sonoanatomy scanning technique and basic pathology of the shoulder

George A.W. Bruyn, Esperanza Naredo

EULAR on-line course on Ultrasound

LEARNING OBJECTIVES Describe and explain the basic application of MSUS in the shoulder.

Hold the probe and optimize the B-mode and Doppler settings of the US machine.

Identify normal US anatomy of the principal structures of the shoulder.

Perform the standard US scans of the shoulder.

Detect basic shoulder abnormalities (e.g. glenohumeral synovitis, biceps effusion and tenosynovitis,

subacromial-subdeltoid bursitis, full-thickness rotator cuff tears, rotator cuff calcification, and

cortical abnormalities such as erosions and osteophytes).

Sonoanatomy

Scanning technique and basic pathology of the shoulder

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Sonoanatomy Scanning technique and basic pathology of the shoulder – Module 4

©2007-2017 EULAR Anatomy images by Sonoanatomy Group - Barcelona University

I. INTRODUCTION

Shoulder involvement is frequent in rheumatoid arthritis and other chronic arthritides. The glenohumeral and

acromioclavicular joints, the biceps tendon sheath and the subacromial-subdeltoid bursa may become

affected by synovitis that frequently results in rotator cuff and biceps tendon structural lesions and bone

erosions. Clinical differential diagnosis between inflammation and structural damage is difficult in the shoulder

due to its depth and function complexity (Murayama et al, 2013).

On the other hand, degenerative painful shoulder is one of the most common soft tissue diseases. It is a

clinical syndrome and the principal causes are rotator cuff and biceps tendon degeneration usually associated

with the chronic dynamic impingement of the rotator cuff under the acromion and the coracoacromial

ligament. Tendon degeneration or tendinosis may progress to partial and full-thickness tear of the rotator cuff.

Clinical differentiation between the above lesions is challenging and often inaccurate (Naredo et al, 2002).

Ultrasound (US) has demonstrated accuracy in the detection of shoulder inflammation and rotator cuff lesions

(Bruyn et al, 2009; Bruyn et al, 2010; Swen et al, 1999; Ottenheijm et al, 2010; Sakellariou et al, 2013; Ottaviani

et al, 2014). In addition, US can be used as a guide for performing accurate and safe periarticular or intra-

articular, intralesional or perilesional injections.

This module reviews the basic anatomy of the shoulder, the standardised US scanning technique, the basic

normal US findings and abnormalities as well as the principles in handing the probe and optimizing the settings

for shoulder US. Following this, US assessment of specific inflammatory shoulder conditions is discussed and

interactive cases will help to provide a more in-depth view of two selected conditions.

II. ANATOMY

A deep knowledge of musculoskeletal anatomy is mandatory for successful US examination. The shoulder is

made up of three bones: the humerus, the clavicle and the scapula. There are three joints: glenohumeral (GH),

acromioclavicular (AC) and sternoclavicular (SC) joints. The major joint of the shoulder is the GH joint. The latter

is surrounded by the rotator cuff, which is composed of four muscles and their corresponding tendons, the

subscapularis, supraspinatus, infraspinatus and teres minor. The subscapularis muscle is the most anterior

component of the rotator cuff, arises from the subscapular fossa of the scapula, and inserts into the humeral

lesser tuberosity (Figure 1). The supraspinatus is the most superior muscle, originates on the supraspinatus fossa

at the posterior aspect of the scapula, and inserts into the most anterior aspect of the humeral greater tuberosity

(Figure 2). The bipennate infraspinatus muscle runs from the infraspinatus fossa at the posterior aspect of the

scapula to the greater tuberosity just posterior and inferior to the supraspinatus tendon (Figure 2). The

subacromial-subdeltoid bursa, which covers the rotator cuff is lined by synovial membrane. The deltoid muscle

is located superficial to the above structures. The tendon of the long head of the biceps muscle originates from

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the supraglenoid tubercle just above the shoulder joint from where its tendon passes down along the bicipital

groove between the greater and lesser tuberosities of the humerus (Figures 3 and 4). It is surrounded by a

synovial sheath on the bicipital groove. The humeral transverse ligament covers the proximal bicipital groove

and the pectoralis major tendon covers the distal bicipital groove. The GH joint capsule extends from the glenoid

rim to the anatomical humeral neck and is lined by synovial membrane. The fibrocartilaginous labrum surrounds

the glenoid rim. The AC joint contains a fibrocartilaginous intra-articular disk.

