Transcript
- [Laura] Welcome to the Sonosite Behind the Scan webinar
on rotator cuff pathology.
My name is Laura Jacob,
and I will be helping to moderate today's webinar.
With me is Chris Pennell, digital content specialist,
who is helping behind the scenes,
and Daniel Shelton, director of MSK Market Development,
who will be assisting
with the live demo portion of the webinar.
Before we begin, please be advised,
all attendees are muted.
You may type your questions into the Q&A box
located at the bottom of your screen at any time,
and we will conduct a Q&A session
at the end of the presentation and live demo.
This webinar will be recorded and archived
on our Behind the Scan webinar
website for future reference.
I am delighted to introduce our presenter today,
Dr. Ben DuBois.
Dr. DuBois is an orthopedic surgeon
and shoulder surgery specialist
at Grossmont Orthopedic Medical Group.
Ben DuBois is a board-certified
and fellowship-trained orthopedic surgeon
who devotes 100% of his practice
to the treatment of shoulder disorders.
Dr. DuBois has expert training in shoulder surgery
and has extensive experience in shoulder replacements,
rotator cuff disorders, and arthroscopic shoulder surgery.
He has trained in the state-of-the-art techniques,
including reverse ball and socket shoulder replacement,
and performs in-office shoulder ultrasound
for the immediate diagnosis of rotator cuff disorders.
Dr. DuBois has also contributed quite a bit of education
for us here at Sonosite,
including teaching at a cadaver lab
and hosting a couple of webinars
on diagnostic shoulder and shoulder injections,
which can be found on Sonosite Institute.
And today, we're delighted to have
him back for this webinar.
And Dr. DuBois, I will turn it over to you to get started.
- [Ben] Thank you, Laura, for the introduction.
It was very kind of you.
As she said, my name is Benjamin DuBois.
I'm an orthopedic shoulder surgeon in San Diego,
California,
and we're going to spend some time this evening
talking about rotator cuff pathology
and ultrasonography of the supraspinatus tendon,
which is one of the main things we look at
as orthopedic surgeons.
So I'm in San Diego, I'm in private practice,
been here since 2004,
done several thousand shoulder surgeries
throughout my career
so I'm pretty good as far as correlating
ultrasound pathology to what I find during surgery.
About half the surgeries I've done
are shoulder replacement surgeries,
and the other half are arthroscopic surgeries,
such as a rotator cuff repair.
And so my winding journey,
how to learn how to do MSK ultrasound,
started back when I was doing
my shoulder surgery fellowship
with Dr. Rick Manson at the University of Washington
in 2003 and 2004, and at that time,
there really wasn't any regimented program
to teach young orthopedic surgeons,
like myself at the time, how to do ultrasound.
And so one day, at the beginning of my fellowship,
there appeared a laptop-looking device,
and I go, "That looks interesting, what is that?"
And Dr. Manson says, "Well, that is an ultrasound machine."
It's at the very beginning of the advent
of the portable handheld ultrasound machines
that could be used by surgeons in our office.
And so he gave me the choice,
do you want to spend a year in the rat lab doing research,
or would you rather learn how to do ultrasound
and hopefully do some research with that?
So it was a very easy choice for me.
So I spent the year kind of teaching myself how to do it,
use it in my own fellows clinic,
and I got a lot of really good feedback from the patients.
And then when I got into practice in 2004,
first thing I did is I bought myself a ultrasound machine,
and I've been doing it ever since.
And so I've taught numerous MSK courses over the years,
dating back to probably about 2006 or 2007,
probably taught maybe over 1,000 doctors
and physician's assistants how to use
MSK in their practice.
And so I use it predominantly in my practice.
I'd say most of it is for ultrasound guided injections,
but also use it a lot for diagnostic studies,
and that's what we're talking about this evening.
So some of the things when you're starting out
as a beginner, just like I was back in the day,
technique is important.
So you definitely want to learn how to use ultrasound
properly from the beginning.
So I would highly recommend getting hooked up
with UG Films on a site to get some hands-on training
or seek out a course of your own that you'd like to go,
but the key is getting hands-on
and learning how to do it right from the beginning.
Repetition's important.
There's certainly a learning curve in this.
And so you want to get your hands-on experiences
as much as you can,
even if you don't really feel like you know exactly
what you're doing right out of the gate.
The more and more you do,
you're going to get more and more comfortable
simply holding the probe, knowing how to do an exam,
and then also knowing how to interpret
what you're actually seeing on the screen,
because there's really two main things.
It's doing the exam properly, of course,
so you can see the images of what you want to see,
but it's also interpreting what you're seeing on the screen
and understanding the difference between a normal exam
and an exam with pathology.
It does get easier, I promise you that.
A lot of people probably find it takes a couple of hundred,
either ultrasound guided injections or diagnostic studies
to really feel like you know what you're doing,
but certainly it's operator dependent.
You are the operator.
It's just like being a surgeon.
You are the operator, the probe is in your hands,
but like I tell most people who come to my courses
that I teach, I say,
"Look, you got up out of bed this morning,
you got in your car, you drove to work."
All those things are operator dependent,
but no doubt you can handle this or you can handle that,
so it just takes some time.
So why do we want to use MSK ultrasound in our offices?
Well, you can image all the things
that are of interest to you
as an MSK specialist, muscle, tendon, fluid, bone.
