Topic 3 the shoulder Flashcards
(116 cards)
1
Q
What are the attachments of the supraspinatus muscle?
A
Supraspinous/fossa of the scapula
Upper facet of the greater tuberosity of the humerus
2
Q
What are the attachments of the infraspinatus?
A
Infraspinous fossa of the scapula
Middle facet of the greater tuberosity of the humerus
3
Q
What are the attachments of teres minor?
A
Infero medial border of the scapula
Lower facet of the greater tuberosity of the humerus
4
Q
What are the attachments of the subscapularis?
A
Subscapula fossa of the scapula
Lesser tuberosity of the humerus
5
Q
What are the attachments of the biceps brachii long head?
A
Supragelnoid tubercle’
Radial tuberosity
and fibrous lacertus
6
Q
List some causes of shoulder pain
A
- rotator cuff pathology (degeneration, tears, calcific tendinosis) (most common)
- long head biceps pathology
- subacromial subdeltoid bursa pathology (most common)
- arthropathy of the glenohumeral or acromioclavicular joint (which may be of inflammatory or degenerative cause)
- osseous disease.
7
Q
What is the typical presentation of rotator cuff pain?
A
- painful restricted arc
- pain along the deltoid insertion, and often into the elbow
- pain which disturbs the patient’s sleep
- a traumatic event which has caused the pain
- focal pain
8
Q
What is ultrasound able to assess dynamically in the shoulder?
A
subacromial impingement, subcoracoid impingement, and biceps tendon subluxation dynamically. Dynamic compression of rotator cuff tears can aid in the assessment of cuff integrity.
9
Q
What is MRI more useful at assessing in the shoulder?
A
instability, ligamentous injury, or suspected glenoid labral injury
10
Q
When should xray be used?
A
Ultrasound is also of limited value in the evaluation of bony disorders, and plain radiography should be considered.
11
Q
Ultrasound can be used to assess a long list of shoulder pathology. Name 5
A
• Rotator cuff tears • Full-thickness tear • Partial-thickness tear • Rotator cuff tendinopathy • Tendinitis • Calcific tendinitis • Mucoid degeneration • Attrition Effusions/synovitis • Subacromiodeltoid bursa • Subacromial impingement • Glenohumeral effusion • Long biceps tendon sheath • "Geyser" sign of acromioclavicular joint • Long head of the biceps tendon • Tenosynovitis • Tendinitis • Subluxations (see notes for more)
12
Q
What history should you gather before commencing a shoulder scan?
A
- initial injury
- time period over which the problem has been present
- site of tenderness
- movements which cause maximum discomfort
- activities which bring on the pain
- previous treatment
- results of treatment
13
Q
How would you ergonomically scan a shoulder?
A
- Seat the patient on an armless swivel chair, facing the sonographer, with both shoulders exposed to facilitate side to side comparison.
- The patient stool should be lower than yours, so you can comfortably extend your scanning hand to their shoulder height, maintaining your elbow tucked in as close to your side as possible.
14
Q
What three categories should be used to describe tears?
A
Thickness, size, location
15
Q
What are the different ways of describing the thickness of a supraspinatus tear?
A
• complete • full thickness • partial thickness o articular surface o bursal surface o insubstance/delamination
16
Q
How do you describe the size of a supraspinatus tear?
A
• measure length x width
17
Q
How do you describe the location of a supraspinatus tear?
A
- distance from biceps groove; or anterior, mid or posterior
* describe as proximal, mid or insertional (distal)
18
Q
What is a global tear?
A
A shoulder which has tears in a number of tendons
19
Q
Describe the possible appearances of a full thickness supraspinatus tear
A
- a hypoechoic or anechoic gap within the rotator cuff
- may also have a concave contour at its bursal border
- a greatly retracted tear can result in nonvisualization of the rotator cuff tendon
20
Q
What can make visualisation and demonstration of the full thickness tear difficult?
A
- the gap between the retracted tendon end and the greater tuberosity or distal tendon stump may be filled with hypoechoic fluid or echogenic debris and granulation tissue.
