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Transcript

- Hi everybody.

Thank you so much for joining us.

Welcome to the rerun of SonoSite

behind the scan webinar titled Diagnostic Shoulder Exams

Posterior Shoulder.

My name is Chris Pennell

and I'll be moderating today's webinar.

This is the third and a four part series about

shoulder ultrasound.

And if you'd like to check out the previous webinars in the

series, you can visit our webinars page on sono site.com.

We'll be rerunning the fourth part

of the shoulder webinar series Superior Shoulder on

January 16th.

At the same time, that'll have a live q

and a portion just like today's presentation.

With that out of the way, we can get started.

Before we begin, please be advised all attendees are muted.

I'll conduct a q and a session at the end

of the presentation and demonstration,

and you can type your questions into the q

and a box, into the toolbar located at the bottom

or the side of your screen.

And that's only for the Zoom audience.

If you're watching on a different live streaming platform,

you'll need to join the Zoom call in order

to get your q and a.

Questions in this webinar will be recorded

and archived For future reference on our webinars page.

Here with us today we have Daniel Shelton.

Daniel is the director of musculoskeletal market development

for Fujifilm Sono site.

Daniel has spent 19 years

as a dedicated musculoskeletal sonographer,

and 14 of those years have been here at Sono site.

He now leads musculoskeletal market development

where he works to spread the word about the benefits

of point-of-care ultrasound.

We'll go ahead and get the, we'll go ahead

and start the recording now.

Thank you all so much for joining us. Please enjoy

- Today we're gonna, we're gonna discuss the posterior

shoulder specific to the infraspinatus and the Terry's minor

and, and we're also gonna take a glance at the posterior

labrum and what can be visualized there

and the spinal glenoid notch.

Just a little bit about the

anatomy on the posterior shoulder.

Specific to infraspinatus is the origin being over this

infraspinatus fossa of the scaphoid good palpation landmark,

which we'll go over live is the acromion process here

posteriorly and then the spine of the scapula.

Basically you're gonna set your probe right under this

posterior corner of the acromion.

We have highlighted here how lateral this tendon goes when

we're in a neutral position, which is where

what we're gonna be scanning.

And then we'll internally rotate the shoulder when we're

scanning live with the patient's arm across their belly,

and you'll see that this greater tuberosity

travels very lateral.

Here are the image differences between the,

the more proximal over the glenohumeral joint,

and then when we follow the tendon out laterally

to its enthesis, what we actually get.

So over the glen humeral joint,

we get this big comet tailed shaped infraspinatus

with a central tendon and surrounding muscle.

It's a multipennate muscle

and so the central tendon looks really nice

because there's, there's a little bit of muscle on top.

Down below we have the, the cortical landmark

of the humeral head

and then the, the greater tuberosities middle facet back

here, more posterior.

Here's the, the glenoid labrum,

the posterior glenoid labrum,

and then there's a joint capsule that's really,

really thin right here, stretches from the,

the superficial surface of the posterior glenoid labrum over

and then underneath the infraspinatus.

And then when we do our rotations, which will show live,

you can actually see that joint capsule when you externally

rotate, and then when you internally rotate

and then back here a little less clearly seen

as the spinal glenoid notch

and I think it's just better described in the live imaging.

So we will go over the, the scanning technique for that

to, to further clarify the anatomy

one pitfall when you're scanning the distal in infraspinatus

tendon, as that tendon wraps around,

you may get this dark shadow in the center of the tendon.

And very, very commonly you're going

to be scanning under this little deltoid septation here.

So this connective tissue here can, can lay down kind

of a edge artifact on each of its sides

or just the,

the sheer change in density going from a fluid-filled muscle

on both sides to a relatively less than fluid-filled

densely connective tissue structure.

You're gonna end up with a slight fractile change in, in

how the ultrasound beam is portrayed here,

so it's less attenuated superficially

and it may cast a darker version of the image.

Versus here we have this really nice fluid filled deltoid,

which is also enhancing the underlying tendon relative to

what happens underneath the deltoid septation

also here in the posterior deloid muscle may

enhance the tendon.

So if you see a dark shadow there,

just do a couple internal external rotations

that may clear up any of the shadow in the tendon.

You don't wanna call this little margin

of the tendon tendonosis, for example,

here's our transducer location.

Basically you're going to palpate right under

that posterior lateral corner of the acromion.

And then I instruct people just

to aim the beam into the joint.

If you're already doing joint injections,

just pretend the ultrasound beam is the trajectory

of your scope or your needle

and you should be able to land an image like this.

When we go to live scan, I'll show you the, the, the way

to get an image really, really nice

with the bones laying flat with our ultrasound beam.

But this is a good dynamic maneuver when you're trying

to evaluate for joint effusions.

When you externally rotate,

that capsule will unfold whether it's filled with fluid

or not, you're still going to see this little

capsule unfold.

It's very nice. So internal external rotations will help you

delineate these tissue margins.