These are the things that we like to look at
as orthopedic surgeons.
Ultrasound provides you with dynamic live images,
so it's different than just a simple static X-ray
or a static image from a CT scan
or a static image from an MRI.
This is all live.
It allows you to move the probe anywhere you want,
take as many angles as you want at something,
and you can look at it from multiple different views.
So that's one of the nice things.
There's no known side effects.
There's no radiation.
So for example,
if you try to do live images with a CT scan,
that's a lot of radiation
where ultrasound has none of that.
So there's no known side effects.
These machines are portable, either handheld,
you can carry them around,
or you can get one and put it on the rolling cart,
which is very handy,
and they're relatively inexpensive.
Certainly when you compare this
to the cost of a MRI machine,
it's significantly less expensive
and it's more affordable for people
who are in maybe private practice or small group practices.
There's very high spatial resolution.
So you'd be amazed when you get your hands
on one of the newer models,
just how clearly you can see things down to a millimeter.
It's pretty remarkable.
When I was starting back in 2004,
I would equate it to the comparison
of watching a black and white television
versus what we have currently
with the 4K ultra high definition.
So things have come along a long, long way
because of companies like Fujifilm Sonosite.
I mean, they've spent a lot of time and resources
improving the image quality that we have today.
And one of the important things about ultrasound
and one of the main uses I get out of it
in my private practice is using it
on post rotator cuff repair patients,
'cause there's no artifact like you would get on an MRI.
And so I don't know how many of you have seen MRIs
that have had prior surgery before,
but there's a lot of artifact.
It kind of looks very blurry.
It looks like kind of a bomb went off in that shoulder
and you really can't see what you would like to see
because of the artifact of say suture anchors
or metal implants or things like that.
So when you're first starting out,
one of the nice things about ultrasound
and you're learning in my mind,
I try to compare the images that I'm getting
with a shoulder ultrasound to what I would see
on something I was very familiar with looking at,
which is an MRI.
And so the MRI, you're either going to have coronal cuts,
sagittal cuts or axial cuts.
And so on ultrasound,
you are getting those same so-called cuts.
It's just, you have to perform the ultrasound
to put the probe in the appropriate position
so you get the images that you would like.
And so here's a side-by-side comparison
of what a coronal view of
a supraspinatus tendon looks like.
And so on the right side is an MRI,
which is a coronal view of the right shoulder.
And so you see the entire ball and socket.
You see all the way deep down into the axilla.
So it's kind of a big picture.
You can see the supraspinatus certainly draped
over the top of the humeral head and inserting,
but that area is relatively small
compared to the overall picture of the MRI image.
Whereas on the left,
you have a coronal image of a supraspinatus insertion.
And so what you see is right above
the dense transverse white line,
which is the cortex of the humeral head.
You'll see the supraspinatus tendon in really good detail
with a very small dark line surrounding that,
which is the subacromial space.
And so there's a little bit of fluid
in the subacromial space under normal circumstances.
But what you can see with this
is you're really getting a very zoomed-in image
of the supraspinatus compared to an MRI.
There's an important concept that you need to understand
as you're beginning to do ultrasound
and as you're moving forward with your skillset,
because you can get caught up very easily
thinking that there is a tear there,
when in reality, there is not.
And this is something called anisotropy.
And anisotropy is, in essence,
something that you can equate to a false positive
on an ultrasound machine image,
meaning you think you're seeing a tear of a tendon,
for example, but in reality, there's no tear there.
And typically what this has to do with
is the ultrasound probe not being perpendicular
to the fibers that you're looking at.
So for example, on the left side here,
we're seeing a coronal image,
or as if you're looking at someone's shoulder
from the front of the left shoulder.
And the dense white line at the bottom of the screen,
that's the top of the femoral head.
Right above it is a supraspinatus insertion.
And what you notice is there is, for the most part,
generally speaking, the signal is the same.
There's not a lot of heterogeneous signal.
There's not a lot of dark areas in it.
You can really see the tendon quite clearly
as it's attaching to bone.
Whereas on the right, this is the exact same shoulder.
But what I've done is I've just tilted my probe
about 10 to 20 degrees.
And if you notice to the right of the screen,
that area of darkness, which looks like it's enveloping
probably 90% of the lateral supraspinatus,
most people who would look at that, who are beginners,
would say, "Hey, that's a tear.
"That's a high-grade partial thickness undersurface tear."
But in reality, it's not.
And so once you get the ultrasound probe in your hand,
you're going to be able to tell what anisotropy is
because all it really is is angling your probe
10 to 20 degrees.
It's not very much.
And you can literally make tendons disappear.
And so that's a very important concept
to understand when you're struggling.
And this is one of the reasons why
with the supraspinatus tendon, we see anisotropy.
And if you see the area, which is labeled B,
those are more of the superficial dorsal-sided fibers
inserting into the lateral anatomic footprint
of the humeral head.
And if you notice, those fibers are going
relatively transverse at a very shallow
angle as they insert.
And so the ultrasound probe would be overlying that,
would send the transducer waves into that,
and they would bounce directly back into the probe
and be captured by the probe.
And the probe and the computer
would interpret those as a solid tendon.
Whereas if you see the area labeled A,
if you notice those fibers of the supraspinatus
are taking a right turn,
and they're kind of diving down perpendicular
to that medial aspect of the anatomic footprint.