- Alternatively, the subacromial-subdeltoid bursa (frequently thickened) and the deep surface of the deltoid muscle the defect created by the tear may occupy.
- Small foci of debris within the tear gap may give the appearance of mobile or “floating” bright spots
21
Q
How can dynamic assessment help in classifying a full thickness tear?
A
one may be uncertain as to whether abnormal echotexture in the location of the rotator cuff represents a partial tear or a full-thickness tear with intervening granulation tissue and debris. Dynamic compression of the abnormal area may clarify this confusion by causing complex fluid and debris to swirl within the rotator cuff tear.
22
Q
What is the cartilage interface sign?
A
• Fluid within the tear gap my accentuate visualization of the underlying humeral head articular cartilage owing to enhanced through transmission of the ultrasound beam, referred to as the “cartilage interface sign”
23
Q
What are some ways of differentiating acute from chronic tears?
A
the findings of glenohumeral and bursal effusions are more common in acute tears.
Midsubstance tears, medial to the bone-tendon junction, are more likely to be acute
Severely retracted tears are more likely to be chronic.
24
Q
What is one aspect of full thickness chronic tears that may make diagnosis difficult?
A
In chronic full-thickness tears, the tendon gap may be filled with noncompressible, complex echogenic debris and granulation tissue that are contiguous with the subacromial subdeltoid bursa, and this may give the false impression of rotator cuff volume
25
IN what demographic to partial thickness tears mot commonly occur?
* occur more commonly than full-thickness tears in younger patients
* most commonly occur in young athletes
26
What is the most common sub type of partial thickness tears?
• Partial articular-sided supraspinatus tears are the most common subtype
27
What is the most common cause of partial tears in the older population?
Tendon degeneration
28
What are the partial thickness tear sub types?
o Bursal sided
o Articular sided
o Intrasubstance
o Rim rent tear
29
What is a rim rent tear?
occurs at the articular side of the supraspinatus tendon, extending into the tendon footprint on the greater tuberosity
• most commonly seen in athletes who engage in overhead-throwing activities
30
What are the different grades of partial thickness tears?
Grade 1 <25%
Grade 2 25-50%
Grade 3 >50%
31
What is the ultrasound appearance of a bursal partial thickness tear?
o flattening of the bursal contour of the tendon
| o may lead to an hourglass-like diameter shift between areas of normal and attenuated tendon
32
What ultrasound appearances are common to full and partial thickness tears?
o cortical irregularity of the greater tuberosity
o 75% positive predictive
o more severe in full-thickness tears
o represents bony remodeling with irregularity, pitting, and erosion
o A second sign that can be seen in both partial articular-sided and full-thickness tears is the “cartilage interface” sign
33
What is the correct way to measure a tear?
• Always measure the medial to lateral tear length should be made in long axis, and a measurement of the anterior to posterior tear width should be made on short-axis imaging.
34
After surgery what is the best way to diagnose a re tear?
• A gap within the tendon and nonvisualization of the tendon owing to retraction are the most reliable signs for a recurrent tear
35
What are some normal post surgical changes?
* loss of normal soft tissue planes and abnormal echotexture of the rotator cuff tendon
* Bony irregularity at the site of anchor placement is expected
* echogenic suture material within the tendon may contribute to the heterogeneous appearance
• A thinned tendon or one with subtle contour abnormality is considered intact.
36
What is shoulder tendinosis?
* degenerative process that may be associated with shoulder pain
* There is mucoid degeneration and frequently chondroid metaplasia
37
How does shoulder tendinosis appear on ultrasound?
o heterogeneous or hypoechoic
o tendon thickening
o loss of the normal fibrillar pattern
• Although discrete defects or tears are not encompassed by this diagnosis, they may coexist.
38
How does degenerative arthropathy appear on ultrasound?
* Osteoarthritis is common at the AC joint
* characterized by bone spurs—osteophytes—at the margin of articular surface
* may be small associated joint effusions
* echogenic intraarticular bodies, which may be calcified, can be observed
39
How does shoulder inflammatory arthropathy appear on ultrasound?
