Shoulder pathology

Biceps Tendon

Biceps effusion and Tenosynovitis

  • The long head biceps tendon should be seen in the bicipital groove.
  • Continuous to the musculotendinous junction.
  • A trace of fluid in the dependent aspect of the sheath, just distal to the bicipital groove.

Longitudinal ultrasound view of the biceps tendon with a small effusion in the tendon sheath.

Transverse ultrasound view of a biceps effusion.

Ultrasound image- Biceps tenosynovitis:
A markedly hyperaemic biceps tendon and sheath suggesting tenosynovitis.

Longitudinal ultrasound view of biceps synovitis. There is only mild tendon thickening with hyperaemia of the thickened sheath.

Ultrasound image- Chronic synovitis:
The tight echogenic synovium surrounding the biceps tendon is suggestive of a chronic synovitis / capsulitis.

Ultrasound image- Adherent biceps tendon:
The biceps is adhered to the antero-lateral aspect of the sheath by the synovial thickening.

Ultrasound image- Loose calcification in the biceps tendon sheath.

DISLOCATED BICEPS TENDON

  • The long head biceps tendon always dislocates medially out of the groove. This is due to the medial tension as it pulls against the groove on its course to insert on the glenoid.
  • If the biceps is dislocated out of the groove, it indicates a disruption of the trans-humeral ligament which must involve a tear of subscapularis and/or supraspinatus.

Ultrasound image- The biceps is seen against the medial edge of the biciptal groove. There is bony degenerative change.

Bony irregularity within the bicipital groove is a contributing factor to tears and tenosynovitis

Ultrasound image- The biceps tendon is very medial, overlying the subscapularis tendon.

Ultrasound image- Dislocated Biceps tendon (green)

RUPTURED BICEPS TENDON

  • The long head biceps tendon generally tears at the musculotendinous junction
  • The patient will present with bruising of the anterior upper arm, a history of a painful snap/pop, but only mild tenderness or pain.
  • Often it occurs in advancing age and requires no treatment.
  • The short head biceps is still functional resulting in only about a 20% loss of strength.

Transverse Ultrasound view. Typical ruptured biceps at the musculotendinous junction.

Ultrasound image- Fluid along the long head biceps muscle belly secondary to a tear at the musculotendinous junction

Ultrasound image- Acute rupture of the long head biceps tendon.

Subscapularis

TIP:

Beware the multi-pennate nature of the subscapularis tendon which creates heterogeneity of the echotexture in both longitudinal and transverse planes.

Ultrasound of a subscapularis insertional tear (red arrow) and intratendinous calcification.
There is a small effusion in the overlying subdeltoid bursa.

Ultrasound of a ruptured and retracted subscapularis tendon. The yellow indicates the retracted/bunched musculotendinous junction.

Supraspinatus

Normal shoulder anatomy.

Move the cursor over the image to see a Full thicknes tear V’s a complete rupture.

The humeral head (grey) is visible through the torn part of the tendon.

Calcific Tendinopathy

Ultrasound image- Calcification in the bursal surface of the supraspinatus tendon.

Ultrasound image- A large calcification within the supraspinatus tendon. Note the heterogeneous, likely torn insertion (red arrow).

Tears

Ultrasound image- A full thickness tear.
The blue arrows show the flattening of the deltoid due to transducer pressure.
The red arrows show dipping of the tendon contour disproportionate to the deltoid flattening. This is consistant with substance loss.
There is also loss of the normal fibrillar architecture in the area measured.

Ultrasound image- A full thickness supraspinatis tear.  This is full thickness because the tear extends from the bursal surface to the articular surface.

Ultrasound image- Partial Thickness Tear
The dipping of the tendon surface (arrows) indicates substance loss consistant with a partial thickness tear.

It is important not to compress the tendon with transducer pressure causing a false positive result. Note the convexity of the overlying bursa eliminating this.

Ultrasound image- An articular surface partial thickness tear of suraspinatus (SSP). The dipping of the tendon is readily seen with thickening of the overlying subdeltoid bursa (SDB).

Avulsion fracture of the greater tuberosity

Ultrasound image- An avulsion fracture of the greater tuberosity.
An associated tear of the supraspinatus can be seen, indicated by the small arrow heads.

Xray showing the avulsed fragment off the greater tuberosity

Bursae

The subdeltoid and subacromial bursae are subject to thickening, fluid, haemorrhage and calcification. Any thickening will contribute to impingement.

Ultrasound image- Normal subacromial bursa (green).
The subacromial and subdeltoid bursae are intimately against, and indistinguishable from, the overlying deltoid muscle.

Ultrasound image- The subacromial bursa.  The bursae are subject to thickening and /or fluid.  This image shows both thickening and fluid.  The measurement indicates how little is required to be symptomatic.

Ultrasound image- Thickening of the subacromial bursa.

Ultrasound image- The coraco-acromial ligament impresses on the thickened bursa.

Ultrasound image- A large bursal effusion.

Ultrasound image- Bursal fluid spanning the biceps tendon and the bicipital groove.

Ultrasound image- Acute bursitis, markedly increase vascularity seen with power doppler. A focus of ‘soft’ calcification is present in the bursa.

Ultrasound image- Impingement of the bursal calcification against the Coraco-acromial ligament during abduction.

More details on impingement dynamic assessment

Gleno-Humoral Joint

Posterior Joint Recess

  • A transverse plane with the probe on the posterior humeral head.
  • Assess dynamically with internal and external rotation and ‘stop-sign’.
  • Use either a linear or curvi-linear probe to obtain better penetration and an adequate field of view.

Posterior shoulder joint probe position.

A curved probe is useful on larger patients or if you require a better over-view.

Ultrasound image- An effusion in the posterior joint recess of the shoulder.

Ultrasound of a labral cyst arising from the posterior glenohumeral joint.

This is suggestive of a labral tear.

Small simple effusion in the inferior recess of the posterior glenohumeral shoulder joint,

Anterior Joint Recess

  • A transverse plane with one end of the probe on the coracoid process.
  • Assess dynamically with internal and external rotation and ‘stop-sign’.
  • Use either a linear or curvi-linear probe to obtain better penetration and an adequate field of view.

Probe position to view the anterior joint recess.

A transverse plane. The deeper anterior joint may be better visualised with a curvi-linear probe.

Ultrasound image- Anterior shoulder joint labral cysts suggestive of a likely labral tear. MRI would be required to investigate the labrum if clinically indicated.
Images courtesy of Mrs Jody Ferguson.

Ultrasound of the anterior shoulder joint effusion

 

Ultrasound image- The large, complex fluid collection extends down off the AC joint.

Ultrasound image- A small synovial cyst from the acromio-clavicular joint.

Abduction and impingement