Also on external rotation, there's a vein that dilates

and we'll cover that in the live skin going

to short axis, pretend this animation has flipped

to a short axis of the tendon following these pains

that have been superimposed over the animation

and the extreme proximal, more proximal than

that posterior lateral corner of the acromium.

We see the central tendon of the infraspinatus is not

yet formed to the more dense solid tendon.

So it's still kind of surrounded

by its multipennate structure of the muscle

overlying the body of the scap of the scapula over the

infraspinatus fossa, which is outlined here.

This is the inferior glenoid

and we'll talk about that when we get to the Terry's minor.

But it is a great landmark for you

to look at the muscle belly As we travel distally towards

the humeral head, you will start

to see a more dense central tendon

and perhaps some cartilage here.

And then you're gonna get a lot of shadow from the acromion

and we're gonna do some maneuvers in the,

in the live scan to get rid of those.

And then distally,

it's a frustrating view sometimes if you're not gonna move

the shoulder, but you're gonna catch the enthesis

of the tendon here over that middle facet

of the greater tuberosity.

And a lot of it may be overshadowed by the acromion.

So we're gonna wanna raise the elbow up

and drop that emeral head down a little bit

and we'll do that when we scan line long axis.

Switching this way, we're going to the Teri minor.

Now you're gonna follow that humeral head inferiorly.

Remember when we were scanning the anterior shoulder,

specifically when I told you every time you translate the

transducer down

because we're scanning the surface of a ball, you have

to aim the handle down as well, which directs the beam up so

that you stay 90 degrees to the surface of the bone.

So we're trying to stay 90 degrees to the surface

of the cortex of the humeral head

and it's inferior facet here.

And whether you're internally or externally

or rotated will get you the difference

between these two images here.

So internal rotation,

you get this really nice feather shape muscle

for a joint injection for example.

This is a great place to land your needle not under the

infraspinatus because of that, that real hard pop

that you would get with that large central tendon.

So if you could find that that deloid

or not the deltoid, if you could find the muscle bellies

of either the cherry miner

or the inferior muscle belly of the infraspinatus,

your needle will slip right

through the muscle easier without

that muscle, that hard pop.

And because we're using ultrasound guidance, the need

for lots of resistance technique and injection is much less.

But we're just taking a look at the,

the very much more inferior Terry minor here in long axis.

And then we'll switch over to short axis.

These are numbered out of order on purpose.

The short axis view can be kind of frustrating for a lot

of people at first, so can the long axis view honestly.

But if either of you is difficult for you,

what I would instruct you to do is just find

that posterior tal head neck junction here, just like a hip.

And this will be your cortical landmark.

And there at that posterior margin, you're going

to see the Terrys minor here sitting in that head

and neck junction just like you would in a hip if you,

if this were the joint capsule or something like that.

Here we have the deltoid overlying this

and then up here the in infraspinatus most inferior margin.

And then from there you just want to go

translate the entire transducer either towards the scapula,

which you'll catch the inferior margin of the glenoid here,

and then come back to your home base of the,

the humeral head, neck junction, posteriorly,

and then slide laterally to, to catch that inferior facet.

So here we are at the enthesis of the Terry Minor

and highlighted, I've got the muscle belly of the,

of the Terry minor, the distal muscle belly

of the Terry minor here at our, at our kind

of landmark centrally, and then the

tendon of the Terry miner.

Most distal and lateral, remember we're scanning the surface

of a curved object, so you wanna stay 90 degrees

to the cortical landmark here,

but the triceps tendon makes a really, really nice landmark.

As it inserts is the longhead of the triceps, it inserts

to the inferior glenoid as well.

It'll kind of hold the shape up of the Terry's minor.

Lemme go back one slide.

- No, we're not.

- All right, well let's just go to the live demonstration.

I couldn't get my slide to go back

and we'll just cover those two tendons plus the,

plus the posterior glenohumeral joint as well

as the spinal glenoid notch.

So just a second while we get things transitioned over.

Alright, so now we'll move to the live scan

and today we're gonna be scanning on the new newly released

cyte px.

I'll be starting with the L 15 to four megahertz transducer,

which is the overall general musculoskeletal

exam probe.

And then for some of your patients

to get a little bit larger than I would say like my

shoulder, you may want to opt to the curve linear

for the posterior shoulder, especially in injections.

This is a curved five to one megaherz transducer.

So if there's time at the end, we will switch over to that.

But for now, I just wanna point out

my most frequently used palpable landmark,

which you should always start with a a skeletal

reference point if you can.

This is that posterior lateral corner

of the acromion process

and I just want you to reach back here on your own shoulder

and feel for that little bony prominence

because we're gonna use it for the majority of this exam.

What I like to do, and I'm gonna keep screen left medial

for this exam, what I like to do is palpate

that bony landmark, set the upper part of the probe,

this surface and long axis across

that lower edge of the acromion.

So I'm, I'm, I'm actually physically bumping that

up against the acromion,

so I'm just gonna set the transducer down right here.