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III. US SCANNING METHOD

US examination should be systematic and standardised (Backhaus et al, 2001; Naredo et al, 2007; Bruyn et al,

2011)(Table 1). Firstly, bony landmarks (i.e. humeral head, glenoid, coracoid process, acromion and clavicular

bone) should be identified in the corresponding standard scans. Transverse and longitudinal scans of the biceps

tendon groove, rotator cuff and subacromial-subdeltoid (SASD) bursa, transverse scan of the posterior GH recess

and glenoid labrum as well as longitudinal scan of the GH axillar recess and AC joint are performed in basic US

examination of the shoulder. Comparison with the opposite shoulder is very useful for diagnosing unilateral

shoulder abnormalities.

III-1 Anterior US Examination

In the anterior aspect of the shoulder the biceps tendon, the subscapularis tendon and the AC joint are evaluated

with the patient sitting, the shoulder in neutral position, the elbow flexed 90º and the hand supinated on the

thigh.

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III-1-1 Transverse scan of the biceps tendon (i.e. tendon of the long head of the biceps muscle). VIDEO SHOULDER

part 1 – see Images library

The probe is placed transversely to the bicipital groove on the anterior aspect of the shoulder and is moved

superior and inferiorly following the bicipital groove. The bony landmarks that should be identified are the

bicipital groove, the greater tuberosity of the humerus, and the lesser tuberosity of the humerus. The biceps

tendon is visualized oval-shaped and hyperechoic into the bicipital groove, between the hyperechoic profiles of

the greater and lesser tuberosity of the humerus (Figure 5). The biceps tendon can be surrounded by a thin

hypoechoic halo which represents normal fluid within the synovial sheath. The hyperechoic transverse humeral

ligament covers the proximal bicipital groove. The tendon should be scanned from the proximal (Figure 6) to the

distal aspect of the bicipital groove where the insertion of the tendon of the pectoralis major is seen (Figure 7).

Figure 5. Transverse scan of the biceps tendon (right shoulder). gt, greater tuberosity; bg, bicipital groove; lt,

lesser tuberosity.

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Figure 6. Transverse scan of the rotator cuff interval, proximal to the bicipital groove.

Figure 7. Insertion of the pectoralis major tendon at the distal bicipital groove.

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III-1-2 Longitudinal scan of the biceps tendon (i.e. tendon of the long head of the biceps muscle) VIDEO SHOULDER

part 2 – see Images library

The probe is placed longitudinally to the bicipital groove, pressing slightly more with the lower pole of the probe.

The bony landmark that should be identified is the flat bicipital groove between the greater and lesser

tuberosities of the humerus. The biceps tendon shows a fibrillary hyperechoic pattern between the hyperechoic

humeral profile and the hypoechoic deltoid muscle (Figure 8). The tendon should be scanned from the proximal

to the miotendinous junction at the distal aspect of the bicipital groove.

Figure 8. Longitudinal scan of the biceps tendon. bg, bicipital groove.

III-1-3 Longitudinal scan of the subscapularis tendon

VIDEO SHOULDER part 3 – see Images library

The probe is placed transversely to the bicipital groove. The bony landmarks that should be identified are the

bicipital groove, the greater and lesser tuberosities of the humerus, and the coracoid process. Medial to the

biceps tendon, the insertion of the subscapularis tendon is identified on the lesser tuberosity with some fibres

continuing across the bicipital groove to form the humeral transverse ligament. To scan the subscapularis tendon

properly, the shoulder should be moved into external rotation. The subscapularis tendon has a convex superficial

margin and a hyperechoic echotexture (Figures 9 and 10). The hyperechoic profile of the coracoid process can

be seen medially to the subscapularis musculotendinous junction.

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Figures 9 and 10. Longitudinal scans of the subscapularis tendon (right shoulder) in maximal external rotation

(Figure 9) and neutral position (Figure 10). lt, lesser tuberosity; cp, coracoid process.

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III-1-4 Transverse scan of the subscapularis tendon


The probe is placed transversely to the subscapularis tendon. The bony landmark that should be identified is the

lesser tuberosity of the humerus. The subscapularis tendon appears convex-shaped with hyperechoic

echotexture (Figure 11).

Figure 11. Transverse scan of the subscapularis tendon.

III-1-5 Longitudinal scan of the acromioclavicular joint


Cranial to the biceps tendon, the AC joint is scanned. The probe is placed cranial to the bicipital groove,

longitudinally across the superior and anterior aspect of the AC joint. The hyperechoic profile of the acromion

and clavicle, the hyperechoic joint capsule, and the peripheral aspect of the intra-articular fibrocartilage are

visualized (Figure 12).

