Shoulder Ultrasound

Anatomy
Glenohumeral Joint Stabilization
A key stabilizer of the glenohumeral joint is the
rotator cuff, which is composed of the
subscapularis tendon anteriorly, the
supraspinatus tendon superiorly, and the
infraspinatus and teres minor tendons
posteriorly.
Of these posterior tendons, only the
infraspinatus tendon is partially visible in this
illustration.
Rotator cuff interval
The rotator cuff interval is a distinct gap in the
rotator cuff located between the superior edge of the subscapularis tendon and the anterior edge of the
supraspinatus tendon.
In this interval, the humeral head is not
covered by the rotator cuff but is instead
covered by the intra-articular portion of
the long head of the biceps tendon,
which is stabilized by the coracohumeral
ligament.
When assessing for supraspinatus tendon
tears, it is crucial to examine its
attachment to the greater tuberosity,
particularly along the posterior border of
the rotator cuff interval.
This anterior region of the supraspinatus
tendon is a common site for partial-
thickness tears, known as "rim-rent
tears."
The biceps tendon is stabilized by the capsuloligamentous complex, referred to as the biceps pulley,
which consists of the superior glenohumeral ligament, the coracohumeral ligament, and the distal
insertion of the subscapularis tendon.

This posterior view of the shoulder

highlights the supraspinatus, infraspinatus,
and teres minor muscles and their associated
tendons.

1
Spinoglenoid notch

The spinoglenoid notch is the anatomical

region located between the lateral base of
the scapular spine and the glenoid process.
It serves as a connection between the
supraspinatus and infraspinatus fossae and
allows passage for the suprascapular nerve
and artery.
Ganglion cysts can develop in this area,
potentially compressing the suprascapular
nerve and leading to shoulder pain and
atrophy of the infraspinatus muscle.
These cysts are often secondary to tears in
the posterosuperior glenoid labrum.

Standard Ultrasound
Examination

Ultrasound Examination of the Shoulder

A high-resolution linear probe (≥10 MHz)
is typically used for shoulder ultrasound.
Occasionally, a curvilinear probe (3.5
MHz) is employed to provide a broader
view of the glenohumeral joint.
The examination generally begins with the
long head of the biceps (LHB) tendon,
assessing for effusion, tears, or
subluxation.
Fatty atrophy may also be observed, either
within the muscle belly or at the
myotendinous junction.
Next, the tendons of the subscapularis,
supraspinatus, and infraspinatus muscles
are evaluated, with particular attention to
identifying tears.
The examination can be expanded to
include the acromioclavicular (AC) joint,
spinoglenoid notch, posterior labrum, and
the glenohumeral joint.
A checklist (see Table) is recommended to ensure all structures have been thoroughly examined.

2
Long head of the biceps tendon
The LHB tendon is best visualized by positioning the probe over the muscle belly of the biceps brachii in
the upper arm and moving proximally to the myotendinous junction and the tendon.
The patient’s forearm should be supinated and slightly internally rotated toward the contralateral knee.
In this position, the LHB appears as a rounded structure with a fibrillary echotexture (black arrow)
situated within the intertubercular groove (white arrowheads).

Anisotropy of the LHB

Anisotropy
Anisotropy is an artifact that occurs when the ultrasound beam is not perpendicular to the LHB tendon.
This misalignment leads to reduced sound wave reflection, resulting in a loss of resolution and a
darkened, hypoechoic appearance of the structure (black arrow). In some cases, this may give the
impression that the LHB tendon is dislocated from the intertubercular groove.
To correct for anisotropy, reposition the transducer so that the ultrasound beam is perpendicular to the
tendon. The LHB will then regain its typical echogenic, fibrillary appearance (white arrow).
It is important to note that anisotropy can also affect other structures, such as the subscapularis tendon in
this image, which similarly appears anechoic due to this artifact.

3
Rotator cuff interval
When the patient moves the elbow slightly backward while maintaining forearm supination, the intra-
articular portion of the biceps tendon within the rotator cuff interval becomes more clearly visualized.
This positioning is referred to as the Jugger’s position (see figure).
Image
Transverse view of the rotator cuff interval.
The LHB (arrow) is located between the subscapularis tendon anteriorly and the supraspinatus tendon
posteriorly.
The LHB is covered by the coracohumeral ligament (arrowheads).

Subscapular tendon
The arm is positioned alongside the trunk, with the elbow flexed at a 90º angle between the arm and
forearm.
The forearm is placed in supination and external rotation.
The ultrasound probe is positioned medially to visualize the subscapularis (SSC) tendon as it passes
beneath the coracoid process.

4
Supraspinatus tendon
The optimal position for examining the supraspinatus tendon is the modified Crass position. In this
position, the patient is instructed to place their hand on the ipsilateral hip or toward their back pocket (see
figure).
An alternative is the Crass position, in which the patient places their arm in internal rotation behind the
back.

Infraspinatus tendon
Examining the infraspinatus tendon can be challenging due to the difficulty in distinguishing it from the
supraspinatus tendon. The optimal position for visualizing the infraspinatus tendon is to have the patient
place their hand on the contralateral shoulder.
Position the probe in the same orientation as for examining the supraspinatus tendon. Once the
supraspinatus is in view, gradually move the probe inferiorly. A subtle gap will become evident, followed
by the smaller, distinct outline of the infraspinatus tendon.
Video of the infraspinatus tendon.
Double click on the video for a full screen view.

5
Acromioclavicular joint
The acromioclavicular joint is easily appreciated by palpating the bony projection and then placing the
probe over it.
A normal acromioclavicular joint shows a smooth contour of the bony articular surfaces.

