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A number of pathologic conditions can be diagnosed with ultrasound. Large, full-thickness rotator cuff tears are hard to miss. Even my patients who have no medical knowledge can appreciate the tear when I show them their contralateral normal shoulder. Partial-thickness tears can be more difficult to visualize, especially low grade tears. Also differentiating between a high-grade partial-thickness tear and a full-thickness tear can be hard. This is certainly no different than an MRI, where the radiologist will often dictate something like "a small non-displaced full-thickness tear cannot be excluded". The nice thing about ultrasound is you can spend as much time as needed focused on the structure in question, and you can have the patient perform an isometric contraction of the cuff muscles to see if there is any retraction of the tendon fibers, confirming the tear. Some conditions, such as a SLAP lesion or a Bankart tear are not visualized with ultrasound. I have included a couple of images demonstrating something called anisotropy. This is an ultrasound "artifact". It is a falsely hypoechoic signal that occurs when the face of the probe is not parallel with the tendon that is being visualized. The ultrasound waves reflect off the tendon at an angle and are not captured by the probe giving the false picture that the tendon is absent. This is corrected by simply correcting the angle of the probe. Below you will find a number of great slides showing all kinds of examples of shoulder pathology.


Normal appearing biceps tendon in the bicipital groove visualized in the transverse plane. The face of the probe is perfectly parallel to the tendon.

If the probe angle changes even ten degrees the biceps tendon looks like it has disappeared. This is anisotropy. If the probe is angled back to parallel the tendon will be visible again.


This is a classic coronal image of a full thickness supraspinatus tear. You can see the defect in the tendon (dark area) on the right adjacent to the greater tuberosity. It has minimal retraction but joint fluid is extending through the tear into the subdeltoid space.

This is an arthroscopic image of a similar tear. You can see the full thickness defect in the tendon with remnants of the tendon still attached to the tuberosity at the left. 

This is a coronal image of a full thickness retracted tear of the supraspinatus. Note the small amount of fluid adjacent to the greater tuberosity. The deltoid muscle is essentially draped over the humeral head, as the cuff tendon is retracted far to the left.

This is the corresponding arthroscopic image showing the retracted supraspiantus tendon at the level of the glenoid. The insertion of the frayed biceps tendon is just below.

This is a coronal image of an acute full-thickness supraspinatus tear with about one cm of retraction. Note the fluid filled void with fluid in the subdeltoid space.

This is the sagittal view of the same tear.

This appears to be a delaminated bursal sided    partial thickness supraspinatus tear. However the large subdeltoid fluid collection should tip you off that there is a full-thickness component

Note the detailed view of the delaminated bursal sided fibers.

At arthroscopy it was confirmed that there was a full-thickness supraspinatus tear visible at the right, but the delaminated fibers were easily visible to the left of the shot.

Another view of the delamination.

Another coronal image of a full-thickness supraspinatus tear.

Another tear with a larger degree of retraction.

This is a coronal image of a larger full thickness supraspinatus tear with a moderate degree of retraction. Note the fact that the deltoid has come to rest on the greater tuberosity as the thickness of the cuff retracts medially.

This is a sagittal image of the same tear. Note the defect (dark area) in the tendon just superficial to the humeral cortex and deep to the deltoid fascia.

This is the corresponding arthroscopic image showing the degree of retraction of the tendon.

This is an axial image showing a full-thickness retracted infraspinatus tear with retraction. The dark area superficial to the humeral head is fluid in the void where the tendon has retracted.

Full-thickness subscapularis tear.


This is an image that looks just like a Steve Lippitt drawing out of one of Dr. Matsen's textbooks. There is a small avulsion of bone off the greater tuberosity on the articular side of the partial thickness supraspinatus tear.

Bursal-sided moderate grade partial thickness tear with articular-sided fibers still attached to the tuberosity.

It's hard to tell if this is a full thickness tear or not. You can see a thin remnant of the supraspinatus still attached to the greater tuberosity. There is however a fluid collection outside the cuff suggesting a full thickness tear.


Coronal image of a large calcium deposit within the substance of the distal supraspinatus.

Sagittal image of the same deposit.

Arthroscopic view of the calcium deposit within the substance of the supraspinatus tendon.

After the calcium deposit has been removed. You can now see the void left in the tendon.

This is after the arthroscopic repair of the tendon.

Coronal view of calcium in its early stages of development. This did not show up yet on plain xrays.

Sagittal image of same deposit.


This is a axial image of the LHB in the bicipital groove with a large surrounding fluid collection. Remember fluid on ultrasound is dark, unlike on MRI where it appears bright white.

