By Dr. Raham Bacha From Lecture Notes Of Professor. Dr. S. Amir Gilani.

1. قالو سُبحانك ل ا ع لام لنا
ال اما عا لمتنا انك انت العليمُ الحكيم
Surah Al Baqarahverse 32

3. By: Dr. Raham Bacha
MD, MSc Sonology Gold Medalist (UOL)
PhD Ultrasound
The university of
Lahore

4. BY

5. Gleno-humeraljointhasthewidestrangeofmovementcomparedwithanyotherjointinthebody,thisisaccomplishedthroughsacrificeofthebonystabilitywhichisseeninmostjoints.

6. Thegleno-humeraljointisamulti- axialball-and-socketjoint.Thebonysocketistheglenoid,whichisonlyaboutonethirdoftheareaofthehumeralheadincontrasttotheacetabulumofifhip,whichcoversmostofthefemoralhead.

8. Tocompensateforthelackofbonystabilitythereisacloselyappliedsystemofligaments,tendonsandmusclesaroundthegleno-humeraljoint,whichactasdynamicstabilisers.ThemostwidelyknownofthesestructuresistheRotatorCuff.

9. HUMERUS:
Thehemisphericalarticularsurfaceisborderedbytheanatomicalneckofthehumerusandiscoveredbyhyalinecartilage.GreatertuberosityLieslateraltotheanatomicalneck.Ithasthreefacets.

11. 1.Thesuperiorfacetforinsertionofthesupraspinatustendon
2.Themiddlefacetliespostero-inferiorto"1".andisthesiteofinsertionfortheinfraspinatustendon.
3.Theposteriorfacetliesposterio-inferinrto"2."theinsertionoftheteresminortendonoccursonit.
Lessertuberosity-liesanteriortothehumeralhead. subscapularistendoninsertsonitsapex.
Bicipitalgrove-Liesbetweenthegreaterandlessertuberosities.Isnormallyoccupiedbythelongheadofbicepstendm.

13. Acromion
Broad,flatplateofbonethatiscontinuouswiththespineofthescapula.Liessuperiortothegleno-humeraljoint.Articulateswith
theclavicle
Projects from the superior aspect of the neckof the scapula and lies anterior to the gieno- hurneraljoint
Coracoid Process

14. TheAcromiumandtheCoracoidProcessarejoinedbythecoracoTacromialligamenttoformacontinuousprotectivearchovertheshoulderjoint.Therotatorcuffandthelongheadofbicepstendonmaybecomecompressedbetweenthehumeralheadandthecoraco-acromialarch-RotatorCuffImpingementSyndrome.

15. Coveredwithhyalinecartilage.Connectedtothelateralaspectofthescapulabyabroadneck.Theglenoidlabrumisawedge-shapedfibrocartelagenousstructureattachedtothemarginofthebonyglenoid.Thisincreasesthestabilityofthegleno-humeraljointandcushionsthehumeralhead.
Glenoid

17. Attachedtothemarginofthearticularsurfaceoftheglenoid,externaltothelabrumandtothelabrum
Humeralattachment:Anatomicalneckofthehumerus,
exceptinferiorlywhereitattachesmoreinferiorlytothemedialshaftofthehumerus.Thesynovialmembraneoftheglenotumeraljointlinesthecapsule.Thesuperiormiddleandinferiorgleno-humeralligamentsstrengthenthecapsuleanteriorly.Thecoraco- humeralligamentstrengthensthecapsulesuperiorly.
Capsule

18. Therearetwobreachesinthecapsuleoftheshoulderjoint
1.Abovethesuperiorgleno-hunieralligament,forthetendonofthelongheadofbiceps.
2.Betweenthesuperiorandmiddleglano-humeralligament'sforthecommunicationwiththesubscapularbursa,whichliesbetweenthecapsulaandthesubscapularistendon.Thisbursamayextendsuperiorlytoliebeneaththecoracoidprocesstoformsubcoracoidbursa,however,thisbursausuallydoesnotcommunicatewiththesubscapuiarisbursaortheshoulderjoint.
3.OccasionallythereisasmalldefectInthebackofthecapsuleforasmallinfraspinatusbursa.