And the reason that area disappears with anisotropy
is because those ultrasound waves
are bouncing off of that A area at an angle
and they're reflecting away from the probes.
The probe is not capturing all of the waves
that it's sending down there.
They're not all coming back to the probe.
And how the computer on the inside of the machine
interprets that is there's nothing there.
And so that's why it ends up being dark.
So when you're getting patients ready to be examined,
I think it's important that you have both shoulders exposed
just in case you would like to look
at the contralateral shoulder as a comparison view.
What we always want to do is set things up
so we can get coronal views and sagittal views.
And so with a coronal view,
typically I would have the patient put their hand
in their hip and bring their elbow back
'cause what we're trying to do is deliver the insertion
of the supraspinatus out from the undersurface
of the acromion.
Because ultrasound waves are not going to penetrate
through the acromion 'cause it's a thick bone.
The ultrasound waves will just reflect off of it
and you won't be able to see the tendon.
So as you deliver that insertion out
from underneath the humeral head,
or I'm sorry, the acromion,
what you do is you put your probe parallel
to the fibers of the supraspinatus.
And so those fibers of the supraspinatus
are originating right up underneath the trapezius
and they're inserting right there
in the lateral anterior aspect of the humeral head.
And so on the right side of the screen,
what we see is a nice coronal view
of the insertion of the supraspinatus.
So there's no tear there.
It's a normal appearing coronal view.
Now, in order to get a sagittal view,
all I do is turn my probe 90 degrees.
It's simple as that, 90 degrees.
Now it can be difficult
because you've got a bunch of gel on there
and things are a little slippery.
So you've got to stabilize the probe on the shoulder
as you're rotating at 90 degrees.
And as you do that, you're going to get a sagittal view.
So now my probe has been turned
so it's actually perpendicular
to the line of the fibers of the supraspinatus.
And so on the right side of the screen,
what we see is on the very left side of that image,
you see that dense hyper-echoic oval.
That's the biceps tendon.
And the biceps tendon runs in the rotator cuff interval,
which is just in between the anterior supraspinatus
and the upper border of the subscapularis.
And so that's kind of a landmark we look for
in shoulder ultrasound is looking for that biceps tendon
'cause then you can tell exactly where you are.
You know you're in the rotator cuff interval.
Just to the right of that
is the anterior aspect of the supraspinatus.
So once again, we've got a nice thick, healthy tendon here.
No tears.
Now, this is what a full thickness tear looks like.
I know many of you are just starting out,
but if you go to your office tomorrow
and put the ultrasound probe on someone's shoulder,
you shouldn't miss this
because sometimes it's really this obvious.
So on the left side of the screen,
what we've got is a coronal image of the left shoulder.
And so the right side of the screen there
of the image is lateral.
The left side of the screen is medial.
And so what we see is that very clear
bird's beak appearance of the supraspinatus.
It starts out quite thick on the left side of the screen
and it tapers off into the bird's beak
on the right side of the screen.
And so that is a normal looking supraspinatus.
The bottom white line, that hyperoclip line
is a cortex of the humeral head.
The second hyperoclip white line above the supraspinatus
is the interval between the superior supraspinatus
and the fascia of the undersurface of the deltoid.
And so normally you would see a
double white line like that.
Now on the right side of the screen,
right smack dab in the middle of the image,
you see a bunch of darkness, okay?
And darkness on ultrasound typically equates to fluid.
And so the dummy's approach to ultrasound
is if you see a bunch of fluid
where there should be a rotator cuff,
that's a full thickness tear typically.
And so what we see is fluid where fluid doesn't belong.
And the other thing you see is the deltoid,
which are those transverse fibers
running right above that hyperoclip dark area.
The deltoid is almost touching the top of the humeral head.
It shouldn't be doing that
because there should be a big thick supraspinatus tendon
there like there is on the left side of the screen.
So this is a coronal image of a full thickness tear
of a supraspinatus with about two centimeters
of retraction at least.
There's a little stump to the left side of the screen,
that hyper-echoic area
that's probably the retracted edge of the tendon.
Now, if I turn my probe 90 degrees, same shoulder,
on the left side of the screen,
I've got a perfectly normal appearing sagittal image.
So there's that hyper-echoic oval on the right side.
That's the biceps tendon.
Just to the left of that is a nice, thick,
healthy looking supraspinatus tendon,
anterior, middle, and posterior.
So there's no areas of fluid there.
You look at the right side of the screen
and what you've got is the same thing
as the previous images.
You've got fluid where fluid doesn't belong.
You've got fluid going from the top of the humeral head
all the way to the undersurface of the deltoid.
That is a full thickness tear.
To the left side of that image,
you'll notice there's some tendinous stuff
in between the humeral head
and the undersurface of the deltoid.
So that's probably getting
into some posterior supraspinatus
or maybe upper part of infraspinatus that's still intact.
Now, as a surgeon, I scope a lot of these shoulders.
And so I have the benefit of being able to see
what it looks like on ultrasound or MRI
and comparing that to what I actually find during surgery.
And so this is the same patient.
This is a torn, full thickness supraspinatus tendon
that's retracted over to almost the level
of the articular margin.
So this is about a two centimeter retracted tear.