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Figure 12. Longitudinal scan of the acromioclavicular joint (right shoulder). ac, acromion; cl, clavicle.

III-2 Anterolateral US Examination

In the anterolateral aspect of the shoulder the supraspinatus and infraspinatus tendons, the SASD bursa, the

humeral cartilage and the humeral cortex accessible for US are examined. The supraspinatus and infraspinatus

tendons should be examined with the patient´s shoulder in hyperextension and internal rotation (e.g. dorsum

of the hand resting over lumbar spine or over the opposite back pocket) in order to expose them from

underneath the acromion and to allow a maximal length of tendon to be visualized. This manoeuvre is also

referred to as the Crass position (Crass et al, 1987). If the above position is very painful for the patient, shoulder

internal rotation with the hand over the ipsilateral pocket also allows us to visualize the supraspinatus and

infraspinatus tendons.

III-2-1 Transverse scan of the supraspinatus and infraspinatus tendons, and subacromial-subdeltoid bursa


For scanning the supraspinatus tendon, the probe should be placed transversely, just below the anterolateral

aspect of the acromion and moved laterally and up and down just below the acromion. The bony landmarks that

should be identified are the coracoid process, and the humeral head. Lateral to the coracoid process, the

intracapsular biceps tendon can be seen. The supraspinatus tendon is seen hyperechoic with convex superficial

margin, deep to the hypoechoic deltoid muscle, and covering the humeral head (Figure 13). The hyperechoic

humeral cortex and the humeral articular cartilage, which is seen as a thin anechoic layer between the tendon

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and the humeral head are identified. The SASD bursa is visualized as a thin hypoechoic line with a variable

amount of peribursal echogenic fat between the deltoid muscle and the supraspinatus tendon. For scanning

the infraspinatus tendon, the probe is moved further laterally, up and down just below the lateral aspect of the

acromion. The infraspinatus also appears convex-shaped, the most posterior aspect usually thinner than the

supraspinatus tendon. In the posterolateral aspect below the acromion the infraspinatus miotendinous junction

is visualized (Figure 14).

Figure 13. Transverse scan of the supraspinatus tendon. cp, coracoid process; hh, humeral head.

Figure 14. Transverse scan of the infraspinatus tendon. hh, humeral head.

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III-2-2 Longitudinal scan of the supraspinatus and infraspinatus tendons, and subacromial-subdeltoid bursa


The probed is placed obliquely to the arm, longitudinal to the supraspinatus and infraspinatus tendons. The

probe is moved laterally. The bony landmarks that should be identified are the greater tuberosity of the

humerus, the anatomic neck of the humerus, the humeral head, and the acromion. The supraspinatus (Figure

15) and infraspinatus (Figure 16) tendons are triangular, with convex superficial margin, extending from the

greater tuberosity and disappearing under the acromion. The hyperechoic humeral cortex and the anechoic

humeral cartilage are identified. The SASD bursa is seen as a thin hypoechoic line with a variable amount of

peribursal echogenic fat between the deltoid muscle and the above tendons.

Figure 15. Longitudinal scan of the supraspinatus tendon. gt, greater tuberosity; hn, anatomic humeral neck;

hh, humeral head.

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Figure 16. Longitudinal scan of the infraspinatus tendon. hh, humeral head; ac, acromion.

III-3 Posterior US Examination


The posterior US examination of the shoulder includes the posterior aspect of the infraspinatus tendon, the

posterior GH recess and the posterior labrum with the arm in neutral position, the elbow flexed 90º and the

hand supinated or the hand on the opposite shoulder. The probe is placed transversely to the arm, just below

the spine of the scapula. Dynamic external and internal shoulder rotation is performed to improve posterior GH

recess view. Identifiable bony landmarks are the posterior aspect of the humeral head, and the glenoid fossa

or cavity. The profile of the humeral head and the glenoid, the hyperechoic joint capsule covering the posterior

glenohumeral recess, and the infraspinatus tendon and muscle are identified (Figure 17). The cartilaginous

posterior labrum is imaged as a hyperechoic triangle separating the infraspinatus tendon from the glenoid. In

dynamic scanning (i.e. shoulder external and internal rotation), the posterior GH recess can be seen a thin

hypoechoic triangular structure (Video 1).

Video 1. Posterior glenohumeral recess (left shoulder) – see Images library

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Figure 17. Posterior glenohumeral recess scan (left shoulder). hh, humeral head; gl, glenoid fossa.