And then if you're already doing injections in a shoulder,

the direction of your beam will be relatively exactly like

you do a glenohumeral joint injection.

If you're not familiar with this anatomy on the anterior

part of the shoulder is the corticoid process

and you can feel that with your finger right up here

and you'll basically point your beam towards the corticoid.

But the upper margin

of the transducer is just rested against the inferior margin

of that posterior lateral acromion point.

This, this little prominence on the back,

I'm just gonna rest the palm of my hand on the top

of the shoulder so I can scan comfortably.

What we should see, and without even looking at the screen,

I was able to see all of this

or I expected to see all of this was the humeral head first.

- Pull the arrow up.

So cortical landmarks are key. If you get

- A blurry image like this

and you see what vaguely looks like a a bone down there,

you're gonna tilt the transducer

until you get a nice sharp hyper echoic bony cortex.

In this case it's the humeral head,

articular lene cartilage.

And then this little white area here is the joint capsule.

I'm gonna follow the cortical landmark deep

until we can't see it anymore

and I'm gonna bring my depth down, just a click

or two there.

And then point out the next cortical landmark

that we rely on, which will be the

posterior glenoid tubercle

- Here.

- So this is the posterior glenoid tubercle

and then back here, if we keep following the slope, is the

infraspinatus fossa of the scapula.

And then above this is infraspinatus muscle in central

tendon, one of the penate directions

of the central tendon.

We'll get to the rest of the tendon momentarily.

So between the humeral head

and the posterior glenoid tubercle, we,

we have this labrum here.

This triangular fibrocartilage of the labrum is,

is shown really nicely on ultrasound,

just in the posterior shoulder.

Don't rely on ultrasound for anterior labrum,

don't rely on ultrasound for inferior or superior labrum.

But posteriorly, if you see some pathology bacteria,

you're probably, you're probably not far off whatever the

diagnosis is leading to.

If you suspect labral pathology back here

and you do maneuvers and everything looks normal,

but the the patient's clinical presentation is

that they may have some sort of instability or, or,

or if your clinical exam is pointing to labral pathology,

don't rule it out with ultrasound, you still need

to rely on a standard MRI for labrum.

With that said, we will continue to examine

what we can see back here

and what we're gonna watch now is how to evaluate

for a joint effusion of the posterior shoulder if we don't

already see a protruding joint effusion coming out from

under the joint capsule here and

and spilling out posteriorly, let's see if we can cause one

by doing a dynamic maneuver.

And what I'm gonna have our patient do is just slowly

externally rotate

and we're gonna watch that, that most posterior middle facet

of the infraspinatus attachment come back here

and almost bump against the labrum.

And then here's our, our labrum.

Mona, we, we've changed some densities there

and it's not as nice

because the overlying in infraspinatus is not really

shining over the labrum.

So I'm just gonna bump my gain up in the far field.

There we go. And then let's

point out what we're seeing here.

So the labrum is now this blunted edge instead of

that sharp triangle.

And then just above that blunted edge, here's the capsule

that has redundantly folded posterior and more medial here.

So I'm pointing at the capsules interface.

This is the central tendon of the infraspinatus.

We have gone into external rotation,

which has brought the thesis posterior.

So this is the anatomical position.

If you're looking at an anatomy poster

or book when we're in external rotation, we expect

to see the infraspinatus back here.

The thing is, when we do these exams,

typically the patient is in a relatively neutral position.

So let's watch where the infraspinatus goes.

I'm gonna get off track here

and we're gonna chase, I'm gonna rotate our shoulder

for the camera here,

that way we can chase this probe direction down all the way

anterior and,

and we're actually just following the enthesis

of the infraspinatus so that you get a general sense of just

how anterior it goes.

Remember it's the neighbor of the superspinatus, right?

So here I am on the most anterior part

of the lateral shoulder

as we did in our lateral shoulder webinar

and you can see that the EM infraspinatus looks a lot like a

supraspinatus except it doesn't have that in

that inflection point of the greater tuberosity anteriorly.

If I were to keep going anterior, you'll see

supraspinatus has this inflection point

on the greater tuberosity.

As I go posterior,

you'll see the greater tuberosity flatten out.

We get a lot more acromion in the shot

because the infraspinatus is gonna dive under it.

Now let's follow the in infraspinatus central

tendon posteriorly.

Now until it's there laying over the joint here,

I don't see it laying over the point very

well, which is okay.

Sometimes you can just have the patient grab their opposite

shoulder and that will cause the infraspinatus

and the humeral head to inferiorly drop.

So there I do see that central tendon really nicely

and it makes it easier to evaluate the long

axis of the upper infraspinatus.

So counting our layers underneath here we've got glenoid

emal head, here's that posterior labrum

and then let's watch this joint capsule under the upper

infraspinatus kind of unfold itself.

I'm gonna keep our patients' elbow down to her side here

and then she's just gonna slowly externally rotate

and let's watch this joint capsule unfold.

Here we go right there. And then let's internally rotate.