So on the left side there,
you see at the bottom of the screen,
the anatomic footprint
from where the tendon has tore away from.
Now, I've already prepped out this area
with my burr to kind of get it ready to repair.
So it's a nice smooth surface, bleeding surface.
That's good for something to heal to.
And then at the top of the screen,
you see that dense or thick white tendon that's retracted.
That's the supraspinatus tendon.
And so my job is to take that tendon
and repair it down to that anatomic footprint
from where it tore away from.
And so how we typically do that is with suture anchors.
And so on the right side of the image,
this is after the repair.
So you'll see there's three small holes
that I tapped in the tuberosity area,
passed the sutures through the tendon,
pulled the tendon back over,
and then I anchored it down
with things called suture anchors,
which can either be titanium or bioabsorbable plastic.
And so it doesn't really matter what they're made of,
but the concept is to tack that
thing back down to the bone.
And these typically take about 10 to 12 weeks
to be completely healed after repair.
So that is a solid-looking rotator cuff repair
with three sutures and three anchors.
This is also a full-thickness rotator cuff tear.
So on the left, you have a coronal image,
and on the right, you have a sagittal image.
And what we see, once again,
is the dark fluid that goes all the way
from the surface of the top of the humeral head
all the way up to the undersurface of the deltoid.
And on the left side of the left image there,
you'll see a stump of the supraspinatus tendon
overlying the humeral head,
and that stump is a retracted tear.
Also what you notice on the right,
there just appears to be a lot of debris
and a lot of kind of shredded up stuff in that area,
which oftentimes we'll find arthroscopically
to be a lot of shredded up bursal tissue.
Sometimes it's torn up tendon.
I could just tell before I scoped the shoulder
that I was going to find some kind of
ratty-looking tissue in there.
And so that's exactly what I found.
And so on the left side of the screen,
this is what the full-thickness tear looks like.
This is more of a degenerated kind of shredded up,
ratty-looking tear where you still have some remnants
of the tendon attached to the tuberosity
at the bottom of the screen
that I would subsequently remove
before I did my repair.
At the top of the screen on the left,
you have this kind of shredded up,
supraspinatus tendon that's retracted
about a centimeter and a half or so.
And then that kind of bright white thing
right from the middle of the screen,
that's the long head of the biceps
as it's running out of the shoulder joint
down the bicipital groove.
And so my job here, once again,
is to kind of remove all this shredded up stuff,
prep this thing,
pass a couple of sutures through the tendon,
tap two holes down there in the anatomic footprint
and dump my anchors into there and tighten it down.
And so that's another good-looking repair.
This is a very interesting case
and we'll see these periodically,
which is a delaminated full thickness tear.
And so in the middle of the screen here,
what we've got is it is a coronal image.
So as if you're looking at a shoulder from the front
of the right shoulder.
So to the left of the screen would be lateral deltoid,
to the right of the screen is medial
going more towards the patient's head.
And what I see here in the middle of the screen
is I see almost two layers of a tendon.
It looks like a V turned on its side
where in the subacromial space,
I'll see what appears to be a delaminated,
differentially retracted tendon
right about here at the top.
Whereas underneath what I see
is what appears to be still intact tendon
on the articular side.
So this to me looks like it could be a partial tear.
It could be a delaminated full tear.
But what tipped me off
that this is probably a full thickness tear
is I see once again, darkness here.
Fluid where fluid doesn't belong.
Fluid like this is a lot
and this should be retained within a joint space.
But what I see is that dark area outside the rotator cuff.
That indicates to me
there's probably a full thickness perforation
of the tendon and it's accumulating
outside of the rotator cuff.
And so when I scoped the shoulder,
I found exactly what I thought I would find
and what remarkably looked just like the ultrasound limit.
So on the left side of the screen
kind of tells a whole story.
At the top of the screen,
I've got that differentially retracted,
versatile sided tear.
But if you notice underneath that,
just to the bottom of the screen,
we've got that intact band of supraspinatus
that's still attached to the greater tuberosity.
But as we fill the shoulder up with sterile fluid
during arthroscopy, all of a sudden a hole appeared.
That's where the fluid's coming from.
That's the bottom right side of the screen.
That's the full thickness perforation through the tendons.
That's where all that fluid is kind of extravagating
out of and accumulating in the subacromial space.
And so what I'll do is I'll debris all this stuff up
and I'll end up repairing it.
So if you're a beginner with ultrasound,
here is a good thing to start with.
Somebody who comes into the office,
typically they're elderly,
they can barely raise their arm away from their body.
You get an X-ray and it shows evidence
of something called rotator cuff arthropathy.
And rotator cuff arthropathy is the end result
of a massive chronic retracted atrophic rotator cuff tear
that typically involves a supraspinatus,
the infraspinatus and oftentimes the subscapularis.
And so what you'll find on X-ray is these telltale signs
that they've got chronic massive tears.
You'll notice the humeral head is articulating
with the undersurface of the acromion.
So there's no space in between those two bones
for a rotator cuff to be existing.
And so automatically you know
that this is going to be a big old tear.
And so to develop your confidence with ultrasound,
why don't you ultrasound one of these?
Because you're 100% sure
before you ever put the ultrasound probe
on somebody's shoulder,
that you're not even going to be able to see a rotator cuff
because it's all torn and retracted.
