Ultrasound of Common Disclosures:
Shoulder Pathology
• Consultant: Bioclinica
• Advisory Board: GE, Philips
Jon A. Jacobson, M.D. • Book Royalties: Elsevier
Professor of Radiology
Director, Division of Musculoskeletal Radiology
University of Michigan
Note: all images from the textbook
Fundamentals of Musculoskeletal Ultrasound are copyrighted
by Elsevier Inc.
Rotator Cuff
Outline: Supraspinatus
Supraspinatus
• Rotator cuff:
– Cuff tear and tendinosis
– Secondary signs of cuff tear Subscapularis Infraspinatus
– Calcific tendinosis
Teres Minor
– Post-operative cuff
• Biceps brachii tendon abnormalities Biceps
Long Head
• Subacromial-subdeltoid bursa
Note: Subacromial-subdeltoid Bursa (light blue)
Supraspinatus Tendon: normal Supraspinatus Tendon: proximal
• Hyperechoic and fibrillar echotexture
• Convex superior surface
• Uniform thickness: transverse
GT
Humeral Head
Long Axis Short Axis
(Intra-articular)
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Supraspinatus Tendon: distal Supraspinatus Tendon: distal
GT GT BT
GT GT
Long Axis Short Axis Long Axis Short Axis
(Greater Tuberosity) (Greater Tuberosity)
Supraspinatus and Infraspinatus Tendons Supraspinatus and Infraspinatus Tendons
Superior
Facet BT
Middle
Facet
Inferior
Facet
Short Axis
(Greater Tuberosity) Short Axis
Infraspinatus Footprint Supraspinatus – Infraspinatus Junction
Superior
Facet
Note: angle Middle
Facet
Note: flat
Middle Facet: Infraspinatus
overlaps supraspinatus
From: Mochizuchi T. JBJS 2008; 90:962
From: Chang EY et al. AJR
2014; 202:w376
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Rotator Cuff Ultrasound: Rotator Cuff Tear:
• Accuracies: • Meta-analysis: 65 articles
– Full-thickness tear: 96%1 • Full-thickness tears:
– Partial-thickness tear: 94%2 – MRA, MRI, US = in sensitivity (92 – 95%)
– MRA more specific
– Equal to MRI: accuracy, size of tear3
• Partial-thickness tears:
• Patients prefer ultrasound over MRI4 – MRA most sensitive (86%) and specific
1Teefey, JBJS Am 2000; 82:498. – MRI (64%), US (67%)
2van Holsbeeck, Radiology 1995; 197:443.
3Teefey, JBJS Am 2004; 86:708. de Jesus, 2009; 192:1701
4Middleton, AJR 2004; 183:1449.
Rotator Cuff Tears Rotator Cuff: pathogenesis
• Tears are hypoechoic / anechoic • Extrinsic:
• Indirect signs at ultrasound: – Repetitive microtrauma: microtears
– Cortical irregularity: supraspinatus footprint – Subacromial impingement
• If present on radiographs, 75% have tear • Intrinsic:
– Volume loss – Degeneration: predispose to tear
• Massive tear: non-visualization – Avascular region: critical zone
• Usually over age of 40 years
AJR 1998; 171:229
Radiology 2004; 230:234
Supraspinatus: normal
Rotator Cuff Abnormalities:
Bursal Surface
Categories:
• Partial-thickness tear
• Full-thickness tear Greater
Tuberosity
• Intra-substance tear Articular Surface Surface
• Tendinosis
Long Axis
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Supraspinatus Tears: extent Supraspinatus Tears: extent
Rim-rent Tear
B
B
Partial Articular Partial Bursal Intrasubstance Full thickness
From: Fundamentals of Musculoskeletal Ultrasound From: Fundamentals of Musculoskeletal Ultrasound
Articular Partial-thickness Tear: supraspinatus Articular Partial-thickness Tear: supraspinatus
Deltoid Deltoid
Humerus Humerus
Long Axis Coronal T2w Short Axis Sagittal T2w
Articular Partial-thickness Tear: supraspinatus Pitfall Alert!