Okay, and then it's, it's folded in tightening over the

articular hylan cartilage of the humerus.

Now let's externally rotate again,

and this is where I'm looking for debris, calcium deposits

that pop out of there, loose bodies, all kinds

of things can just be shoved into this joint recess.

But you can see that that little fold right here

and it's a normal joint.

And then internally rotate, that's

where we would see a big joint effusion and then just relax.

Yep. After our long axis plus that dynamic evaluation,

I typically switch over to a short axis evaluation of the

the posterior infraspinatus.

And by, by just going over the scapula here, that's

that infraspinatus faucet, I think it's the easiest

to obtain the short axis image.

So I'm just gonna go transverse

and I have the left side of the screen facing superior up

towards the spine of the scapula, which is here.

So here's the spine of the scapula on the most upper screen

left and you can see

where the in infraspinatus begins right here,

this whole corner.

We're just gonna follow it down all the way to here.

And then that's that inferior glenoid right there.

So that's about where you would stop visually

evaluating infraspinatus.

So all of this is in infraspinatus,

it's a multipennate kind of aate muscle.

So we see three different heads here very distinctly.

Then the central tendon is still forming here, so it kind

of looks like a tree.

I've always kind of told myself

that it looks like a tree top here, the more proximal you go

and then the more lateral you go it, it tapers together

and becomes that central tendon.

A lot of times it gets caught under the acromion

shadow and you can't see it.

That's when we have our patient reach up

and grab the opposite shoulder there.

And you actually saw the in infraspinatus roll

out from under the acromion.

And then I'm gonna adjust my depth. There we go.

And then let's just follow that anterior edge here.

You can see the leading edge of the infraspinatus

before it makes its way to the

supraspinatus in in this case.

So I'm just following that, looking for involved tears that

that may involve infraspinatus and supraspinatus.

Typically you don't normally see an isolated infraspinatus

tear, although I've seen a couple, it's just pretty rare

to see just an infraspinatus tear.

They're usually involved with supraspinatus as well.

So let's follow this transverse infraspinatus posteriorly

again and just check our work

and go all the way down to its proximal

musculotendinous junction.

Drop my depth, just a few clicks.

And then here's that central tendon again.

And I'm looking for atrophy of either of these muscle heads.

Any, any of these three groups.

I need to see hypoechoic muscle outer out

to this outer rim of fascia around the muscle.

I don't wanna see a grainy thickened appearance around the,

the muscle that would indicate some sort of fatty atrophy.

Same with the supraspinatus exam.

You would want to compare this muscle belly, for example,

either with the Terry's minor, which we're about

to segue into, or you can climb up north on the shoulder

and compare the in infraspinatus muscle belly

to the supraspinatus muscle belly

and make sure they look similar in echo texture.

So here's our, here's our spine

of the scapula now, and then here's our clavicle anteriorly.

Okay. And now we see the trapezium superficially

and the supraspinatus muscle deep.

And I need that supraspinatus muscle

to also look like the infraspinatus.

It needs to have a nice hypoechoic echogenic

appearance all the way out to this fascia.

And then I'm just gonna fall over that spine

of the scapula posteriorly and compare its texture

and thickness to the em infraspinatus.

So carry that into your clinical exam.

If you're, if you're curious about fatty atrophy,

fatty atrophy will look like a grainy rind

around this cross section of the muscle

and you'll almost see the outer edge of the muscle taper in

and and look exactly like this tendon.

So there won't be this hypoechoic normal gap of muscle.

For example, I'm gonna use this view to get us down

to the, to the Terry's minor.

So the way I like to show people to do Terry's minor

because this can be a bit confusing, is go ahead

and relax this shoulder.

Good. And once we're over that humeral head,

then follow the humeral head to the head neck junction.

Kinda like you would a hip, when we did the anterior hip

webinar, we had a landmark of the an of the,

the head neck junction for a hip injection.

In this case, you're gonna get a very similar view

and that's gonna be for isolating

and locating the Terry's minor so that it's easy for you

to to compare.

So here's that, that humeral head, neck,

this is all Terry's minor here, muscle belly, yeah.

And then right here is the central tendon.

It's a bit superficial compared

to the infraspinatus for example.

And what I'm gonna do now is just like in the PowerPoint,

this being my home base view, I'm gonna go laterally

to its insertion on, on the inferior facet there

you can see it not up above my arrow.

That's still some infraspinatus involvement.

This is the facet that I'm talking about.

This is the, the Terry's miner.

You can even see those little musculo tendonous slips

or the little interdigitated slips kinda

like we see in a subscap.

I don't know if that's gonna be real easy to see on zoom,

but what I can do is zoom in on that so

that you can see the detail

of those little tendon bundles there.

So here we see very nicely

- Individual little heads of the Terry minor right there.

So I'm gonna un zoom, I'm gonna back out

- Now let's follow approximately

until we see another bony landmark.

Remember, I'm, I'm, I'm scanning the surface

of a cylinder in this case instead of a round ball

and as I go posteriorly, I have

to aim back into the cylinder, right?