* including rheumatoid arthritis and ankylosing spondylitis
* may have glenohumeral effusion
* best assessed posteriorly, and a thickness of 3 mm or more from the humeral head to the capsule may represent effusion and/or synovial thickening
* Colour Doppler can help separate thickened synovium from complex intraarticular fluid.
* Bone erosions may also be present, characterized by bony cortical surface rounded or steplike deformations, often at the humeral head margins
40
What else may patient with inflammatory arthropathy present with?
• Patients with inflammatory arthritis may also be affected by subacromial-subdeltoid bursitis, in addition to rotator cuff and biceps tendon tears.
41
IN what demographic to partial thickness tears mot commonly occur?
* occur more commonly than full-thickness tears in younger patients
* most commonly occur in young athletes
42
What is the most common sub type of partial thickness tears?
• Partial articular-sided supraspinatus tears are the most common subtype
43
What is the most common cause of partial tears in the older population?
Tendon degeneration
44
What are the partial thickness tear sub types?
o Bursal sided
o Articular sided
o Intrasubstance
o Rim rent tear
45
What is a rim rent tear?
occurs at the articular side of the supraspinatus tendon, extending into the tendon footprint on the greater tuberosity
• most commonly seen in athletes who engage in overhead-throwing activities
46
What are the different grades of partial thickness tears?
Grade 1 <25%
Grade 2 25-50%
Grade 3 >50%
47
What is the ultrasound appearance of a bursal partial thickness tear?
o flattening of the bursal contour of the tendon
| o may lead to an hourglass-like diameter shift between areas of normal and attenuated tendon
48
What ultrasound appearances are common to full and partial thickness tears?
o cortical irregularity of the greater tuberosity
o 75% positive predictive
o more severe in full-thickness tears
o represents bony remodeling with irregularity, pitting, and erosion
o A second sign that can be seen in both partial articular-sided and full-thickness tears is the “cartilage interface” sign
49
What is the correct way to measure a tear?
• Always measure the medial to lateral tear length should be made in long axis, and a measurement of the anterior to posterior tear width should be made on short-axis imaging.
50
After surgery what is the best way to diagnose a re tear?
• A gap within the tendon and nonvisualization of the tendon owing to retraction are the most reliable signs for a recurrent tear
51
What are some normal post surgical changes?
* loss of normal soft tissue planes and abnormal echotexture of the rotator cuff tendon
* Bony irregularity at the site of anchor placement is expected
* echogenic suture material within the tendon may contribute to the heterogeneous appearance
• A thinned tendon or one with subtle contour abnormality is considered intact.
52
What is shoulder tendinosis?
* degenerative process that may be associated with shoulder pain
* There is mucoid degeneration and frequently chondroid metaplasia
53
How does shoulder tendinosis appear on ultrasound?
o heterogeneous or hypoechoic
o tendon thickening
o loss of the normal fibrillar pattern
• Although discrete defects or tears are not encompassed by this diagnosis, they may coexist.
54
How does degenerative arthropathy appear on ultrasound?
* Osteoarthritis is common at the AC joint
* characterized by bone spurs—osteophytes—at the margin of articular surface
* may be small associated joint effusions
* echogenic intraarticular bodies, which may be calcified, can be observed
55
How does shoulder inflammatory arthropathy appear on ultrasound?
* including rheumatoid arthritis and ankylosing spondylitis
* may have glenohumeral effusion
* best assessed posteriorly, and a thickness of 3 mm or more from the humeral head to the capsule may represent effusion and/or synovial thickening
* Colour Doppler can help separate thickened synovium from complex intraarticular fluid.
* Bone erosions may also be present, characterized by bony cortical surface rounded or steplike deformations, often at the humeral head margins
56
What else may patient with inflammatory arthropathy present with?
• Patients with inflammatory arthritis may also be affected by subacromial-subdeltoid bursitis, in addition to rotator cuff and biceps tendon tears.
57
What are some ultrasound limitations in assessing the shoulder?