III-4 Axillary US examination


The axillary GH recess is scanned with the arm in 90º of abduction and the probe placed longitudinally to the

axilla (Koski, 1991). The bony landmarks that should be identified are the humeral head, and the surgical neck

of the humerus. The humeral head and humeral surgical neck profiles and the joint capsule which covers the

axillary GH recess are identified (Figure 18).

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Table 1. Scanning method for shoulder US examination

Standardised scans Patient position Probe placement Bony landmarks Transverse biceps tendon

Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh

Transversely to the bicipital groove on the anterior aspect of the shoulder, moved superior and inferiorly following the bicipital groove

Bicipital groove Greater tuberosity of the humerus Lesser tuberosity of the humerus.

Longitudinal biceps tendon


Longitudinally to the bicipital groove, pressing slightly more with the lower pole of the probe

Bicipital groove Greater tuberosity of the humerus Lesser tuberosity of the humerus.

Longitudinal subscapularis tendon

Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh. The patient moves the arm from neutral to full external rotation

Transversely to the bicipital groove, on the anterior aspect of the shoulder

Bicipital groove Lesser tuberosity of the humerus Coracoid process

Transverse subscapularis tendon

Sitting, shoulder in neutral position, elbow flexed 90º, forearm and hand supinated on the thigh. The patient moves the arm from neutral to full external rotation

Longitudinally to the bicipital groove, on the anterior aspect of the shoulder

Lesser tuberosity of the humerus Coracoid process

Acromioclavicular joint


Cranial to the bicipital groove, longitudinally across the superior and anterior aspect of the acromioclavicular joint

Acromion Clavicle

Transverse supraspinatus and infraspinatus tendons

Sitting, shoulder in maximal internal rotation and hyperextension, dorsum of the hand resting over lumbar spine

Transversely, just below the antero-lateral aspect of the acromion, and moved laterally and up and down just below the acromion

Coracoid process Humeral head

Longitudinal supraspinatus and infraspinatus tendons

Sitting, shoulder in maximal internal rotation and hyperextension, dorsum of the hand resting over lumbar spine

Obliquely to the arm, longitudinal to the supraspinatus tendon, and moved laterally

Greater tuberosity of the humerus Anatomic neck of the humerus Humeral head, acromion.

Posterior glenohumeral joint

Sitting, shoulder in neutral position, elbow flexed 90º, forearm supinated on the thigh or the hand on the opposite shoulder. Dynamic external and internal shoulder rotation

Transversely to the arm, just below the spine of the scapula

Posterior aspect of the humeral head Glenoid fossa

Axillary glenohumeral recess

Sitting, raised arm (90º of abduction)

Longitudinal plane of the axilla

Humeral head Surgical neck of the humerus

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Figure 18. Axillary glenohumeral recess. hh, humeral head; hn, surgical humeral neck.

IV. HOLDING THE PROBE AND OPTIMISING THE GREY-SCALE AND DOPPLER SETTINGS

OF THE US SYSTEM

Equipment for evaluating the shoulder generally includes a linear broadband transducer with a range of 7 to 15

MHz. The use of stand-off pads is not necessary, but generous application of US coupling gel to the skin is

indispensable. Curved-array transducers may be used in evaluating deeper structures such as the axillary recess,

where it also nicely fits in to the anatomic concavity of the arm pit. It is recommended that any pathology is

confirmed in two orthogonal planes, and dynamic manoeuvres are extremely useful in evaluating pathology.

Sometimes, right-left comparison with the other side is advantageous. Dynamic examination can facilitate the

visualization of anatomic structure and the detection of subtle abnormalities (Corazza et al, 2015).

IV.1 Holding The Probe And Optimizing The Grey-Scale Settings.

The shoulder is examined according to a standard protocol. The examiner holds the probe like a pencil, with

extended wrist, when the examiner is seated in front of the patient. The patient usually is seated on a revolving

chair, making examination of anterior, lateral and posterior shoulder easier. Alternately, the examiner is

standing behind the seated patient and the probe is held with a flexed wrist. The probe should not be pressed

too firmly to the skin. During the anterior shoulder examination, the probe is moved from the anterior bony

landmark, the bicipital groove and its 2 tubercles, from medial to lateral. Then the probe is moved from proximal

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to distal to include the full length of the course of the long head of the biceps tendon. Depending on the anatomy

of the patient, the frequency of the probe has to be changed, as well as the focus, gain and depth. A thorough

examination of the long head of the biceps tendon demands that the probe should be manoeuvred in a rocking

procedure as well as a tip-toe procedure, therefore optimizing the visualization of the biceps tendon and

minimising the natural anisotropy of this tendon. Examination of the anterior and lateral shoulder usually does

not require a low frequency or a curved-array transducer, as structures are lying superficially. However,

examination of the deeper seated structures of the posterior shoulder may require a lower transducer frequency

(< 7 MHz) or a curved-array transducer. Helpful procedures to optimize the visualization of posterior structures

include asking the patient to put the hand on top of the contralateral shoulder, thereby better visualizing the

spinoglenoid groove; another procedure is the external rotation manoeuvre of the arm, thus improving the

detection rate of small quantities of synovitis in the GH joint.