So that's the scanning technique I'm applying here,

still following this muscle belly.

Make sure it stays 90 degrees to your beam, it's nice

and bright the whole time.

There we go. Our next skeletal reference point just went

down in depth, A click

and bringing up the arrow is the inferior glenoid.

So at this point the inferior glenoid tubercle is the

insertion of the long head of the triceps.

This makes a really pretty view.

So here's the triceps,

this is the muscle belly of the Terry miner.

You can see a little edge artifact casting a shadow here.

And then coincidentally just posterior to that

or inferior to that is that

this is the quadrangular space on this side of the triceps

here, where you've got a little axillary nerve impingement

that could happen back here, plus the, the

circumplex humeral artery that goes posterior as well.

And then we could follow that triangle more lateral

to the humerus where we get the, the

quadrilateral space here.

So humerus side of the triceps quadrilateral space,

medial side of the triceps, quad angular space

and using the triceps

and the Terrys miner a as a border to do

that evaluation is really nice.

So why do we take this image here?

So this is your evaluation image of the minor

and the infraspinatus in the same shot.

With this larger linear footprint transducer,

it's 50 millimeters, we're able to capture

for the most part the entirety

of the infraspinatus muscle belly

and the Terry minor muscle belly in one shot.

And we want to say

or be able to say that the Terry minor,

it's approximately one third the

size of the in infraspinatus.

If the in infraspinatus

and Terry minor are the same size, you really need

to be looking at why is there either hypertrophy

of the Terrys minor or atrophy of the in infraspinatus.

- Alright, so we've done the short

- Axis of the Terrys minor.

I'm gonna go back to that head and neck junction view.

And I'm gonna rotate the left side of the screen medial

and we'll go over the scanning tips

for the long axis of the Terry minor.

So there's our in thesis of the Terry Minor right here on

that inferior facet.

There we can see it's in thesis really nice here.

And as I go more proximal,

if I don't see a nice bony backboard of landmark down here,

what you want to do, because we're scanning now,

we're on the ball of the humeral head, right?

You're gonna want to drop the transducer inferiorly

and aim up because we're scanning the surface of a ball.

Remember we need to aim up into the ball.

And the goal here is to pinch that Terry's minor tendon

between your transducer in the humeral head.

That way we have a skeletal reference point in the image.

So by by doing this really sharp angulation upward

here, move my big hand outta the way for the camera.

We can see the the central tendon really nicely.

We can see the posterior glenohumeral joint

and we have a nice skeletal reference point to follow.

So I'm gonna have our patient just slowly externally rotate

that brings the enthesis of the Terrys minor

and let's just hold that position and I'll point it out.

Let's internally rotate just a bit more.

Let's follow that in thesis here.

Here's your own thesis

and then internally rotate a little more right about there.

And we can get both the glenohumeral inferiorly

with the labrum and the Terrys minor all in that one shot.

But look at the extreme acute angle I'm having

to take to get that.

You don't want to just follow the skin surface for this

or you might get a little lost in the soft tissue.

You really do need to angle up to get that really nice

- Humeral joint.

And let's internally rotate again.

And there's our muscle belly

with central tendon going proximally.

- And then lastly, following that glenoid tubercle,

posterior glenoid tubercle, more proximally.

Let's look at the spinal glenoid notch,

which I should have covered in the normal

glenohumeral exam earlier.

Here's our humeral head, posterior glenoid tubercle

and our infraspinatus fossa.

If you're looking for the spinal glenoid notch like you saw

on the PowerPoint, the only trick here that

that I recommend people do is plant the lateral side

of the probe and then you're gonna pivot the medial side

of the probe up north towards the scapular spine.

So I'm just gonna set my finger here as a pivot

and I'm just gonna aim north when I do that.

I deepen that spinal glenoid notch.

And then we can see, remove the arrow.

Here's what we're looking at, this divot here,

this is spinal glenoid notch.

So just as a review, we have humeral head,

posterior glenoid labrum, posterior glenoid tubercle.

And now we're in the spinal glenoid notch,

which is holding our our suprascapular nerve posteriorly.

There's also an artery and a vein down in there.

And just to show the vein,

what I'm gonna have our model do is just slowly externally

rotate and you're gonna see this vein dilate here.

So that's normal. Go ahead and relax.

If they're already in external rotation,

let's say go ahead externally rotate and just hold it.

And you're doing this exam

and you fall into that spinal one oh notch.

Don't call this big hypoechoic structure a cyst.

This is not a paralegal cyst at this point, it's just

that dilated vein

and certainly don't throw a needle in there.

Go ahead and relax and you'll see that vein collapse.

So just know that that is where we're looking for

the posterior suprascapular nerve back here.

There are those other neurovascular

structures in the area too.

So if I were looking for a paralabral cyst,

sometimes they dump from the nine o'clock labrum back here,

but for the most part, from what I understand, they,

they also can happen in the superior labrum

and drop down into this notch.