* patient habitus
* patients with restricted shoulder movement
* previous surgery
* inability to fully assess the labrum, SLAP lesions, glenohumeral ligaments, and the rotator cuff proximal to the coraco-acromial arch
58
List some important things to remember when scanning the shoulder
* Beware of anisotropy
* Compare with contralateral side
* Try multiple patient positions
* Don't apply too much pressure (but graded pressure can be useful as normal tendons should not compress)
* Document the limitations of the examination
59
What is the critical zone?
* (approximately 1 cm lateral to the bicipital groove)
* most tears occur in this area.
* This is an area which is relatively hypovascular
60
Why do we check the supraspinatus fossa?
(increased echogenicity and decreased size in the case of a full thickness tear)
61
What can bony erosion or enthesopathy of the greater tuberosity indicate?
• indicate tendon tears or degeneration
62
What does discontinuity of the greater tuberosity mean?
• occult fracture
63
What indicates tendinosis?
• Look at tendon echotexture; diffuse changes (hypoechoic, heterogeneous tendon) may indicate tendinosis
64
How does calcific tendinitis appear?
* Look for focal changes such as shadowing or non shadowing calcification
* Soft calcification (as in calcific tendinitis) can be very painful
65
What is important to be aware of when examining the musculotendinous junction?
• the muscle fibres can come well into the tendon and mimic a tear
66
What should you look for when examining the bursa?
• Check subacromial-subdeltoid bursa for fluid or thickening. Loss of normal convexity may indicate underlying tendon pathology
67
What can echogenic lines in the tendon represent?
• Echogenic lines may be seen extending into the tendon from cortical erosions on the tuberosities (these may be caused by scar from old tears, calcification or normal anatomical planes of the tendon)
68
How should tears be described?
• complete/full thickness/partial thickness
• anterior/mid/posterior
• proximal/distal
• deep surface/insubstance/bursal surface
Note: global tears are those involving more than one rotator cuff tendon.
69
What should you look for when examining the infraspinatus?
* Tendon echogenicity changes for tears, calcification
* Bony surface as irregular concavity in the posterior humeral head may be a Hill Sachs lesion as a result of a previous anterior dislocation
70
What is the best way to assess for a GHJ effusion?
• Posterior joint line (glenoid labrum) for effusion of the glenohumeral joint: can be better assessed with internal/external rotation as the fluid will change shape
71
Where will you find teres minor?
• Teres minor is inferior to the infraspinatus and rarely shows any pathology
72
What should you look for in the spinoglenoid notch?
• a cyst/fluid which may represent a ganglion compressing the suprascapular nerve
• Suprascapular nerve paralysis at the spinoglenoid notch is characterised by:
o atrophy of the infraspinatus (increased echogenicity and decreased size of the muscle belly)
o tenderness of the belly of the infraspinatus
o weak external rotation of the shoulder
73
What should you look for in the supra scapular notch?
* Look for fluid/ganglion which can cause nerve paralysis
* Compression of the suprascapular nerve at the suprascapular notch will result in both supraspinatus and infraspinatus atrophy
* You can assess for supraspinatus muscle belly size and echotexture and compare with the contralateral side. Fatty atrophy may occur in the presence of a complete tendon tear
74
What movements are important when assessing the subscapularis tendon and why?
* Limited external rotation is an important marker for adhesive capsulitis.
* The final subscapularis assessment is internal and external rotation to ensure it transits freely beneath the coracoid process.
75
What is a common appearance for the subscapularis tendon?
* Bony surface irregularities are common, and probably represent a site of continued microtrauma where the lesser tuberosity and anterior labrum oppose each other during internal rotation.
* These can be noted but are of limited clinical significance
76
What clinical sign indicates a torn subscapularis?
• A torn subscapularis tendon yields a positive Gerber's sign (with the arm behind the back, the patient finds it impossible to lift the arm away from the body)
77
Where does most pathology occur in the subscapularis?
* Most tears, calcifications and tendinopathies occur at the osseo-tendinous junction.
* Reducing the extent of external rotation will improve your visualisation of this segment
78
What does the normal shoulder bursa look like?