IV.2 Optimizing The Doppler Settings

The frequency of the Doppler examination for the shoulder is usually between 6-10 MHz, the PRF around 750

KHz, a low wall filter and the gain set just above the threshold when noise artefacts appear. One pitfall should

be mentioned when examining the anterior shoulder. It is important to make the distinction between

tenosynovitis and the normal presence of a signal due to the lateral branch of the anterior circumflex humeral

artery, just below the biceps tendon seen in the long axis plane and adjacent to the bone.

V. BASIC US PATHOLOGY OF THE SHOULDER

V.1 Synovitis (Synovial Hypertrophy And Effusion)

The GH joint, the AC joint, and the SC joint are synovium-lined joints and may become, either simultaneously or

sequentially, involved in inflammatory rheumatic disease. The shoulder joint can also be affected by

microcrystalline or septic processes. For editorial reasons, we will focus on the GH joint. Common inflammatory

diseases of the shoulder joint are rheumatoid arthritis (RA), psoriatic arthritis and other spondyloarthropathies,

and amyloid arthropathy in chronic haemodialysis patients. Clinical examination of the shoulder joint is

notoriously treacherous and shows a poor correlation with imaging techniques for swelling of the shoulder (Kim

et al, 2007; Luukkainen et al, 2007). US has become nowadays an indispensable tool for the rheumatologists

in finding synovitis of the shoulder joint. Over recent years, reproducibility and validity studies has been

conducted to establish the metric qualities of US for detection of shoulder disease in patients with RA. These

studies showed a fair to good correlation between US and MRI for the presence of fluid in the axillary and

posterior recesses (Bruyn et al, 2009). Reliability studies has showed a good intraobserver agreement for the

presence of fluid in posterior and axillary recesses and excellent agreement for synovial Doppler signal.

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Interobserver agreement varied from good to excellent for the detection of fluid in these recesses (Bruyn et al,

2009; Bruyn et al, 2010).

Shoulder joint synovitis may be found ultrasonographically in various recesses and bursae. Synovitis on US is

characterized by anechoic or hypoechoic abnormal intraarticular material that displaces the shoulder joint

capsule on the axillary longitudinal scan (i.e. axillary GH recess) (Figure 19) and/or the posterior transverse scan

(i.e. posterior GH recess) (Figures 20-23). Synovitis can content fluid (displaceable) and/or synovial hypertrophy

(non displaceable and poorly compressible) (Wakefield et al, 2005). However, differentiation between synovial

hypertrophy and effusion using US might be difficult in deep anatomic areas such as the GH recesses (Wamser

et al, 2003). Anterior to the shoulder joint, fluid will collect in the biceps sheath, around the long head of the

biceps tendon, which communicates with the GH joint. Thus, an anechoic or hypoechoic halo around the biceps

tendon on transverse scan (Figure 24) and band on longitudinal scan (Figure 25) may be considered a feature of

synovitis of the GH joint.

Figure 19. Synovitis in the axillary glenohumeral recess. hh, humeral head; hn, surgical humeral neck.

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Figure 20. Synovitis in the posterior glenohumeral recess. hh, humeral head; s, synovitis.

Figure 21. Synovitis in the posterior glenohumeral recess. hh, humeral head.

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Figure 22. Synovitis (s) in the posterior glenohumeral recess and SASD bursitis (b).

Figure 23. Synovitis (s) in the posterior glenohumeral recess with Doppler signal. hh, humeral head

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Figure 24. Biceps sheath effusion (arrowhead), transverse scan. gt, greater tuberosity; bg, bicipital groove; lt,

lesser tuberosity.

Figure 25. Biceps sheath effusion (arrowheads), longitudinal scan. bg, bicipital groove.

Dynamic external rotation of the patient´s shoulder facilitates the detection of synovitis in the posterior GS

recess (18)(Schmidt et al, 2008) (Video 2).

