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Rotator cuff
1. ROTATOR CUFF ULTRASOUND;
A CASE AND TECHNICAL CONSIDERATIONS
(RADIOLOGIC SOCIETY OF PAKISTAN)
Adnan Rashid, MD
Department of Diagnostic Radiology,
SIMS & SERVICES HOSPITAL, LAHORE
2. Case!
34 years old male was referred to our
Ultrasound service for evaluation of “Left”
shoulder pain and abduction weakness.
Pain started 3 months back after shoulder
trauma (falling from bike on to his “Left”
shoulder).
Radiographs acquired after trauma were
normal.
4. Methods/options to evaluate:
Ultrasound of the shoulder: High-resolution
linear transducer (5 to 13 MHz)
MRI:
Coronal plane T1,T2, Fatsuppressed (STIR
or PDFS)
Axial -T1, fatsuppressed
Sagittal - T2 and fat suppressed.
MR- Arthrography:
5. Accuracy of MRI, MR Arthrography, and
Ultrasound in the Diagnosis of Rotator Cuff
Tears: A Meta-Analysis(65 articles..2009)
MR arthrography is the most sensitive
and specific technique for diagnosing
both full- and partial-thickness rotator
cuff tears.
Ultrasound and MRI are comparable in
both sensitivity and specificity.
6. Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean Leblond2,
François Desmeules3,4,Clermont E Dionne1,5, Joy C
MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5
Diagnostic accuracy of
ultrasonography, MRI and MR
arthrography in the characterisation
of rotator cuff disorders: a meta-
analysis(82 articles…2015)
Centre interdisciplinaire de recherche en réadaptation et en intégration sociale
(CIRRIS), 525, boulevard Wilfrid-Hamel, local H-1710, Quebec, Canada G1M 2S8
7. Diagnostic accuracy of imaging modalities for
Full-thickness RC tears
Similar performance of the three imaging
modalities for overall estimates of
Sn (0.90 to 0.91)
Sp (0.93 to 0.95)
8. Diagnostic accuracy of imaging modalities for
Partial thickness RC tear
Sensitivity:
US and MRI were similar (0.68 and 0.67 respec)
MRA has higher (Sn 0.83).
Specificity:
the three imaging modalities performed
equivalently (0.93–0.94).
9. Why shoulder Ultrasound??
Sensitivities and specificities in excess of 90%.
Easily available & Cost effective
Focused use in clinics, operating room, & at
point of injury………Quicker diagnosis
No radiation
Useful in pts with Metallic prosthesis
Dynamic &Interactive evaluation
Allows therapeutic interventions as well
10. Pit-fall;
Highly operator dependant; Requires skill to
ellucidate and identify a specific tendon.
Due to Parallelism of collagen fibers within
the cuff; the echogenicity of the tendon
depends on the angle of the transducer.
Tendon may appear hypo-echoic
(torn/absent) when the angle of the beam is
not perpendicular (Anisotropy)
23. Step 4a:Supraspinatus(Transverse)
Transducer is placed between the anterior acromion and the
coracoid & swept from the edge of the acromion down to the level
of the lateral greater tuberosity.
24. Step 4 b – Supraspinatus(Long axis)
transducer is placed perpendicular to the curvature of the acromial
process ;Translate the probe anterior to posterior 2.5 cm lateral to long
Biceps tendon.
26. Step 5 – Infraspinatus, and posterior labrum
Long axis
Moving the transducer posteriorly and in the plane parallel to the scapular
spine. Optimal image contrast for detection of intra-articular fluid will
be obtained by bringing the arm in external rotation(B).
28. Teres minor insertion(Long-axis
view )
The probe placed parallel to the spine of the scapula and just
proximal to the prominence of the teres major …
The insertion appears hypoechoic, due to more muscle fibers
35. References:
1) Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis
of Rotator CuffTears: A Meta-Analysis:O. de Jesus1, Laurence
Parker,Andrea J. Frangos and Levon N. June 2009,Volume 192,
Number 6
http://www.ajronline.org/doi/abs/10.2214/AJR.08.1241Joseph )
2)Diagnostic accuracy of ultrasonography, MRI and MR arthrography
in the characterisation of rotator cuff disorders: a meta-
analysis;Jean-Sébastien Roy1,2, Caroline Braën2,3, Jean
Leblond2, François Desmeules3,4,Clermont E Dionne1,5,Joy C
MacDermid6, Nathalie J Bureau7, Pierre Frémont1,5
3)) The Rotator Cuff; MarnixT. van Holsbeeck, DzungVu, and J. Antonio
Bouffard…Chapter 22 ■The RotatorCuff 879, Rumack Ultrasound.
4) RSNA, US of the shoulder, January 2006
tendon appears sandwiched between two hypoechoic
layers. Note that the normal subdeltoid bursa (black arrow) remains slightly thinner than the hyaline cartilage (white arrows) over the
humeral head (HH).
arm and forearm on the patient’s
thigh, the palm supinated (Fig. 22-2). The bicipital
groove serves as the anatomic landmark to differentiate
the subscapularis tendon from the supraspinatus tendon.
It is important to scan the lowest recess of the biceps synovial sheath.
In a patient who sits for the examination, fluid will precipitate to the most dependent portion of the synovium. Such small biceps sheath collections are a very sensitive indicator of joint fluid.
Sc tendon is visualized as band of medium-level echoes deep to the deltoid muscle/subdeltoid fat and bursa..
Dynamic evaluation of ScCoraco humeral interval distance,Fluid collection in superaspinatous tear..
The short-axis view of the subscapularis is best evaluated over the ledge of
the lesser tuberosity as close as possible to the bicipital
groove (Fig. 22-6).
Probe is parralell to clavicle..
With the arm in extension and internal rotation, the transducer is placed between the anterior acromion and the coracoid. The transducer is swept from the edge of the acromion down to the level of the lateral greater tuberosity. The critical zone is that portion of the tendon that begins approximately 1 cm posterolateral to the biceps tendon.
A normal bursa does not exceed the thickness of normal cartilage.
During longitudinal scanning, the transducer is placed perpendicular to the curvature of the acromial process (overlays the acromion medially and the greater tuberosity laterally). This sweeping motion through the supraspinatus tendon starts anteriorly next to the long biceps tendon. We cover an area of approximately 2.5 cm lateral to the long biceps tendon. Infraspinatus tendon is scanned beyond this point.
Scanning of the supraspinatus tendon is followed by the visualization of the infraspinatus and teres minor tendons by moving the transducer posteriorly and in the plane parallel to the scapular spine. The infraspinatus tendon appears as a beak-shaped soft tissue structure as it attaches to the posterior aspect of the greater tuberosity (Fig. 22-9). Internal and external shoulder rotation may be helpful in the examination of the infraspinatus tendon. This maneuver relaxes and contracts the infraspinatus tendon in alternating fashion. At this level, a portion of the posterior glenoid labrum is seen as a hyperechoic triangular structure. The fluid of the infraspinatus recess surrounds the labrum. Optimal image contrast for detection of intra-articular fluid will be obtained by bringing the arm in external rotation (Fig. 22-10). In this position the normal labrum will be covered by infraspinatus tendon. Both structures appear hyperechoic and become almost indistinguishable in a joint without effusion. In contrast, hypoechoic fluid or synovium may considerably separate these tissues in the patholjoint with arthritis.
“muscular” (fleshy) insertion of the teres minor tendon; Teres minor is seen as a
trapezoidal structure deep to the inferior deltoid.
The insertion appears hypoechoic, as opposed to other rotator cuff tendon insertions that have more fibrinous and therefore more hyperechoic insertions