* very fine hypoechoic line between two echogenic lines.
| * The bursa is the hypoechogenicity while the echogenic lines are adjacent peri-bursal fat.
79
What can focal thickening of the bursa indicate?
• This is unusal but probably related to a chronic bursitis where parts of the bursa has become adhesive.
80
What is the point of dynamically assessing the shoulder?
* to determine whether the bursa and/or the tendon bunches on the acromion or the C-A ligament with abduction or forward flexion.
* If there is bunching or blocking, this should be correlated with the clinical presentation.
81
How is the long head biceps commonly injured?
• can be injured in the setting of concomitant rotator cuff tear, shoulder dislocation, or overhead sports
82
Why is fluid in the tendon sheath important?
• fluid in the tendon sheath may relate to intraarticular processes, particularly if associated with glenohumeral effusion.
83
When should long head of biceps tendon tenosynovitis be suspected?
* the tendon appears abnormal
* if there is hyperemia on color Doppler imaging
* if there is no sign of alternative glenohumeral pathology or effusion
* if there is localizing tenderness
84
Why do we note if the tendon is in the groove?
• It can dislocate medially with and without subscapularis tear
85
What indicates a partial tear or LHB?
• Look at tendon size and echotexture – hypoechoic clefts could be insubstance tears (better viewed in longitudinal section) may result in splitting the tendon into two distinct parallel components, termed a longitudinal split tear
86
What appearances indicate tendinosis?
• loss of normal tendon fibrillar pattern, abnormal hypoechogenicity, and often thickening
87
What should you look for if LHB is ruptured?
• note the 'Popeye' appearance of the muscle belly and check the musculotendinous junction.
o typically occur close to the tendon origin
o The LHB muscle belly will appear more echogenic than the adjacent SHB.
o Note: The LH biceps can rupture and then attach to the biceps groove. Known as tenodesis
o care should be taken to assess for medial dislocation of the tendon as an alternative cause if the tendon is not seen within the bicipital groove
88
Why dynamically assess the LHB?
* To check for subluxation of the biceps
* The biceps tendon is normally stabilized within the tendon groove by the thin transverse ligament.
* Medially, displacement is resisted by the subscapularis tendon. If the subscapularis tendon is torn at its insertion, this may allow medial displacement of the biceps tendon, deep to the subscapularis tendon
* Alternatively, if the transverse ligament is torn, this may permit medial dislocation of the biceps tendon, which then lies superficial to the otherwise intact subscapularis tendon.
89
What signs associated with LHB and supra tendon indicate a FT supra tear?
* marked LH Biceps Tendon tendinosis with surrounding fluid in the biceps sheath
* marked fluid and synovial thickening in the SD Bursa overlying the LH Biceps Tendon.
* This combination is around 90% predictive of a FT tear of the supraspinatus
90
Why is examining the ACJ important?
• Acromioclavicular (AC) joint lesions can mimic rotator cuff disease because of the proximity of this joint to the tendons.
91
What is the most common pathology of the ACJ?
• Osteoarthrosis
92
What sign in the ACJ can be associated with rotator cuff rupture?
• Geyser sign
93
What does an effusion at the posterior labrum look lie?
* abnormally increased joint fluid distends the capsule
* splays the infraspinatus tendon
* and forms an echo-poor crescent around the posterosuperior glenoid labrum
* may appear complex, with synovial thickening or debris in cases of chronic or inflammatory disease.
94
What is a common appearance of the non effusive labrum?
• In the noneffusive shoulder normal intraarticular gas can be seen on real-time examination as hyperechoic "dots-and-dashes" that freely arise in the joint space
95
What is the best way to identify labrum pathology?
• Right-left comparison of the posterior shoulders is the easiest way to appreciate the abnormal glenoid labrum
96
What is the point of dynamically assessing the shoulder?
* to determine whether the bursa and/or the tendon bunches on the acromion or the C-A ligament with abduction or forward flexion.
* If there is bunching or blocking, this should be correlated with the clinical presentation.
97
What two types of movement should be assessed?