Anisotropy
• Sound beam oblique to
tendon fibers
• Artifactually hypoechoic
• Most common location for
this error: rim rent area
Supraspinatus: long axis
Long Axis Sagittal T2w
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Bursal Partial-thickness Tear: supraspinatus Bursal Partial-thickness Tear: supraspinatus
Long Axis
Short Axis
Long Axis Coronal T2w
Bursal Partial-thickness Tear: supraspinatus
Bursal Partial-thickness Tear: supraspinatus
Long Axis Short Axis Short Axis Sagittal T2w
Full-thickness Tear: Full-thickness Tear:
supraspinatus supraspinatus
BT BT
Short Axis Short Axis
Long Axis Long Axis
Note: Cartilage Interface Sign (open arrow) Note: Cartilage Interface Sign (open arrow)
Short Axis Short Axis
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Full-thickness Tear: Full-thickness Tear: supraspinatus
supraspinatus
Short Axis
Long Axis
IST
Long Axis T2w Coronal-oblique
Short Axis
Full-thickness Tear: supraspinatus Large Full-thickness Tear: supraspinatus
Deltoid
Humerus
Short Axis T2w Sagittal-oblique Long Axis Coronal T2w
Large Full-thickness Tear: supraspinatus Intrasubstance Tear:
supraspinatus
Deltoid Deltoid
Humerus Humerus
BT
Long Axis
Short Axis Sagittal T2w *Note lack of cartilage interface sign
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Tendinosis or Tendinopathy Tendon Tear versus Tendinosis
• No inflammatory cells *both may appear hypoechoic
– Mucoid degeneration, chondroid metaplasia
Tear Tendinosis
• Hypoechoic, ill-defined
• Anechoic • Hypoechoic
• Possible increased thickness
From: Hodler J, et al. J MRI; • Well-defined • Ill-defined
• No cortical irregularity* 2010: 32:165
• Homogeneous • Heterogeneous
• Thinned • Swollen
• Bone irregularity* • Smooth cortex
*Radiology 2004; 230:234 *At supraspinatus tendon footprint in patients over 40 years old
Tendinosis: supraspinatus tendon
Outline:
• Rotator cuff:
– Cuff tear and tendinosis
– Secondary signs of cuff tear
– Calcific tendinosis
– Post-operative cuff
• Biceps brachii tendon abnormalities
• Subacromial-subdeltoid bursa
Longitudinal Coronal-oblique T2w
Secondary Findings of Tendon Volume Loss:
Rotator Cuff Tears:
• Flat or concave outer margin of
• Volume loss of tendon substance supraspinatus*
– Deltoid muscle dips into tendon gap
• Cortical irregularity • Full-thickness tears
• Bursal sided partial-thickness tears
• Effusion (articular & bursal)
• Not seen in tendinosis
• Cartilage interface sign
*Hodler et al. Radiology 1988; 169:791
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Full-thickness Tear: supraspinatus
Cortical Irregularity:
• Greater tuberosity: at
supraspinatus insertion
• When present: 75% have
rotator cuff tears
– Patient over 40 years old
• When absent: 96% normal
cuffs by sonography
AJR 1998; 171:229
Radiology 2004; 230:234
Short Axis
Cortical Irregularity: no significance
Joint & Bursal Effusions:
• Joint effusion (biceps tendon)
• Subacromial-subdeltoid bursal fluid:
>1 mm distention
Humerus
• If both: 95% positive predictive value for
rotator cuff tear*
Long Axis Short Axis
*Hollister et al. AJR 1995; 165:605
Subscapularis Tendon
Joint Effusion:
Joint Effusion and Bursal Fluid
posterior glenohumeral joint recess
Deltoid
BT
Short Axis Long Axis
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Small Full-thickness Tear: supraspinatus
Cartilage Interface Sign:
• Reflective interface between Deltoid
hypoechoic hyaline cartilage and
adjacent fluid
• Indicates articular extension of tear
• Limited value Humerus
Long Axis Short Axis
Fatty Infiltration and Muscle Atrophy
Fatty Infiltration and Muscle Atrophy
• Supraspinatus and infraspinatus
– Infraspinatus: only variable to predict cuff healing1 • Indistinct tendon-muscle border
• Associations: • Increased muscle echogenicity
– Chronic, large, anterior supraspinatus tears2 – Compare to teres minor
• Ultrasound: • Decreased muscle bulk
– Moderate to good correlation with MRI3 – Compared to teres minor
– Improved reliability with extended field-of-view4 – Bone landmark: ridge in scapula
1Chung et al. Am J Sports Med; 2013; 41:16764
– Short axis: infraspinatus 2x size
2Hodler et al. Radiology 2005; 237:584.
3Khoury et al. AJR 2008; 190:1105.
4Nazarian et al. 2008; 190:27.
