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Intro to Musculoskeletal Ultrasound of the Shoulder

Intro to Musculoskeletal Ultrasound of the Shoulder. John Hill, DO Tim Mazzola, MD University of Colorado Office Based Sports Medicine Saturday, May 17, 2014. Disclosure Statement. Newton Shoes: Physician Advisory Board

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Intro to Musculoskeletal Ultrasound of the Shoulder

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  1. Intro to Musculoskeletal Ultrasound of the Shoulder John Hill, DO Tim Mazzola, MD University of Colorado Office Based Sports Medicine Saturday, May 17, 2014

  2. Disclosure Statement • Newton Shoes: Physician Advisory Board • MuscleSound: Physician advisor for software development to determine muscle glycogen content.

  3. Objectives Discuss the normal ultrasound appearance of the shoulder and the individual structures Describe the AIUM standard shoulder exam Discuss the uses of dynamic imaging

  4. Shoulder The Standard Examination

  5. Sonography of Shoulder • Complex structure containing • Muscles • Tendons • Bursa • Bone • Labrum • Fixed and Dynamic evaluations

  6. Sonography of Shoulder Physician Practice Guideline is established by AIUM & ACR for the Shoulder U/S • Biceps tendon • Subscapularis tendon • Supraspinatus tendon • Infraspinatus tendon • Teres minor • Dynamic evaluation

  7. Examination of: Joint effusions Bursa effusions Comparison of contralateral side Evaluate for: Bursal thickening Loose bodies Tendon calcification Muscle & bone abnormalities Sonography of Shoulder

  8. Biceps Tendon- Short Axis Transverse Normal transverse Normal Notch view

  9. Biceps Tendon- Short Axis Transverse Chronic Tendinopathy Acute Tendinopathy

  10. Biceps Tendon - Long Axis Long Axis Normal Biceps LA Normal Long Axis

  11. Biceps Tendon - Long Axis Chronic Tendinopathy Fluid in tendon sheath Long Axis Acute Tendinopathy

  12. Long Head of Biceps Tendon Normal internal/external motion Normal long axis appearance

  13. Is there subluxation of the Long Head of Biceps Tendon?

  14. Subscapularis Tendon • Instruct patient to place their arm in full EXTERNAL rotation • Sagittal view (Short axis) Short Axis view of Subscap Short Axis Subscap

  15. Subscapularis Tendon • Instruct patient to place their arm in full EXTERNAL rotation • Transverse view (Long axis) Long Axis view of Subscap Long Axis Subscap

  16. Subscapularis Tendon • Instruct patient to place their arm in full EXTERNAL rotation • Transverse view (Long axis) • Sagittal view (Short axis) Short Axis view of Subscap Long Axis Subscap

  17. Supraspinatus Tendon • Instruct patient to place their arm in INTERNAL rotation • Place hand in back pocket • (Long axis)45 degrees Coronal/ Sagittal SST WNL SST Normal Long Axis view

  18. Supraspinatus Tendon • Instruct patient to place their arm in INTERNAL rotation • Place hand in back pocket • (Short axis) 90 degrees Rotation of long axis SST, internal shoulder rotation SA view SST Short Axis WNL

  19. Supraspinatus Tendon • Instruct patient to place their arm in INTERNAL rotation • Place hand in back pocket • (Long axis)45 degrees Coronal/ Sagittal • (Short axis) 90 degrees Rotation of long axis SST WNL SST with Tendinopathy

  20. Supraspinatus Tendon-Long Axis Subacromial Bursa GT Supraspinatous, birds beak view (insertion)

  21. Supraspinatus Tendon-Short Axis WNL SAB

  22. Dynamic Motion Good Humeral Head Depression Rotten Humeral Head Depression Poor Posture, Weak Scapula Stability

  23. Infraspinatus Tendon • Instruct patient to place their arm in full INTERNAL rotation • Place hand in back pocket • Similar to Supraspinatus, but moved posteriorly • (Long axis)45 degrees Coronal/ Sagittal • (Short axis) 90 degrees Rotation of long axis

  24. Infraspinatus Tendon • Instruct patient to place their arm in full INTERNAL rotation • Place hand in back pocket • Similar to Supraspinatus, but moved posteriorly • (Long axis)45 degrees Coronal/ Sagittal Long Axis appearance of IST Normal appearance of IST

  25. Teres Minor Tendon • Instruct patient to place their arm in full INTERNAL rotation • Place hand in back pocket • Similar to Infraspinatus, but moved Inferiorly • (Long axis)45 degrees Coronal/ Sagittal • (Short axis) 90 degrees Rotation of long axis

  26. Teres Minor Tendon • Instruct patient to place their arm in full INTERNAL rotation • Place hand in back pocket • Similar to Infraspinatus, but moved Inferiorly • (Long axis)45 degrees Coronal/ Sagittal Normal Long Axis of Teres minor

  27. Teres Minor Tendon • Instruct patient to place their arm in full INTERNAL rotation • Place hand in back pocket • Similar to Infraspinatus, but moved Inferiorly • (Short axis) 90 degrees Rotation of long axis Normal Short Axis of Teres minor

  28. Contralateral Comparison Long Axis Views Left SST is WNL Right SST Thickened chronic Tendinopathy

  29. AC Joint AC Joint

  30. AC Joint AC Joint If the person is very thin, you might need standoff/interface disc

  31. AC Joint Arthritic Changes but no effusion Less evidence of DJD, but effusion present

  32. Summary • Many structures in the shoulder are superficial and can be examine accurately with MSK ultrasound • Diagnostic Ultrasound should incorporated static and dynamic image • If you examine many normal shoulders, then you will soon be able to pick-up even subtle changes

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