21. Arisesfromthesubscapularfossaandinsertsontheanterioraspectofthelessertuberositybyabroad,thicktendon.Separatedfromthecoracoidprocessbythesubcoracoidbursaandtheshouldercapsulebythesubscapularisbursa.Fibresfromthesubscapularistendonincombinationwithcapsularfibers,crossthebicipitalgrove, formingthetransversehumeralligament.
Rotator cuff
Subscapularis

22. Arisesfromthesupraspinousfossaofthescapula.Passesanteriorlyandlaterallybeneaththecoraco-acromialarchtoinsertonthesuperiorfacetofthegreatertuberosityofthehumerusbyabroad,"beakshaped"tendon.Thelongheadofbicepstendonmarkstheanteriormarginofthetendon.
Supraspinatus

23. Arisesfromtheinfraspinousfossaofthescapula.Itstendonblends(mix)withthesupraspinatustendonandinsertsonthemiddlefacetofthegreatertuberosityofthehumerus.
TeresMinor
Arisesfromtheuppertwothirdsofthelateralborderofthescapulaandinsertsontheinferiorfacetofthegreatertuberositybyathickflattendon.
Infraspinatus

24. Theshortheadarisesfromthecoracoidprocess. thelongheadarisesfromthesupraglenoidtubercleandtheglenoidlabrumbyalong,roundtendon. Theproximaltendonlieswithinthegleno-humeraljointasitpassesantero-laterallytothebicipitalgroovewhereitpassesbeneaththetransversehumeralligamentandthroughtheshouldercapsule.
Thetendontakeswithit,throughthecapsule.asheathofsynoviumforavariabledistanceintothebicipitalgrooveThetendoninsertsontheradialtuberosityandthebicipitalaponeurosis.
Biceps Brachii

25. Arisesfromthelateralonethirdoftheclavicle,thelateralborderoftheacromion,thespineofthescapulaandthefasciaoftheinfraspinatusmuscle.itisabroad,flatmusclethatconvergeslaterallytoinsertatthedeltoidtubercleonthelateralshaftofthehumerus.
Deltoid

26. Bursae
Thesubacromial-subdeltoidbursaseparatesthedeltoidfromtheunderlyingrotatorcuff,thelongheadofbicepstendonandthegreatertuberosity.Itextendsmediallyundertheacromionanddoesnotcommunicatewiththegleno-humeraljoint.Thesubscapularissubcoracoidandinfraspinatusburshavebeendiscussedearlier.

28. ThemusclesoftherotatorcuffandthetendonofthelongheadorbicepsplayacrucialroleinthestabilityoftheshoulderjointbyactingasantagoniststomusclegroupsactingintheOppositedirection.Theantagonisticactionoftherotatorcuffmusclesmaintainsthehumeralhead,centeredintheglenoidthroughthefullrangeofshouldermovement.

29. Inabduction,thedeltoidmuscletendstodrawthehumerussuperiorly.Thesupraspinatusmuscletendoncontractsatthebeginningofabduction, therebyresistingthesuperiormovementofthehumeralhead.Thesupraspinatusmuscleisassistedinthisfunctionbythelongheadofbicepstendon,whichalsoresiststhesuperiormovementofthehumeralhead.

30. Whenthereisalossofbalancebetweenthesupraspinatusmuscle,thelongheadofbicepstendonandtheactionoftheabductors,therotatorcuffandtheadjacentsofttissuesbecomecompressedbetweenthehumeralheadandthecoracoacromialarch.Thisisthebasisofrotatorcuffimpingementinamajorityofcaseswherenobonycauseisfound.

31. 1.Abduction
2.Adduction
3.Flexion/Extension
4.Internal rotation
5.External rotation
6.Circurnduction-Which is aconibinatior) of the above movements
The planes of movement of the shoulder joint are:

32. Trueabductionoccursthroughaverticalplane, anteriortothecoronalplane,inlinewiththeaxisofthescapula.
•Thedeltoidisthemainabductorofthearm.
•Thesupraspinatusisimportantintheearlyphasesofabductionandthenhelpstomaintainthejointstabilitybyrestrainingthismovement.
•Theremainderoftherotatorcuffmuscleshelptomaintainthehumeralheadwithintheglenoid.
Abduction

33. Thereverseofabduction
Latissimusdorsi,teresmajor, subscapularisandthepectoralmusclescombinetoeffectactiveadduction.
Adduction

34. •ItIsinaplaneat90degreestotheplaneofabduction.Thebisepsbrachii,coraco- brachialis,pectoralismajorandtheanteriorfibresofthedeltoidmusclearethemainflexors.
•Theposteriorfibresofthedeltoidandtheteres_majorarethemainextensorsoftheshoulderwiththelatissimusdorsiandthesterno-costalfiberesofthepectoralismajorrestrainigfromfullflexion.
Flexion/Extension

35. Internalrotationiseffectedbysubscapularis,teresmajor,latissimusdorsi, pectoralismajorandtheanteriorfibresofthedeltoid.
Externalrotationiseffectedbyinfraspinatus, theposteriorfibresofthedeltoidandtheteresminor.
Rotation