So you may not see the stock of the cyst back here.

It may be that this is a, a superior lab tear

that has dumped its cyst down this notch so that

that cyst can just pull down there instead

of it being something

that you see originating from this part of the labrum.

So if you do see a cyst there

but you can't find the tail, obviously you're gonna need

to have an MRI anyways to see the extent of the lab tear.

But that is what you should be aware of.

Also, that is the

posterior shoulder from a rotator cuff

and standard evaluation minus the axillary nerve involvement

back there in the quadrilateral space, quadrangular space.

But from reviewing the infraspinatus tendon

as a rotator cuff structure

and the Terry's minor as a rotator cuff structure,

those are the standard things to look for.

I would say the Terry's minor is very

forgotten in the shoulder exam.

Almost nobody looks at it.

So if it's not a part of your normal protocol, I,

I would say it's normal for it not to be a part

of your normal protocol.

But don't forget about it

because sometimes you do need to measure it against the in

infraspinatus and it is a requirement in the A IUM

protocol for shoulder exam.

So you shouldn't skip it.

You should at least get the two views long

and short axis of the Terry's minor as a part

of your routine shoulder exam.

But that will conclude today's webinar on

the put your shoulder.

If you have any questions, go ahead

and just type those in the chat portal while we're waiting

on those questions.

Don't forget, next webinar is over the superior shoulder

where we're gonna cover AC joint,

some dynamic maneuvers here

and some other surrounding structures

after the basic shoulder exam of the AC joint

and its dynamic maneuvers.

We will also cover some of the surrounding muscles

and nerves and answer your questions live like we always do.

- All right, as Daniel said, it is time for q and a.

If you want to, you can put your questions in the q

and a box located at the bottom or the side of your screen.

Just go ahead and type those in there and we'll go ahead

and get to those as we get to them.

Daniel, do you have anything that you would like to add on

to what we saw?

Sorry, what we just saw,

- You know, that was a prerecorded webinar

that took place in 2021

and since then our, our patient has had a shoulder injury

that we actually mentioned on the last webinar.

So her left shoulder's been operated on, so

a little interesting change in the landscape here.

So I'll point a few of those things out.

Seemingly normal labrum at this slice here,

but as I go more inferior, we start

to see an anchor site divot in the humus.

And then if I go even more inferior, we'll start

to see the sutures in her labrum down here where she's had a

inferior cap repair.

So she's got anchors in the front

of her shoulder and the back of her shoulder.

But these are deep sutures down here,

right where my arrow is.

And anytime you're evaluating things

that have been healing over time,

it's always a good idea just to check

for new blood flow neo vessel.

So I'm gonna do that today.

I'm gonna press the C button here on the Cyte PX

and we're gonna look for new blood vessels

that typically don't traverse down into the labrum.

So very light pressure, you don't wanna push down too much

and we have some normal arteries sitting back here in

that superscapular notch, which is a great place

to calibrate your color actually.

So while we wait on questions to come in, just listen

to some scanning tips on calibrating your color.

If you don't see the superscapular art back there,

you might wanna consider changing a few settings on screen.

May you consider turning your gain up a little bit.

Pulse repetition, frequency

or scale needs to be down low enough to see low level flow.

There we go. Other consideration is go look

for the wall filter on your machine,

which is like a noise suppressor

and you wanna make sure the wall filter's fairly on low,

but it's gonna subject your transducer to a lot of

tissue motion as well.

So I, on the sauna site px, I find that I get away

with a medium wall filter very nicely on the MSK exam type.

And I'm gonna, I'm gonna track these arteries

and we're gonna follow one

or two of them down into that labrum,

which we don't normally see.

So kind of like a cooking show.

I've previously scanned our patient today and there we go.

You can see that little off shooting artery.

Let's get my arrow back up.

We're gonna watch this one little vessel

feed off there it goes.

Little steady hand

and that is kind of a new communication into the lab.

We can follow that all the way down into the anchor site.

A lot of, a lot of times

you wanna very suspicious of color activity next to bones

because these little flashes

are most likely just the tissue motion really fast against a

hard specular reflector and ultrasound.

So what we're looking for are these teeny,

teeny tiny little blood vessels to be

in areas we don't normally see them.

Like we saw that first arch artery making its way over into

the, to the majority of the labrum there.

There we go. But open

for the questions, Chris is on the chat portal

and he can ask those live.

Let's get a new external rotation on our patient

because those,

those sutures definitely take a little bit of a different look.

So let's go external, there we go. And then

- Internal, you can see that divot site where the anchor is

right in there and externally rotate.

Very good

superficially on our patient today.

We can see a portal,

- See our arrow highlighted.

So this little divot in the skin right there,

that dark shadow, that's one of her scope portal.

So it was interesting to see that heel over the course

of a year and it had its own little neo

vessels associated with it.

And then we have another scope portal right up here

where there's kind of a shadow at the skin level where that

they're fairly obvious once you go over them.