And so typically what you're going to see
is on the right side of the screen,
the dense white line is the cortex
of the superior humeral head.
And just above it, you've got that little dark area fluid,
which is fluid emanating from the joint.
And just on top of that is the deltoid.
And what you'll see in these cases
is deltoid is draped right over the
top of the humeral head.
There's no rotator cuff in sight.
Okay, and so these are pretty easy cases to start out with.
This is what it looks like arthroscopically
as I'm in the joint,
looking up at the undersurface of that supraspinatus.
So that area that looks like a little walled border
going from top to bottom,
that is the edge
of the retracted atrophic supraspinatus tear.
And that shredded up thing right there,
kind of the bottom of the screen,
that's actually where the long head of the biceps
is attaching to the superior glenoid.
So you can see this tendon is retracted
all the way to the level of the glenoid,
which was not a surprise based on these X-rays
and ultrasounds.
One of the most satisfying things in my practice
is dealing with something called calcific tendonitis.
And so calcific tendonitis can be a very debilitating,
painful disorder that people get
for really unknown reasons.
And so they come to the office,
they're hurting like heck,
you get an X-ray,
you see this big wad of calcium
overlying the anatomic footprint
and the greater tuberosity.
And so most of these cases,
the calcium is residing within the substance
of the supraspinatus.
Sometimes it's escaped out of it
into the subacromial space,
but oftentimes you'll see this residing within the tendon.
And so if I'm ultrasounding the same patient,
what we'll see here right smack dab
in the middle of the screen is the supraspinatus
as it's attaching to the greater tuberosity
will have this dark hypoechoic circular area
within the substance of the tendon.
That is a calcium.
Oftentimes this calcium is so dense,
ultrasound waves are not penetrating through it.
They're all reflecting off of a superior aspect
of the wad of calcium
and they're reflecting back into the probe.
And so the probe interprets that as a hypoechoic area
with nothing residing in there.
Now we know there is something residing in there.
It's just such a dense calcium.
The ultrasound waves are not penetrating it.
And what you notice is on the undersurface
of where the calcium is,
there's something that I refer to as a bone shadow.
And so the ultrasound will not penetrate
through the calcium.
And so what you'll get is almost a shadowing
where the cortex of the superior humeral head
disappears underneath it.
And so it's not a fracture, but the cortex is there.
You're just not seeing it
because the ultrasound waves are not penetrating.
Now these are super fun cases
'cause they're very satisfying.
On the left side of the screen,
I have an image of what one of these red hot,
painful calcific tendonized cases looks like.
So I'm in the subacromial space.
I kind of got a bird's eye view.
That's my shaver.
The metallic thing on the left is my shaver.
And right below that, you see that white area.
It looks like a zip ready to be popped
or a volcano about to erupt.
And surrounding it is just this very intense,
inflamed, dorsal action going on.
This is why people hurt.
And so as soon as you take a needle
and you poke a little hole in that tendon,
it's like squeezing a tube of toothpaste.
This calcium just comes flying out of it,
explodes out of it like a volcano erupting.
So these are super satisfying cases
'cause you can solve people's problems
essentially immediately, get rid of it,
wash all that stuff out of there and you're done.
Bursitis cases.
Normally we don't see a lot of rip roaring bursitis cases,
but periodically we will.
We'll see patients with something that looks like this.
And so this is a coronal image of the left shoulder.
And so to the medial aspect of the screen,
we've got the medial aspect of the supraspinatus.
To the right, we've got the insertion of the supraspinatus
over the anatomic footprint.
And the area directly surrounding that,
you'd see a dark band of fluid
in between the cortex of the humeral head
and the undersurface of the deltoid.
So that's a lot of fluid in there.
And so these are super duper easy to get at
with ultrasound guided injections
because your target is such a large area of fluid.
It's like throwing a rock into the ocean.
You can't miss, particularly using ultrasound.
You can watch the needle go right into that fluid.
And as you're injecting some anti-inflammatory cortisone
in there, you can see that fluid
actually filling up that space.
So that's what the bursitis looks like.
One of the main benefits I get out of my practice
being a shoulder surgeon
and doing lots and lots of orthoscopic rotator cuff repairs
is if somebody down the road ever was not doing well
after their rotator cuff repair
or sometimes people take their slings off
four weeks after surgery and take the dog for a walk
and trip over the curb and hurt their shoulder,
those people are really concerned
that they may be disrupted the
repair that I just performed.
And so ultrasound is really, really good
for looking at these because an MRI
is going to probably be just about worthless
'cause of all the artifact
because of the suture and the suture anchors.
But with ultrasound, you don't get any artifact.
You simply can actually see the sutures.
So on the left and the right,
you're going to notice right in the middle of the screen there
over the top of the humeral head
within the substance of the supraspinatus itself,
you're going to see a dense white line.
That is one of the orthoscopic sutures
which are typically non-absorbable,
thick nylon-based type of sutures
that stay in there forever.
And so you'll be able to see on the ultrasound
whether that tendon is torn or not.
And so both of these on both the left and the right images,
I would feel super happy about the results of this
if someone came to the office not doing well
'cause I would see this and I'd say,
"Listen, I see bone, I see tendon,
"I see suture within the substance of the tendon.
"I don't see a bunch of fluid where tendon belongs."