• Perform active (patient directed) and passive (sonographer assisted) abduction
98
How does CA impingement appear?
• Bunching of bursa and/or supraspinatus tendon beneath the C-A ligament indicates coraco-acromial impingement
99
What is something you should look for that may cause supra tendon bunching?
• upward movement of the humeral head
100
What should you do if there is bunching and no pain?
• check the contralateral shoulder
101
What does Lack of movement of the supraspinatus tendon under the C-A lig (that is, blocking) indicate?
• is a sign of capsulitis.
102
What are some causes (other than impingement) of Loss of ability to abduct?
* fracture
* pain
* arthritis or
* adhesive capsulitis
103
What is adhesive capsulitis?
• Adhesive capsulitis is a fibrous contraction of the rotator interval and coracohumeral ligament. The contraction acts as a check-rein, causing a global restriction of movement. There is loss of active movement, especially external rotation and abduction.
104
How does adhesive capsulitis appear on ultrasound?
• Sonographically we cannot see capsulitis, but a triad of excess fluid in the biceps sheath, painful and restricted external rotation, and restricted abduction with 'blocking' of the supraspinatus tendon are helpful aids to suggest capsulitis.
105
What are the three stages of adhesive capsulitis?
* Freezing (painful stage)
* Frozen (transitional stage)
* Thawing stage
106
What are the timelines of the different stages of adhesive capsulitis?
* Freezing (painful stage) 3-9 months
* Frozen (transitional stage) 4-12 months
* Thawing stage 12-42 months
107
What are the symptoms of freezing (painful) stage?
* symptoms progress
* pain worsens
* ROM becomes more restricted
* typically lasts between 3 and 9 months
* characterized by acute synovitis of the glenohumeral joint
108
What are the symptoms of the frozen stage?
* shoulder pain does not necessarily worsen
* arm movement may be limited, causing muscular disuse
* can last between 4 to 12 months
* historically described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation
* eventually, in the frozen stage, pain does not occur at the end of the range of motion
109
What are the symptoms of the thawing stage?
* begins when the range of motion starts to improve
* lasts anywhere from 12 to 42 months
* defined by a gradual return of shoulder mobility
110
Why is staging adhesive capsulitis important?
Adhesive capsulitis is a self limiting disease that resolves in a couple of years usually and perhaps the stage can determine the course of the treatment. Steroid injection, physio etc
Basically, no one has adhesive capsulitis until they have 3-6 months of symptoms
111
How dies adhesive capsulitis appear on ultrasound?
• Sonographically we cannot see capsulitis
• Suggested by a triad of
o excess fluid in the biceps sheath
o painful and restricted external rotation
o restricted abduction with 'blocking' of the supraspinatus tendon
• thickened coracohumeral ligament can be suggestive
• thickening of the inferior glenohumeral capsule
* echogenic material around the long head of biceps at rotator interval
* increased vascularity of long head of biceps at rotator interval
112
What is outlet impingement?
Outlet impingement can be caused by narrowing of the subacromial arch due to:
• acromial shape
• anterior acromial spur
• ossification of the coraco-acromial ligament
• inferior acromioclavicular joint spur
113
How does outlet impingement affect the shoulder?
```
It causes attritional rotator cuff wear due to:
• repeated microtrauma
• glenohumeral instability
• internal impingement
• episode of macro trauma
```
114
What does fluid around the tendon of the long head of biceps indicate?
* It may indicate GHJ effusion
| * May also be normal
115
What does fluid around the tendon of the long head of biceps as well as in the sub-acromial / sub-deltoid bursa often indicate?’
• Rotator cuff full thickness tear
116
How do you test for impingement, and what scan plane you use?
subacromial impingement using dynamic method:
Place the transducer in the coronal-oblique place showing the bony landmark of acromion tip and the greater tuberosity, compare in neutral position and active arm elevation whether gradual pooling of SASD bursal fluid exists or upwar movement of the humeral head
What's more, sliding the transducer anterior to the acromion may indicate the thickened bursa, or abrupt movement of the thickened bursa.