Yeah, a little lower. Okay,

- Are there any other injuries where it's helpful

to have the, the color on?

- Yeah, you bet. So even if it's not an acute injury,

chronic disease,

chronic tendonitis can also show up that way.

We should not see those vessels inside tendons.

So in a normal tendon we don't see the vessels.

So if we just wanted to check out for some sort

of a a tendonitis,

- You want an appropriate depth on your machine,

- Fairly centered.

So all your focus is in the middle.

And then we're gonna throw the C button again for color

and we should have a pretty healthy tendon here.

These fibers look normal longitudinally striated,

I don't see any swelling in the fibers like a

loaded paintbrush.

So I don't, I don't see a tendonitis look,

I don't see a degeneration of the fibers either.

So the fact that I'm seeing nice ations is just telling me

that we have a healthy tendon here.

If it were diffusely dark, what we call hypoechoic

and I lost the filar pattern of the tendon,

but the shape of the tendon was still there,

it start looking into things like tendonosis, which

depending on its stage can also have hyperemia

or the, the, the neo vessels within the tendinosis as well.

So mainly it's those

and also the, to avoid structures when you're doing

procedures in the shoulder, you imagine the injections

around that quadrilateral

or quadrangular space, you might wanna miss the artery

and the nerve if you're just trying

to free one up like a hydrodisection where you get in there

and infiltrate the whole space with saline and,

and really free everything up.

You'd wanna have your color turned on for that as well.

So say we wanted to miss the vessels in this

quadrangular space here.

We could drive a needle right into that little triangle,

maybe even use the left right side

so we can drive the needle on screen right

without all the tissue motion associated

with the needle moving and we can see the

artery really, really nicely.

What we're gonna try to miss, or you can go top bottom

and have the whole transducer, just a smaller field

of view on the screen,

but it's very helpful in procedures to run color

alongside your needle

because it can be, it can be a minefield in there.

Great question.

- Yeah, we've got another question coming in.

What is the approach for posterior GH steroid injection?

- Okay, so I, I get this question a lot

and it depends on your subspecialty, I think.

I think a lot of people are just trained to go

and palpate right underneath the acromion process

and drive their needle towards the oid.

I've even seen people drive the needle down in there

and then turn the humerus

to see which bone they're hitting with the needle.

You don't have to do that with ultrasound.

You now can visualize your approach.

So instead of going straight in 90 degrees to the joint,

which would be the blind approach

and it is a slightly shorter approach

and that's fine, we're gonna come out more lateral so

that we can slide the needle right under the joint capsule.

So the most traditional approach by ultrasound guidance

that's that's taught throughout the country really is

to bring your, and,

and what I will say from a technical standpoint is if you

have too much humeral head in the shot,

like say this is a great diagnostic picture, okay,

all our landmarks are there, it looks really pretty.

But if you come in from lateral

and you're trying to get into the joint here,

you're probably gonna hit the humal first.

So my tip for you is to put half the humeral

head over on screen, right?

- There you go. So that way when you drop your needle in

this way, you'll see your needle.

And I'm just gonna freeze

because our patient definitely will not,

lemme drop a needle in there, there

and then I'm gonna hit caliper and we'll

- Simulate our needle trajectory.

You can stop the needle at the tip

of the labrum under the joint capsule, right where

that caliper is at about that trajectory.

And that's coming in at about, I dunno, 30 degrees or so.

And you wanna be right under that long

axis of the transducer.

There's a factory seam on the transducer typically,

and if you just drive your needle right under that,

align your syringe handle with the seam at the top

of the handle and you should stand,

that's the most traditional approach by ultrasound.

I also see it taught to go the opposite way in a lot

of parts of the country, depending on your specialty.

And I see a lot of sports guys going this way.

So basically bringing your target more screen left,

I'm gonna hit freeze

and then they would drop their needle right through the edge

of the labrum and just give it a little puncture.

Which, you know, I guess if that's what you wanna do,

you can drive your needle through

a little bit of the labrum.

I, I guess no harm, no foul,

but for me, why, why would you wanna hit the labrum

with a corticosteroid which could

degenerate the connective tissue if you're trying

to avoid surgery down the road, you know?

But those are the two main approaches

and then less commonly seen.

But I think it's, it's more an adaptive change

for people'll center the joint

and do something like center line on their machine

and right under that arrow on the transducer,

they'll go out a plane.

You just gotta be real careful not to overshoot

and you're definitely gonna go

through the labrum on this one

and drive the needle outta plane this way.

What you need to be careful of is if you're going under,

depending on how your patient's positioned,

if you go under the probe like this,

you may have gel coming into your,

into your needle puncture site.

So you don't want that, you want your transducer

to be under the puncture site, but that's pretty common.

But I think it's, it's just an early adoptive phase

of doing these injections to go this way.

The more familiar you get with ultrasound,

the better you get with positioning your patient.

It's more common to put 'em into a lateral decubitus

position with a affected shoulder up in the patient facing,

you just have them hug a pillow

and that puts you in a really comfortable ergonomic

position this way.