Infraspinatus Atrophy Supraspinatus Atrophy
Teres
Minor
C S
Scapula
Short Axis Long Axis
Short Axis Long Axis
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Atrophy: supraspinatus and infraspinatus No Atrophy
Teres
Minor
Teres
Minor
Supraspinatus Infraspinatus Supraspinatus Infraspinatus
Short Axis (extended field-of-view) Short Axis (extended field-of-view)
Outline: Tendon Calcification:
• Rotator cuff: • Degenerative: thin, linear deposit
– Cuff tear and tendinosis • Calcific tendinosis:
– Secondary signs of cuff tear – Formative: well-defined, dense shadow
– Calcific tendinosis – Resorptive:
– Post-operative cuff • Globular, amorphous
• Biceps brachii tendon abnormalities • Variable shadow
• Subacromial-subdeltoid bursa • Best success with aspiration
Uhthoff. J Am Acad Ortho Surg 1997; 5:183
Degenerative Calcification
Calcific Tendinosis
• Hydroxyapatite deposition: dystrophic
– Usually do not have cuff tear
• Appearance:
– 79% hyperechoic & shadowing
– No shadow: 7%
• Two phases:
– Formative
– Resorptive: painful
Farin et al. Skeletal Radiol 1996; 25:551
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Subscapularis: calcific tendinosis
Calcific Tendinosis
Formative Resorptive
Defined, shadow Amorphous, little shadow
Outline:
Post-operative Rotator Cuff:
• Rotator cuff:
– Cuff tear and tendinosis • Post-op tendon: echogenic & thin*
– Secondary signs of cuff tear • Reimplantation trough
– Calcific tendinosis • Echogenic sutures & anchors
– Post-operative cuff
• Biceps brachii tendon abnormalities
• Subacromial-subdeltoid bursa *Mack et al. AJR 1988; 150:1089
Intact Post-operative Cuff
Post-operative Rotator Cuff:
• Recurrent tear: usually large with
nonvisualization
#1 #2
• Focal hypoechogenicity: equivocal
#3 #4
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Post-operative cuff: recurrent tear Post-operative cuff: recurrent tear
Long Axis PDw fat-sat coronal Short Axis PDw fat-sat sagittal
Open arrow = bioabsorbable suture anchor Open arrow = suture
4 4
Arthroplasty: Intact Cuff Arthroplasty: Cuff Tear
GT
Arthroplasty Arthroplasty
Arthroplasty
Long Axis Short Axis
Long Axis
Outline: Biceps Tendon:
• Rotator cuff: BT
• Shoulder joint effusion:
– Cuff tear and tendinosis
– Collects around biceps Short Axis
– Secondary signs of cuff tear tendon
– Calcific tendinosis – Tendon sheath
– Post-operative cuff communication
• Biceps brachii tendon abnormalities – Joint fluid collects
• Subacromial-subdeltoid bursa dependently
Color Doppler
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Inflammatory Tenosynovitis: biceps tendon
Deltoid
Biceps Tendon:
• Tendinosis:
• Hypoechoic
Humerus
• Swollen
• No inflammatory cells
(not tendinitis)
Long Axis • Possible tenosynovitis
Aponeurotic Expansion
Biceps Tendon: of Supraspinatus Tendon
• Partial-thickness tear: • Up to 49% of shoulders
• Cleft: coronal plane
– Hypoechoic /anechoic cleft
Split + • Origin: supraspinatus
– Tenosynovitis tenosynovitis • Distal: pectoralis or
– Sensitivity: 27% bicipital groove
– Accuracy: 88%
– Subluxation / spur
• Important secondary signs
Skendzel J, et al. AJR 2000;
197:942 Split + Subluxation
Moser et al. Skeletal Rad 2015; 44:223
Biceps Tendon Biceps Tendon Subluxation
*
* Lesser Lesser
Tuberosity Tuberosity
Subluxation Dislocation
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Subacromial-subdeltoid Bursa: fluid
Outline:
• Rotator cuff:
Deltoid
– Cuff tear and tendinosis
– Secondary signs of cuff tear
– Calcific tendinosis
Suprasp.
– Post-operative cuff
• Biceps brachii tendon abnormalities
• Subacromial-subdeltoid bursa
Coronal Coronal T2w
Subacromial-subdeltoid bursa: anterior
Subacromial-subdeltoid Bursa: thickening
Deltoid
Proximal Distal
Biceps
Humerus
Long Axis Long Axis
Sagittal
Calcific Bursitis
Bursal Thickening Simulating Intact Cuff
Long Axis Short Axis
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Impingement Test
Impingement: bursal fluid
• Abnormal pooling of subacromial-subdeltoid
bursal fluid
• Lateral acromion1:
– Coronal plane, active arm elevation
– Not visible in neutral position, no cuff tear
• At coracoid2:
– Axial plane, active elevation internal rotation
1Farin et al. Radiology 1990; 176:845
2Stallenberg et al. AJR 2006; 187:894
Impingement Syndrome Impingement: supraspinatus
A
A
Take-home Points
• Must follow a protocol
• Cuff tears: avoid anisotropy
• Cortical irregularity: important indirect sign
– Supraspinatus tears
• Dynamic: impingement
• Joint effusion: biceps
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