Video 2. Dynamic detection of synovitis at the posterior GH recess – see Images library

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In addition, fluid may collect in the subcoracoid bursa and the superior subscapularis recess. The subcoracoid

bursa is located between the anterior surface of the subscapularis and the coracoid process. The subcoracoid

bursa does not communicate with the GH joint but it sometimes does with the SASB (Grainger et al, 2000).

The superior subscapularis recess, also known as the subscapularis bursa, is a genuine recess of the anterior

shoulder capsule and projects between the superior and middle glenohumeral ligaments. The recess lies deep

to the subscapularis muscle and anterior to the scapula; it may extend proximally in a manner that it may hang

over the superior margin of the subscapularis tendon like a saddle bag (Figure 26). Therefore, it is easy to confuse

an effusion within the superior subscapularis recess with an effusion of the subcoracoid bursa. The former may

be physiological, whereas the latter is probably due to a pathologic process. In addition, it must be kept in mind

that there is considerable variation in the number and size of anterior shoulder recesses (Rockwood et al,

2004) (Table 2).

The degenerative AC joint frequently shows effusion associated with massive tears of the rotator cuff. This

pathologic fluid distends the AC capsule. In one study, 126 AC joints of 63 healthy subjects were examined. One

of the prominent findings was that if US distance of the joint capsule was < 3 mm, there was no effusion on MRI

scans (Alasareela et al, 1997).

Figure 26. Synovitis in the subscapularis recess. cp, coracoid process.

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Table 2. Anatomical variation in the synovial recesses found within the anterior capsule of the shoulder joint

(Rockwood et al, 2004)

Type Description % Prevalence

Type I One recess above the middle glenohumeral ligament 7 % – Cadaveric study 30% - Cadaveric study

39% - Cadaveric study Type II One recess below the middle glenohumeral ligament 3% – Cadaveric study

2% – Cadaveric study 0% - Cadaveric study

Type III One recess above and below the middle glenohumeral ligament 89% – Cadaveric study 47% – Cadaveric study 46% – Cadaveric study

Type IV One large recess with absent middle glenohumeral ligament 1 case – Cadaveric study 9% – Cadaveric study 6% – Cadaveric study

Type V Two small synovial folds 0% – Cadaveric study 5.1% – Cadaveric study 0% – Cadaveric study

Type VI No recesses present 0% – Cadaveric study 11% – Cadaveric study 10% – Cadaveric study

V.2 Biceps Effusion and Tenosynovitis

The biceps sheath communicates with the GH joint. Thus, abnormalities detected in the biceps synovial sheath

frequently represent an extension of GH joint pathology. Biceps sheath effusion in most patients appears

associated with rotator cuff tears. In addition, biceps sheath effusion can be secondary to biceps tendinopathy,

rupture or dislocation. It is seen as a pathological hypoechoic or anechoic halo surrounding the biceps tendon

that can be displaced with the pressure of the probe. Biceps tenosynovitis is defined as hypoechoic or anechoic

thickened tissue with or without fluid within the tendon sheath, which is seen in two perpendicular planes and

which may exhibit Doppler signal (Wakefield et al, 2005) (Figures 27-30). The presence of tenosynovial

proliferation or hypertrophy is characteristic of inflammatory arthritides.

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Figure 27. Biceps tenosynovitis, transverse scan. bg, bicipital groove.

Figure 28. Biceps tenosynovitis, longitudinal scan. bg, bicipital groove.

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Figure 29. Biceps tenosynovitis with Doppler signal, transverse scan. bg, bicipital groove.

Figure 30. Biceps tenosynovitis with Doppler signal, longitudinal scan. bg, bicipital groove.

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V.3 Bursitis

Bursitis may accompany rotator cuff lesions and impingement or be inflammatory , microcrystalline, traumatic,

or septic. Most frequently, bursitis involves the SASD bursa. The subcoracoid bursa, which can communicate

with the SASD bursa, can also be involved in inflammatory and degenerative conditions. Bilateral SASD bursitis

has been shown to be a hallmark of PMR and recently has been included in the EULAR/ACR criteria for

classification for this disease (Dasgupta et al, 2012). Bursitis appears as an increase of hypoechoic fluid and/or

tissue depending on its nature within the bursa and may show Doppler signals (Figures 31-35).

Figure 31. SASD bursitis (b), transverse scan. hh, humeral head.

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Figure 32. SASD bursitis (b), longitudinal scan. gh, greater tuberosity.

Figure 33. SASD bursitis (arrowhead), longitudinal scan. gh, greater tuberosity, hn, anatomic humeral neck;

hh, humeral head.