So you're not trying to do this or do any trick shots.

If you could set the patient up in a way

that they're always set up like a knee injection

where you get to hold the probe real comfortable

and just drive the needle in the same angle every time.

Rotate and set up your patient that way too.

So I would've our patient on the table lay them lateral

decubitus and affected shoulder up

and body facing each other

that way the glenohumeral joint is facing my needle

and I can just come in screen write, drop the needle down,

not quite 45 degrees.

Great question.

- Awesome. You said that the previous,

the recorded part was from, what was it, 2021.

Are there any kind of more up to date techniques

or anything like that that you've learned in that time?

- You know, there are more advanced diagnostic structures

that go beyond the scope of this webinar.

Like some of the other kind

of crazy ligaments in the shoulder that are beyond

traditional diagnostics.

Some of the humeral ligaments are not traditionally

scanned, there's not a lot of protocols for that.

But it, it is something that, you know,

with my patient here having the shoulder surgery she had, I,

I got to learn a lot about those posterior inferior glen

hemal ligaments and the anterior inferior glenohumeral

complex and that whole axillary scanning fold,

that would be a whole webinar in its in, its in its own just

to go through the axillary recess

and those connective tissues, how to navigate

around neurovascular structures,

looking at ligaments in normal and abnormal

and even torn, which is, which is what we have here.

So I would say I got

to learn a lot about the remaining ligaments

that stabilize the shoulder.

And I've always been fascinated

with postoperative changes in shoulders

and anywhere else in the body,

but shoulders are just so common to get postoperative scans.

So if you kind of plateaued on your diagnostics

with ultrasound of the shoulder, I would, I would say

to venture off into post-surgical shoulders that'll,

that'll pique your interest, trust me.

And there's so many different ways to repair a shoulder.

I would study the orthopedic hardware company websites.

You go to their animated videos

and some of their intraoperative videos on their websites

and they'll walk you through step by step

how these surgeries are done, where the anchors go,

why they do it from a mechanics standpoint.

And that helps me go chase things down like those inferior

posterior glenohumeral ligaments.

You know, if I didn't know that they were relatively going

straight up and down on the shoulder posteriorly

because of how they hang the, the,

the humerus from the glenoid,

I might spend way too much time trying

to chase the ligaments down thinking

that they just bridge the gap transversely when they don't,

these posterior and medial inferior ligament

complex, they, they don't traverse the joint sideways.

They really hang down and,

and hang onto the rest of the undersurface of

that humeral head like a big hammock.

So the direction of the ligaments, you know, it,

it really didn't click to me until seeing these things

intraoperatively and,

and through a lot of the training resources

of the orthopedic hardware companies videos.

So that would be the best learning tool for postoperative

anatomy would be to find out why these surgeons are doing

what they're doing with, with their anchors and sutures.

What kind of sutures they're hope that helped ligaments

of the shoulder, I would say is, is is probably the thing

that has changed for me the most since then.

But rotator cuff protocol hasn't changed since

about 1999.

Middleton is the article that you would look up,

bill Middleton or William Middleton do

that search on rotator cuff ultrasound protocol

and that that protocol has become the standard AI n protocol

and it's such a rock solid protocol

because the imaging technology they had in the late nineties

was far inferior to what we have now.

So what we have now makes the imaging much easier.

Their technique had to be a lot more solid

because the machines were a little less capable in

resolving the tissue.

Their beam had to be much more perfect in their slices.

So we're pretty spoiled on our image quality now

and our training resources.

But if you go study the article, especially from Middleton

and te, I think it was published in 1999

and the American Journal of Radiology,

that's the foundational rotator cuff article

that we still use today

and it's a, it's based, it's

what the A IU protocols are based on.

So there have been no new advances to

shoulder protocol as we know it

and what should be covered since we did this video in 21.

No, but we're never done learning.

That's for sure. Anybody that's doing ultrasound on

in the chat can can tell you that no longer, no, no matter

how long you've been doing this, you're never done learning.

- Alright, well I don't see any more questions coming in.

Okay, so just a reminder, we'll be rerunning the fourth part

of the shoulder webinar series on the superior shoulder

on January 16th.

It'll be at the same time as it is today, 6:00 PM PST.

We'll also be announcing some more webinars soon.

So keep an eye on

behind the skin webinars page on sono site.com

for more details on that.

Daniel, I'd like to thank you for taking the time

to put together the original presentation and coming back

and doing the q and a again,

we appreciate you sharing your expertise, expertise

with our audience and everybody else.

Thank you so much for joining us today,

we really appreciate it and we'll see you at the next one.

- Thanks everybody.

Join us for an exciting discussion on posterior shoulder exams. Our experts will review clinical images and share 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 posterior shoulder including the infraspinatus tendon, glenohumeral joint, teres minor, and posterior facet
  • Learn indications for an evaluation of the posterior shoulder
Daniel Shelton
Presenter: Daniel Shelton, RT(R)
Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

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.

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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.