
and I can feel the AC joint here.
So what I'm going to do is just plop the probe down
and let my finger ride over the groove of the AC joint
or that palpable bump.
And then there's the AC ligament right here.
And I'm just going to jump, follow the acromion
laterally, laterally, laterally,
and like I said, on the front of the shoulder,
let's point that probe this way
because we're internally rotated.
And then let's check out that subacromial space
and its layers, which is here.
So we have a supraspinatus muscle tendon
and peritenon and peribursal fat
and actual bursa, peribursal fat,
subdeltoid fascia, and then the deltoid.
So we have all these layers
and let's slowly chicken wing
just a little to show the layers, and then down.
And then we'll go up again and then down.
Because it doesn't take much to just delineate the layers.
If you're having a hard time, where do I put my needle?
I don't want to give a little deltoid injection.
And here's another tip
is if you're going to do a subacromial injection,
going in the long axis can actually be a little misleading.
So let me go to the broader field of view
L15-4 megahertz transducer,
and we'll scan the subacromial in two directions.
And I'll show you a beneficial way to do these injections.
If you're doing an injection
in long axis to the rotator cuff structures,
you can actually accidentally go in
just a little too superficial
and hit one of these strands of a deltoid.
You may see one of these bright white stripes,
because remember I said
scanning the rotator cuff supraspinatus,
the deltoid runs parallel, right?
So you may actually just inflate one of these deltoid fibers
and that may look like a subacromial space right there,
right where my arrow is, and it's not.
I'm going to zoom.
I'm going to show one thing on the subdeltoid
because I think it's super, super important
and I didn't get around to it on the slides.
Now, if you turn your transducer short axis this way,
now we're looking where the fibers are coming
at the screen, right?
And say my needle came in this way.
You can see my finger blanch
the skin on the left side of the screen.
Well, I'm zoomed in, so it's a little less prominent,
but we're going to pretend
my finger's coming in on the left side of the screen.
As our patient slowly internally and externally rotates,
you can see that the subacromial space
is moving with the tendon
and that subdeltoid fascia is not.
So let's relax right across the belly.
There we go.
And if you were to throw your needle in this way,
you would go screen left to right,
turn that caliper off,
I'm going to freeze
with this shot here, caliper.
Let's say this was your needle trajectory
starting right up here.
And then you inject right across here.
And it can even be posterior to anterior.
Your needle brings the injection
over the whole bursal interface.
And you'll see the anterior,
or sorry, the posterior,
the anterior spread of the injection,
instead of just one fluid ball buildup right there.
That's really important
to see the inject eight spread
all the way throughout that subacromial space.
You really don't want to see it blister up in one spot,
and blistering up in one spot
is exactly what can happen
if you just rely on the long axis injection here.
If you're going to do the long axis injection here,
check short axis to make sure it's not a blister.
If it's a blister, you'd probably just hit
one of those deeper fibers in the deltoid.
I thought that should have been maybe explained
after the slides since we didn't get around to that.
But I think that concludes,
geez, way over time.
- [Chris] Yeah, we're definitely over time.
(Chris and Daniel laughing)
But yeah, it looks like there's no other questions
and, you know, like we said,
this is a very comprehensive look at the shoulder.
So just a reminder,
since this was a really quick presentation,
if you need to review the slides
or any of the live demonstrations,
the webinar will be available on the Sonosite Institute
and on the main page as well.
So thank you all for joining us today,
and we really appreciate it.
Thank you very much.
- Thank you.
Thank you, Chris. Thank you, everybody.
Have a great day.
Join us for an expert-led review of clinical images and live Q&A session to discover how the expanded use of point-of-care ultrasound supports diagnostic lateral shoulder exams. Learn more about this trending topic, including best practices for positioning patients, identifying possible pathologies and assessing for abnormalities.
What You'll Learn
- Review basic principles of MSK ultrasound such as anisotropy
- Identify the anatomy within the lateral shoulder including the greater tuberosity facets, supraspinatus and the anterior/superior facet, and infraspinatus and the middle facet
- Learn indications for an evaluation of the lateral shoulder
Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.