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ShoulderDemonstration data

Shoulder Musculoskeletal Ultrasound

High-resolution ultrasound is an accurate, dynamic and inexpensive first-line tool for evaluating the rotator cuff and periarticular soft tissues. It depicts the supraspinatus, infraspinatus, subscapularis and long head of biceps tendons, the subacromial-subdeltoid bursa and dynamic impingement, with diagnostic accuracy for full-thickness cuff tears approaching that of MRI in experienced hands.

Indications

  • Suspected rotator cuff tendinopathy or partial/full-thickness tear
  • Subacromial impingement and painful arc
  • Long head of biceps tendinopathy, subluxation or dislocation
  • Subacromial-subdeltoid bursitis and calcific tendinopathy
  • Suspected joint or bursal effusion and guided injection/aspiration
  • Postoperative cuff assessment and dynamic instability evaluation

Contraindications & Cautions

  • No absolute contraindications; ultrasound is safe and non-ionising
  • Limited utility for intra-articular labral and bony pathology, which requires MRI/MR arthrography or CT
  • Restricted shoulder movement may limit standardised positioning and dynamic testing
  • Large body habitus and deep structures reduce resolution

Patient Preparation

  • No specific preparation required
  • Patient seated on a rotating stool with the arm accessible for positioning
  • Explain the standardised positions and dynamic manoeuvres that will be requested
  • Compare with the asymptomatic contralateral shoulder when findings are equivocal
  • For guided injection, prepare a sterile field and consent

Technique & Parameters

  • High-frequency linear array 9-18 MHz; a smaller footprint helps in the biceps groove and rotator interval
  • Long head of biceps in transverse and longitudinal planes within the bicipital groove
  • Subscapularis with the arm in external rotation; supraspinatus in the modified Crass position (hand on ipsilateral back pocket)
  • Infraspinatus and teres minor over the posterior shoulder; assess bursa and greater tuberosity cortex
  • Keep the beam perpendicular to the tendon to avoid anisotropy that mimics a tear
  • Dynamic imaging: internal/external rotation and abduction to assess impingement and cuff excursion

Systematic Review

  • Long head of biceps tendon position, echotexture and fluid in the sheath
  • Subscapularis tendon integrity and continuity in external rotation
  • Supraspinatus footprint for thickness, hypoechoic/anechoic clefts and cortical irregularity
  • Infraspinatus and teres minor for tears and atrophy
  • Subacromial-subdeltoid bursa for thickening or fluid and dynamic bunching on abduction
  • Acromioclavicular joint and greater tuberosity cortex for degeneration and enthesopathy

Key Findings & Significance

  • Full-thickness tear: focal anechoic/hypoechoic defect spanning bursal to articular surface, non-visualisation of tendon, cartilage interface sign
  • Partial-thickness tear: hypoechoic or anechoic defect on the articular or bursal surface not spanning the full thickness
  • Tendinosis: thickened hypoechoic tendon with loss of fibrillar pattern and no discrete cleft
  • Calcific tendinopathy: echogenic focus with or without posterior shadowing within the tendon
  • Subacromial-subdeltoid bursitis: bursal thickening or fluid >2 mm with dynamic bunching indicating impingement
  • Biceps pathology: sheath fluid, tendon subluxation/dislocation from the groove or empty groove

Differential Considerations

  • Focal cuff defect: full- vs partial-thickness tear vs anisotropy artifact vs intrasubstance tendinosis
  • Shoulder pain with fluid: bursitis vs joint effusion vs biceps tenosynovitis
  • Echogenic tendon focus: calcific tendinopathy vs intratendinous gas vs surgical anchor
  • Impingement: subacromial (external) vs internal impingement vs adhesive capsulitis
  • Cuff atrophy: chronic tear vs suprascapular neuropathy vs disuse

Pearls & Pitfalls

  • Anisotropy is the commonest pitfall; rock the probe to keep the beam perpendicular before calling a hypoechoic tear
  • The cartilage interface sign and joint/bursal fluid tracking through a defect support a full-thickness tear
  • Dynamic imaging uniquely demonstrates impingement and reducible biceps subluxation that static imaging misses
  • Measure tear width and retraction and note fatty muscle atrophy to guide surgical planning
  • Ultrasound is insensitive to labral and articular pathology; escalate to MRI when instability is suspected

Structured Report

  • State transducer, positions used and whether dynamic and comparison imaging were performed
  • Report each tendon (supraspinatus, infraspinatus, teres minor, subscapularis, biceps) individually
  • Describe tears by surface, thickness, dimensions and retraction; note muscle atrophy
  • Report bursal fluid/thickening, calcifications and dynamic impingement
  • Give an impression and recommend MRI or orthopaedic referral where indicated

References

  • ACR-AIUM-SPR-SRU Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination
  • European Society of Musculoskeletal Radiology (ESSR) Ultrasound Guidelines: Shoulder
  • Jacobson JA. Fundamentals of Musculoskeletal Ultrasound, Elsevier
  • Beggs I et al. Shoulder Ultrasound. Radiographics reviews of rotator cuff sonography

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.