And so this looks like an intact rotator cuff to me.
And so I would be very pleased
with the result of ultrasound.
I'd be able to tell the patient that we're doing just fine.
So we have reached the end of my portion here.
I'm going to hand it over to Daniel
who's going to be doing a live
supraspinatus ultrasonography from the studio.
And then we're going to follow that up
with question and answers live.
And so I'll be available to answer any questions
people may have about the presentation.
Thank you so much for joining us this evening.
- All right, thank you, Dr. DuBois.
If you have not visited the Sonosite Learning Institute,
I really encourage you to go check those videos out
that we have previously done
covering a comprehensive rotator cuff.
Tonight, we're not going over
all of the rotator cuff structures.
We will be covering the supraspinatus primarily
as was the topic of interest tonight.
But we have done comprehensive live recorded webinars
to show all the structures ranging from
the biceps all the way around to the teres minor
and some other oddball structures
that were brought up in the Q&A.
So just know that this is a session
with you and Dr. DuBois.
I'm simply going to be running the hands
and I'll do a quick overview of the supraspinatus
and its landmarks here in the studio.
But at any point in time,
if you want to ask Dr. DuBois a question
while we're scanning even, that's fine.
Just feel free to interrupt.
You can type your questions right there in the chat portal
and Laura or Chris will be manning the chat portal.
So with that, we'll go ahead and get started
with the live demonstration.
Today, we've got the Sonosite PX here on the stand
and I'm going to be using the larger footprint linear.
This is the L15 transducer.
So it's 15 megahertz.
And I'm just going to start by patient positioning.
This is a really big deal when
it comes to the supraspinatus
and that we have to deliver this supraspinatus
out from underneath the acromion,
just like Dr. DuBois spoke about.
I'm going to move our chair over just a little bit.
There we go.
Seems like something had moved before we got started.
Okay.
So if you're in the anatomical position,
arm just out to the side,
palm facing forward,
the greater tuberosity is tucked under the acromion.
I'll demonstrate that real quick.
Screen left will be lateral.
And here we can see,
let's see how that's looking on Zoom.
Here we can see the bony acoustic landmark
of the acromion process.
I'm going to turn my gain up just a touch for Zoom.
There we go.
And then here we can see the body of the supraspinatus
and the greater tuberosity out underneath.
So we're looking for bony landmarks first.
So greater tuberosity,
humeral head is underneath this shadow.
So to deliver the rest of this tendon
out from under this acromion,
what I need to do,
it would be great if I could abduct more and pull it out,
but we just, we run out of leverage, right?
So what we have to do
is we have to have our patient lean a little forward
and bring the elbow back
and the hand resting on the back hip.
What that does is it rolls,
it internally rotates the supraspinatus
and the greater tuberosity to an anterior structure.
You can see where my gel was.
Now we're about to roll it anteriorly.
So if I did put my probe right back where it was,
this cuff structure down here
is infraspinatus and transverse.
I have to roll my probe all the way anterior this far
just to start to make out
the greater tuberosity and profile.
There we go.
So again, following our cortical landmark, humeral head,
greater tuberosity,
the further posterior we go,
which we covered on the comprehensive rotator cuff.
If I go more posterior,
the greater tuberosity flattens out
and we get the fibers of the infraspinatus.
So you don't want to go too far posterior.
You want to go anterior enough
that we leave the humeral head
and it's kind of cartilaginous look
and the supraspinatus on top.
Let's go find the biceps tendon anteriorly here.
So this is the biceps.
Leaving the joint going in towards the bicipital groove.
And that means we've gone anterior enough.
So my next lateral structure is supraspinatus.
So this is greater tuberosity here,
long axis supraspinatus,
overlying deltoid up here,
these long axis fibers.
And then right here is that subdeltoid fascia
that Dr. DuBois had mentioned.
So after I assess this for volume
and anisotropic artifact,
which let's show that real quick.
So all I have to do to maintain perpendicularity
to these tendons is drop the handle of the probe
almost to the floor.
Now watch what happens when I bring the handle up,
basically causing the fibers that are insertional
where my arrow is,
to dive away from the transducer.
We get these anechoic fibers
or these zero or lack of echo fibers.
And that's what anisotropy artifact looks like.
- [Ben] That's a really good,
that's a great image, Dan, to show everybody
because that is the number one thing
that I see people getting tripped up on
these so-called false positive exams
where you're pretty convinced that there's a tear there.
And it's always that exact same spot too.
It's that articular sided fibers of the supraspinatus
where they take that little right turn
and nosedive into the bone.
So that's good to show.
And the other thing folks is the probe that Dan's using,
that is the workhorse probe typically
for someone who's doing a bunch of MSK ultrasound.
I use that probe for probably 80% of what I do.
I use the curvilinear probe, which he's got also there.
I think he's got a deeper probe,
which is a lower frequency probe.
That goes deeper into the body,
but the detail that you see with the probe
is not quite as good.
So you would use that, for example,
to inject a hip joint,
or I will use that oftentimes
to inject a glenohumeral joint,
which is a little bit of a deeper structure.
- Great point, Dr. DuBois.
So I'm going to move to the sagittal equivalent.
So I'm in the coronal equivalent.
Now what I'm going to do is just turn the probe 90 degrees.
I'm going to keep screen,
let's keep screen left to the patient's posterior.