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Figure 34. Inflammatory SASD bursitis (asterisks), showing power Doppler signals. hh, humeral head; BT,

bicipital groove.

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Figure 35. SASD bursitis containing large quantities of bursal fluid (bf) and proteinaceous material (pm).

V.4 Rotator Cuff Tears

US is highly sensitive and comparable to MRI in detecting rotator cuff tears (Fischer et al, 2015; Roy et al,

2015).Rotator cuff tears can be partial-thickness or full-thickness. Partial thickness tears can involve the articular

side, the bursal side or the inside of the rotator cuff tendons. Full-thickness tears that involve the entire width

of a tendon are called complete tears.

Full-thickness rotator cuff tears are those extending from the humeral cartilage to the SASD bursa. Most rotator

cuff tears involve the supraspinatus tendon and occur at the insertion site and frequently extend posteriorly to

involve the infraspinatus tendon and/or anteriorly to involve the subscapularis tendon.

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US signs of full-thickness rotator cuff tears are non-visualization of the tendon (Figures 36 and 37), fibres defect

from the humeral head to the SASD bursa, usually filled with hypoechoic fluid (Figures 38 and 39) or superior

tendon convexity instead of concavity (Figures 40 and 41).

The main US sign of partial-thickness rotator cuff tears is a hypoechoic partial disruption of the tendon fibres

(Figures 42-45).

Figure 36. Supraspinatus and infraspinatus full-thickness, transverse scan. The US image shows absence of the

tendons and the deltoid muscle covering the humeral head. hh, humeral head.

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Figure 37. Supraspinatus and infraspinatus full-thickness, longitudinal scan. The US image shows absence of

the tendons. The deltoid muscle is now on top of the humeral head. hh, humeral head; ac, acromion.

Figure 38. Supraspinatus full-thickness, transverse scan. The US image shows a hypoechoic defect of the

tendon fibres from the SASD bursa to the humeral cartilage. hh, humeral head; cp, coracoid process.

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Figure 39. Supraspinatus full-thickness, longitudinal scan. The US image shows a hypoechoic defect of the

tendon fibres from the SASD bursa to the humeral cartilage. gt, greater tuberosity; hn, anatomic humeral

neck; hh, humeral head.

Figure 40. Supraspinatus full-thickness, transverse scan. hh, humeral head; cp, coracoid process.

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Figure 41. Supraspinatus full-thickness, longitudinal scan. gt, greater tuberosity; hn, anatomic humeral neck;

hh, humeral head; ac, acromion.

Figure 42. Supraspinatus extensive partial-thickness (articular side) (asterisk), transverse scan. The US image

shows an extensive hypoechoic defect of the tendon fibres with a cortical break at the level of the tear. hh,

humeral head; cp, coracoid process.

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Figure 43. Supraspinatus extensive partial-thickness (articular side) (asterisk), longitudinal scan. The US

image shows an extensive hypoechoic defect of the tendon fibres with a cortical break at the level of the tear.

gt, greater tuberosity; hn, anatomic humeral neck; hh, humeral head.

Figure 44. Supraspinatus partial-thickness (bursal side) (asterisk), transverse scan. hh, humeral head; cp,

coracoid process.

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Figure 45. Supraspinatus partial-thickness (bursal side) (asterisk), longitudinal scan. gt, greater tuberosity;

hn, anatomic humeral neck; hh, humeral head.

Common US findings associated with rotator cuff tears are increased fluid within the biceps sheath and/or the

SASD bursa, and/or AC and GH mild effusion, greater tuberosity cortical irregularities, and the cartilage interface

sign (i.e. visualization of hyperechoic superficial cartilage surface in contact with fluid filling in the tendon

defect).

V.5 Rotator Cuff Calcification

Intratendon calcifications can show different morphology on US (i.e. arc-shaped, fragmented, punctuate).

Calcifications appear as hyperechoic curved lines or foci within the tendon substance (Figures 46 and 47). The

easiest to recognize are those that produce acoustic shadow. These can be asymptomatic or produce acute and

chronic impingement symptoms due to calcific tendinitis or bursitis.

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Figure 46. Supraspinatus calcifications (arrowheads), transverse scan.

Figure 47. Supraspinatus calcifications (arrowhead), longitudinal scan.