Here is an image of an injection into the sheath. The needle can be seen entering from the right.

This is another image demonstrating fluid surrounding the LHB.

This is another sagittal view demonstrating fluid in the sheath.

Axial view of a medial dislocation of the long head of the biceps. The oval structure in the center is the biceps and the groove is located on the left edge of the image.

Another large bicipital sheath effusion in the sagittal view. The fluid is the dark are just above the LHB fibers.

This is an acute proximal rupture of the long head of the biceps in the sagittal view. The retracted tendon stump is to the right with a hematoma surrounding it.


Often times on my initial view of the biceps and subscap I will see lots of fluid in the subdeltoid space superficial to the subscap. This tips me off immediately that I am likely about to see a full-thickness supraspiantus tear.

Sometimes you can see thickened bursal tissue within the fluid collection like you do in the center of this image.

Tons of subdeltoid fluid seen superficial to the cuff. Likely evidence of a full-thickness cuff tear or severe bursitis.

More fluid in the subdeltoid space. Easy to hit this with a needle for an injection.

This is what a large subdeltoid fluid collection looks like. Fluid is dark and is seen separating the humerus and supraspinatus from the overlying deltoid. You can see this finding with severe tendonitis or bursitis, or with a full thickness rotator cuff tear.

This is a sagittal image of the same fluid collection.

This is a large fluid collection visualized anterior to the bicipital groove and subscapularis on an axial view. The bicipital groove and the LHB are to the left and the subscap is seen to the right. The anterior head of the deltoid is to the top of the screen.


This is a small fluid collection emanating from the AC joint. This image is the equivalent of a coronal image viewing the joint from the front. The distal clavicle is to the left seen articulating with the acromian to the right. A small joint effusion is noted to the top of the image.

This is a small synovial cyst emanating from an arthritic AC joint.

This is the mother of all cysts emanating from the AC joint. This was a huge loculated cyst that was almost ready to break out of the skin. Note the multi-loculated appearance of the cyst...you would not know it was like this unless you utilized ultrasound to visualize it and.....

aspirate it under ultrasound guidance. You can see the needle to the right draining one of the compartments. I proceeded to place the needle under direct ultrasound visualization into every loculation to completely drain the cyst.


This is what an intact post-operative supraspinatus repair looks like. The greater tuberosity is to the right. You can see the hole for the suture anchor in the bone with the anchor visible within the bone. The repaired tendon is seen reduced to the humerus with no subdeltoid fluid collection noted.

This is another intact postoperative supraspinatus. Note the tuberosity to the left with the tendon attached to it. You can see the hole for the suture anchor. The hyperechoic white line within the tendon to the right is the suture material.

Another intact repair. Pretty amazing the detail you get with no artifact that comes with an MRI.

Another intact cuff. The tapped hole, the anchor, and the suture within the repaired tendon are visible.

The white dots are what non-absorpable suture looks like. It is a good sign to see this suture material within the substance of the tendon with the tendon still adjacent to bone.

This is what a postoperative cuff re-tear looks like. There is no real visible supraspinatus attached to the greater tuberosity to the right. There is fluid and some remnant of the suture material noted, but the deltoid is draped over the humeral head where the cuff tendon should be.

This is a what an intact supraspinatus looks like on a coronal image after a total shoulder replacement. The greater tuberosity is to the right with the cuff attached. The metallic humeral head is the bright white line to the left deep to the cuff itself.

Another intact supraspinatus on coronal image after a total shoulder. The implant is deep to the left.

This is an intact subscapularis on an axial view after a total shoulder. The bicipital groove is to the far left with the lessor tuberosity just adjacent to the right of it. The subscap tendon is intact attached to the lessor tuberosity.


In order to best visualize the needle as it enters the body, the needle needs to pass under the probe parrallel to the long axis of the probe.

This is what it looks like when you do it this way. You see the needle in profile entering from the right side of the screen. You are able to follow the tip as soon as it enters the body so you can guide it to the correct spot.

If you pass the needle under the probe off axis, you wont see the needle tip until it passes directly under the probe. By this time you may have already missed your target. This is not the ideal way to do it.

If you do it this way all you will see is a dot that represents the needle.

Subacromial injection viewed in the sagittal plane with needle tip just superficial to the cuff.

Coronal view of an injection into the subacromial space just superficial to a partial thickness tear.

This is a coronal view of an injection into the AC joint. See the needle coming in from the left. To the right is the distal clavicle and to the left is the acromian.

Aspiration of a huge multi-loculated AC joint cyst.

Another subacromial injection.



 
   
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