I'm just going to rotate the transducer.
I'm not even looking at the screen.
I want to make sure I was relatively 90 degrees
to where I started.
Now you'll notice that the inside of the probe
is tucked almost towards where the chest is.
That's how far medial you need to go to see the biceps.
So we need to see that bony landmark of the humeral head,
and we're going to follow it anteriorly
and inferiorly here to the biceps.
So here's the biceps tendon and its short axis.
It is still intraarticular at this point,
and it's surrounded by a few ligaments
not spoke about today,
but we did go over in a previous live demonstration.
So we're going to get out of the interval
and go to the anterior margin of the supraspinatus,
which is this guy right here.
So we can see the anterior margin.
Here's the middle and the posterior supraspinatus,
and then the rest of this back here is infraspinatus.
And then we have the nice smooth
cortex of the humeral head.
Articular hyaline cartilage is nice and dark.
And then up superficial to all of this cuff structure,
we have the subacromial subdeltoid bursa,
and at least its interface.
On a normal patient, it can be a little difficult to see,
but sometimes you'll still catch a nice dark line.
If you have trouble seeing it,
you can just slightly wag the elbow,
and you can get the rotator cuff
to slide underneath that fascial interface
independent of the cuff.
So there we have the cuff gliding
under the fascial interface,
and we see a nice volume here.
So Dr. DuBois, when you're in short axis,
is that your summarizing view
because you can see the whole volume?
- [Ben] Yeah, that's a great view.
So people need to understand
that when we're looking for rotator cuff tears,
the supraspinatus, typically where those tears begin
is the far anterior supraspinatus.
So right where that yellow arrow is on the supraspinatus,
which is just posterior to the long of the biceps,
that's where most tears occur.
And as the tear becomes larger and larger,
it'll start to extend more posteriorly.
So oftentimes on ultrasound,
you'll see fluid right there next to the biceps
where there should be tendon
directly above where that yellow arrow is,
but then posteriorly,
getting into the posterior supraspinatus
and the infraspinatus, that'll be intact.
And so you will see
what looks like pretty normal tendon posteriorly,
but then anteriorly,
there'll be usually what you'll see
is the deltoid itself kind of drooping into the gap
where the rotator cuff used to be.
So you'll see it kind of drooping down in there.
One key point here is
as you're learning how to do all these things,
you're going to get lost early and often.
We all do, we all did.
And so if you get lost
and you don't really know what you're looking at anymore,
you don't know, hey, am I looking at the supraspinatus,
the subscapularis, what the heck am I looking at?
Go find the biceps tendon, okay?
Because the biceps tendon uniformly runs
in the rotator cuff interval,
which is going to go right in between
the supraspinatus and the subscap.
And then you can reorient yourself where you are.
So if you see that view that Daniel's showing you,
you know just to the left of the biceps tendon
is the supraspinatus.
- Very nice.
Do we have any questions in the chat portal?
- [Laura] No questions yet, Daniel.
- All right, so I'm going to take the scan a little further
from the humeral head out to the thesis
of the greater tuberosity.
So here we see cartilage.
We have nice cuff structure on top.
And I can show that this is nice healthy tendon.
One tip is to just angle the probe
and use anisotropy to your advantage.
So a healthy tendon will turn dark.
An abnormal tendon will remain echogenic
because it's back filled with dense collagen,
but it's non-linear, non-fibrillar,
and it's not going to respond to angle artifact anymore.
So we have a nice healthy rotator cuff here
and we're going to follow that out laterally.
By laterally, I mean on the greater tuberosity.
I'm going to drop my transducer,
relatively speaking, towards the floor
and we'll be scanning down the greater tuberosity
until it looks like there's a little rooftop.
So we still see biceps screen right.
This is our most anterior or superior facet
of the greater tuberosity.
So that's our enthesis of supraspinatus.
This is our enthesis of infraspinatus.
And here's that apex.
So this is middle facet, anterior or superior,
depending on the text reference there.
But here's the very most enthesis shot.
And here's where you're going to see
the cortex really change and get rough, wouldn't you say?
Or if you're checking out your anchors, Dr. DuBois,
this is a great spot to be looking for loose nylon.
- [Ben] That's right.
And like Daniel alluded to,
if people have chronic rotator cuff tears,
oftentimes instead of seeing that perfect dense cortex
that we're seeing right here,
you'll see it looks like almost like
something's been taken a bite out of it.
It looks very rough, irregular, abnormal.
That's just a chronic problem that develops over time
in people who have longstanding rotator cuff tears.
- All right, so to summarize,
we started in the long axis,
which is, it's really the shot
everybody likes to go straight to.
The easy shot, I've heard it described,
especially at Dr. DuBois' courses
that they hold twice a year there in Vegas,
is to point the proximal side of the transducer
just behind the ear in this diagonal angle.
And now I'm just going to rotate the transducer
and point the rest of the transducer
down towards the umbilicus.
So long axis is nice and pretty.
It gives you that coronal equivalent,
but the sagittal is your summarizing volume view.
So if you catch this image here
and all the volume is there,
and it looks like a,
I've heard this described also as a,
this is a wheel and this is a tire,
and we have a fully inflated tire.
So when we have volume loss, we have deflation,
that deltoid will dip down and fill the spot.