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V.6 Cortical abnormalities (Erosions and Osteophytes)

Erosions and osteophytes are common findings on imaging evaluation of the shoulder. Such bony changes can

be easily visualized with US. In particular, US is able to detect early erosions in RA(Amin et al, 2012). In an in-

vitro study using a bone phantom model, Koski found that ultrasonographers were successful in distinguishing

healthy bones from bones with erosions (Koski et al, 2010). In the above study, US was valid and reliable in

detecting cortical bone erosions in vitro, when the round erosion is at least 1 mm deep and 1.5 mm wide. Bony

changes of the shoulder should be looked for with US anteriorly, laterally and especially posteriorly, where endo-

and exorotation of the arm can expose more surface of the hyaline cartilage.

Shoulder involvement is a critical issue in patients with rheumatic disorders. In RA, literature data indicate

radiographic shoulder damage in 50% of patients after two years and 96% of patients with 12 years of disease.

Ongoing synovial inflammation is the primary driving force for the onset of humeral head erosions. US erosions

are defined as intraarticular discontinuities of the bone surface that is visible in two perpendicular planes

(Wakefield et al, 2005) (Figures 48-51). Although erosions may point to in chronic arthritides, particularly RA,

they can also be found in other conditions and even in normal subjects. Other conditions that feature erosions

include avulsion fracture of the greater tuberosity (Figure 52-54), haemodialysis-related amyloid arthropathy,

crystal arthropathy, post-traumatic cortical changes of a Hill-Sachs lesions, post-shoulder surgery and post-

septic arthritic changes. In a comparative study between conventional radiography, US, and MRI in 43

rheumatoid arthritis patients, erosions were found in 60% of patients with radiography, in 70% with US, and in

91% with MRI (Hermann et al, 2003). Bruyn et al found good intra- and interobserver reliability for US detection

of shoulder erosions in patients with RA (Bruyn et al, 2009; Bruyn et al, 2010).

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Figure 48. Humeral head erosion (arrowhead), transverse plane.

Figure 49. Humeral head erosion (arrowhead), longitudinal plane.

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Figure 50. Humeral head erosions (arrowheads), transverse plane.

Figure 51. Humeral head erosions (arrowheads), longitudinal plane.

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Figure 52. Greater tuberosity fracture (arrowhead), longitudinal scan.

Figure 53. Greater tuberosity fracture (# of humeral head (HH), longitudinal scan.

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Figure 54. Greater tuberosity fracture (#), and accompanied by SASD bursitis (bf), longitudinal scan.

Osteophytes can occur in the GH and the AC joint. In general, these point to degenerative changes in elderly

individuals, though they may also occur in younger persons after trauma The osteophytes of the GH joint are

usually more pronounced at the humeral head compared to the glenoid cavity (Figure 55). At the AC joint,

osteophytes may appear at either site. US can be helpful to identify these, particularly at the AC joint.

Osteophytes appear as prominences at the joint margins (Figure 56).

Figure 55. Humeral head osteophytes (arrowhead), axillary recess. hh, humeral head; hn, humeral neck.

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Figure 56. Acromioclavicular osteophytes (arrow). Hypoechoic AC effusion can be also visualized. hh, ac,

acromion; cl, clavicle.

44



SUMMARY POINTS

Shoulder joint US is best performed by using a linear array broadband transducer with frequencies

ranging from 5 -15 MHz.

It is recommended to perform shoulder US by adhering to a standard protocol.

US of the shoulder joint is more sensitive for picking up GH joint synovitis than clinical examination

and more sensitive for detection for erosions than conventional radiography.

Shoulder joint synovitis may be apparent by detecting fluid in the biceps tendon sheath, axillary

pouch or posterior recess. Synovitis is ultrasonographically characterized by anechoic or

hypoechoic areas with elevation of the capsule, visible on the longitudinal axillary scan or the

transverse posterior scan.

Biceps tenosynovitis is defined as hypoechoic or anechoic thickened tissue with or without fluid

within the tendon sheath, which is seen in two perpendicular planes and which may exhibit

Doppler signal.

Bursitis may accompany rotator cuff lesions and impingement or be inflammatory or

microcrystalline.

Bilateral SASD bursitis has been shown as a hallmark of PMR.

Bursitis appears as an increase of hypoechoic fluid and/or tissue depending on its nature within

the bursa, is very accurate in the detection of rotator cuff lesions. US signs of rotator cuff full-

thickness tears are non-visualization of the tendon, fibres defect from the humeral head to the

SASD bursa, usually filled with hypoechoic fluid or superior tendon convexity instead of concavity.

Rotator cuff calcifications appear as hyperechoic curved lines or foci within the tendon substance

with or without acoustic shadow.

Erosions (cortical breaks) can be found in a healthy person.

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