Spinoglenoid notch
Identify the scapular spine as a hyperechoic bony landmark.
Move the probe laterally until you locate the spinoglenoid notch, which is situated between the lateral
scapular spine and the glenoid process.
The suprascapular nerve appears as a hypoechoic tubular structure with a fascicular pattern (arrow).
Power Doppler can be beneficial to trace the suprascapular vessels in order to find the nerve.
Examine for ganglion cysts, which may appear as hypoechoic, fluid-filled structures compressing the
suprascapular nerve.
These cysts are often associated with tears of the posterosuperior glenoid labrum.

6
Posterior labrum and glenohumeral joint
The posterior labrum can be examined by placing the probe at the posterior aspect of the glenohumeral
articulation.
The labrum is seen as a triangular echogenic structure, which is more echogenic than the adjacent
cartilage (arrow).

Pathology

Biceps tendinopathy
Images
Two examples of a thickened long head of the biceps tendon.
Notice the irregular echo-pattern especially on the image on the right.
There is hypervascularity and some surrounding fluid (arrows).

7
Tear of the long head of the biceps (LHB)
The most common site of injury to the LHB is at the myotendinous junction and the adjacent portion of
the tendon.
LHB tears are readily identified on ultrasound as anechoic fluid disrupting the continuity of the muscle
fibers.
The echogenicity of the fluid varies depending on the chronicity of the injury:
• Acute tears typically appear as anechoic fluid.
• Chronic tears may demonstrate echogenic debris or reflective echoes within the fluid.
Images
The accompanying examples illustrate tears at the myotendinous junction of the LHB. The tears appear
completely anechoic, consistent with acute injuries.

Biceps tendon dislocation

The long head of the biceps (LHB) tendon is
normally located centrally within the bicipital
groove. An abnormal, eccentric, or displaced
positioning of the tendon may indicate laxity or
rupture of the biceps pulley.
Imaging Findings
MR Arthrography with Axial T1-Weighted Fat-
Suppressed Image: The biceps tendon is medially
displaced within the subscapularis tendon, as
indicated by the arrow.
Continue with ultrasound images...

Images
1. Eccentric position of
the long head of the biceps
tendon due to laxity of the
biceps pulley.
2. Dislocation of the
biceps tendon. Notice the
empty bicipital groove
(asterix)

8
 Rotator cuff tears
Partial thickness tears
Partial thickness tears involve only a part of the tendon and do not involve the full thickness.
It can be located on the articular or on the bursal side (figure).
An intrasubstance tear is also a partial thickness tear.
Full thickness tears
Full thickness tears can be complete or may involve only a part of a tendon.
This is called an incomplete full-thickness tear and is just like a hole in a tendon (figure).

Full thickness tears

This image shows a
complete full thickness tear
of the supraspinatus tendon.
There is a small hypoechoic
fluid collection.
Both tendon edges are blunt
and retracted (arrowheads).

9
Here another example of a ful thickness tears of the supraspinatus tendon.
The gap is filled with some fluid from the glenohumeral joint (arrow)

Partial thickness tears

Here two examples of a partial tear on the articular side.

Intrasubstance tears
Intrasubstance tears are partial-thickness tears that do not extend to either the articular or bursal surfaces
of the tendon.

10
Images
The images demonstrate two examples of small intrasubstance tears.

Image
during exoratation (left) and endorotation (right)
Impingement
During endorotation a normal subscapular tendon should show almost complete passage underneath the
coracoid process.
Impingement is suspected when a residual portion of the tendon is still visible during maximum
endorotation.
Images
During endorotation there is incomplete passage under the coracoid and buckling of the subscapular
tendon.
Video of subscapular impingement.
Double click on the video for a full screen view.
Notice the limited range of motion.
This video is of a 58-year-old female experiencing severe pain and limited movement in her shoulder.
In full external rotation, a large subcoracoid bursa bulges over the subscapular tendon.
Double click on the video for a full screen view.
Notice the limited range of motion.

Tendinopathy
The term tendinopathy is used rather than tendinitis because there is no active inflammation, but instead it
is a degenerative process with mucoid degeneration.
The tendon is frequently thickened and may show hypoechoic striated areas.
Images
Thickened supraspinatus tendon with an inhomogeneous echo pattern.

11
Calcific tendinopathy
Calcific tendinopathy occurs when calcium deposits accumulate within the tendons. While this condition
can affect tendons throughout the body, it most frequently involves the rotator cuff tendons of the
shoulder. These calcium deposits may become inflamed, leading to pain.
Imaging Findings:
• Significant thickening of the supraspinatus tendon with large calcifications producing an
extensive posterior acoustic shadow.
• A small calcification observed within the supraspinatus tendon.

Bursitis
The normal bursal space is collapsed and barely distinguishable by ultrasound (arrows).

Acute bursitis appears sonographically as distension of the bursa (yellow arrow).

Chronic bursitis may show a thick wall (white arrow).

12
AC pathology
Osteoarthritis
Diagnosing symptomatic osteoarthritis of the acromioclavicular joint can be difficult, as radiographic and
ultrasound findings of joint degeneration are commonly seen in adults and have a poor correlation with
clinical symptoms.
Images
Osteoarthritis of the AC joint with cortical irregularity and bulging of the capsule.

AC-arthritis
This image is of a 19-year-old male athlete who sustained an injury during a wrestling match.
There were no signs of septic arthritis and he was diagnosed with post-traumatic arthritis.
He improved with anti-inflammatory medication and rest.

13