Those are the two views that everybody comes in
and wants to see immediately if there's a cuff tear.
Let's go ahead and have our patient relax.
You can see a lot of that anatomy
without stressing your patient.
So you might just plop the probe down
and see what you can see like we did in the beginning.
We had the acromion in the view.
We're not in the anatomical position right now
just because our patient's internally rotated
and her arm's just right on the lap.
So I can see a lot of that volume
without having to torture my patient right away.
So if you don't suspect a tear at this point,
that big gaping tear with cortical irregularities
on the tuberosity, go ahead and try your short axis.
See what you can see,
but it's when you put that tendon under tension
that it'll really show itself if it has a tear.
Dr. DuBois, is there any dynamic maneuvers
that you like to employ at this point?
- [Ben] Yes, we do.
So there's something called the dynamic contraction test.
And so we do see in our office a subset of patients
who have a non-displaced full thickness rotator cuff tear.
These are usually relatively acute.
The tendon has been torn so recently
it hasn't really had an opportunity to begin to retract
and become kind of withered away.
And so on static images,
it appears that the tendon is still attached to the bone
because it's just kind of draped right over the top
of the anatomic footprint.
Only with something called a dynamic contraction test
will you see some retraction of the tendon
compared to the tuberosity.
So you'll actually see it pulling away from the bone
as you have the patient flex their deltoid against
and their supraspinatus against your resistance.
So Daniel's putting his hand on her elbow
and she's doing an isometric contraction
against his resistance.
And just when you do this with a patient,
you got to tell them, "Be gentle.
"Gently press your elbow against my hand."
Because if you don't say that,
they're going to fly up and it's going to hit you in the face.
And so it's a nice gentle thing.
And so as the supraspinatus muscle belly is contracting,
if that tendon is not torn like this one
and it's perfectly adherent to the bone,
that tendon's not going anywhere.
You won't see any action really at all with that tendon.
Maybe a tiny millimeter of shift
as the muscle contracts.
But a person who has a non-displaced full thickness tear,
you are going to see the edges of those tendons laterally
pull medially and displace away from the bone.
And also sometimes what you'll see
is some fluid extravasating out of the joint
and coming out that hole
and kind of accumulating outside the rotator cuff.
So that's the dynamic contraction test.
- That's a really awesome dynamic maneuver.
I will say I never saw that
in all of my ultrasound training
and MSK for all of these years
until the workshops put on by you guys
as orthopedic surgeons.
So I will say in the
orthopedic surgery world in particular,
you guys are like the MacGyvers
of figuring out your own maneuvers
because you're doing a lot of these physical exams
in a unique way aside from non-operative folks.
So if non-ops could deploy
some of these techniques ahead of time,
it does also add to the dynamic exam.
This forced abduction,
I had not seen that until I was at your workshop
a long time ago there, Dr. DuBois.
So it's just a unique perspective
to see what somebody that needs this in clinic
to make operative decisions,
to prove to yourself as a surgeon
that this needs to go to the OR,
the other dynamic maneuvers of necessity
that you've come up with.
So very, very cool.
- [Ben] Very useful.
- If we still don't have any questions in the chat portal,
I really thank everybody for their time this evening.
I know it's getting a little late
and look for the recording.
If you have anybody that did register for the meeting,
they will get a copy of the recording.
Laura, do you have anything
or Chris in closing comments before we shut it down?
- [Laura] We do not have anything in the Q and A,
but I do want to second the thank you to you
and Dr. DuBois for joining us today.
This was really, really interesting webinar.
And again, just want to mention those other webinars
on Sunset Institute, they're viewable at any time.
We will post this recording as well.
So stay tuned.
- [Ben] Thank you.
Thank you, everyone.
Have a great night. - Thank you, Dr. DuBois.
Join Benjamin DuBois, MD for a discussion on correlating ultrasound findings of the supraspinatus with inter-operative findings. Dr. DuBois will present an overview of this procedure, review a case study, and demonstrate live scanning in order to portray this innovative use of point of care ultrasound. He will review normal and abnormal anatomy and discuss when ultrasound-guided injections of the shoulder are necessary.
What You'll Learn
Upon viewing this webinar, viewers will be able to provide better patient care by having an increased ability to:
- Use diagnostic ultrasound of the supraspinatus tendon
- Correlate ultrasound findings of the supraspinatus tendon with surgical findings
- Review ultrasound-guided injections of the shoulder
- Recognize when to refer verses when to treat no surgically
Shoulder Surgery Specialist
Grossmont Orthopaedic Medical Group
Benjamin DuBois is a board-certified and fellowship-trained orthopaedic surgeon who devotes 100% of his practice to the treatment of shoulder disorders. Dr. DuBois has expert training in shoulder surgery, and has extensive experience in shoulder replacements, rotator cuff disorders, and arthroscopic shoulder surgery. He is trained in state of the art techniques including the reverse ball and socket shoulder replacement and performs in-office shoulder ultrasound for the immediate diagnosis of rotator cuff disorders.
After receiving his MD with Highest Distinction from Keck School of Medicine of the University of Southern California, he entered orthopaedic surgery residency at the University of Washington. Because of his keen interest in shoulder surgery, he completed a one-year advanced shoulder and elbow surgery fellowship at the University of Washington with a focus on shoulder replacements and rotator cuff disorders.
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.