36. Thismovementisacombinationofalltheabovemovements,withthehumerusdescribingacircleoraconecentredontheglenoid.
Movementofthescapulaalsofacilitatesthismovement.
Circumduction

38. The structures successfully
evaluated by ultrasound
include:
•The rotator cuff tendons
•The long head of biceps tendon
•Bursaearound the shoulder
•Impingement of the above structures on the coraco-acromial arch
•The bony structures of the shoulder
•The A-C joint
•The muscles around the shoulder

39. The advantages of ultrasound include
The ability to examine the shoulder as it is moved through its normal range of movement
Sensitivity and specificities have been reported in the 90% range
Easy comparison with the opposite side
The ability to palpate and localisesites of pain and tenderness with the ultrasound transducer
Wide availability
Relatively low cost

40. The disadvantages of ultrasound include
Highly user dependent
Clinicians find it difficult to interpret images
A number of conditions cannot be evaluated
most labralabnormalities
most bony lesions
capsulitis
A plain film examination should always be performed in conjunction with the ultiasound. This will assist in detection of bony lesions and fine calcifications in the rotator cuff

42. Tears
Tendonitis
Impingement
Tendon Dislocation

43. Tears
Occurmostlyindegenerateorinflamedtendonsandthereforareuncommonintheyoung.Alargeamountofforceisrequiredtotearanormaltendon.About92%ofrotatorcufftearsareofthechronictype,mostcommonlyrelatedtoimpingementandtendonitis.
Only 8% of tears are acute and due to a single traumatic episode.
50% of patientswith rotator cuff tears give no History of injury. The tear of supraspinatusis common.

44. Diagnostic:
Absence of the supraspinatus tendon
A gap within the tendon filled with fluid or blood.
A hypoechoic cleft.
Focal thinning of the tendon with loss of the normal convex contour of the subdeltoidfat plane

45. Inconclusive But Suggestive Signs:
An echogenic line in the tendon
An inhomogeneous area of echogenicity within the tendon
Fluid in the subdeltoidburs?
Fluid in the biceps tendon sheath

46. Tears should be visible in two planes but may be more obvious in one plane than the other.
Laminar tears.horizontally in the plane along the tendon.
Tearsareusuallymoreobviouswhenthetendonisputunderstress.Thisisusuallyachievedbyplacingthearminadductionandinternalrotationthatisachievedbyplacingthearmbehindtheback.Ifthisisnotpossiblethenthearmshouldbeplacedinextension

47. TENDONITIS
Mean inflammation of a tendon, it is a type of tendinopathy. This usually occurs as a result of
aRepetitive micro-trauma due to over use
bSubacromialimpingement

48. SONOGRAPHICFEATURESOFTENDONITIS
Decreaseinechogenicity
Fluidinthetendonsheathoradjacentbursa
Calcification-withacutecalcifictendonitisthecalciumisusuallyliquidandmayruptureintothejointorsubdeltoidbursa.Withchronictendonitis–solidcalcificationmayoccur.
Tendonitiswilloftenprogresstotendondegenerationandatear

49. Tendonitiswilloftenprogresstotendondegenerationandatear.
Bicepsteildonitisisrelativelycommonandisusuallyassociatedwithfluidinthebicepstendonsheath.
Fluidbyitselfisnon-specificandmaybeduetoashoulderjointeffusionorrotatorcuffpathology.Asmallamountoffluidinthebicepstendonsheathisnorrnal.

50. Itreferstocompressionoftherotatorcuffandthelotuheadofbicepstendonbetweenthehumeralheadandthecoraco-acromialarch.
90%ofcasesareduetoshoulderinstability
10%areduetomechanicalcausessuchasosteophytesontheacromionorA-Cjoint.
Thisisthemostcommoncauseofchronictendonitisandrupture.

51. Rotatorcuffimpingementmaybedividedintothreestages
Stage1:swellingandhemorrhagewithinthesupraspinatustendon
Stage2:Thetendonbecomethinandfibrotic
Stage3:Thetendontears

52. sonograpicSigns
DirectSigns:
Bunchingofthesupraspiriatustendonagainsttheacromiononabduction
Fluidmaybemilkedlaterallyinthesubdeltoidbursawithabduction
Thehumeralheadmaybeforcedinferiorlyatthetopofabduction

53. Indirect Signs:
The rotator cuff does not pass freely beneath the acromion(it is sometimes difficult to separate guarding of a painful shoulder from impingement in this situation)
Biceps or supraspinatus tendonitis with no apparent cause.
Thickening of the subdeltoidbursa with no apparent causa

54. Thelongheadofthebicepstendonisheldinthebicipitalgroovebythetransversehumeralligament.Ruptureofthisligamentallowsdislocationofthebicepstendon.Itusuallydislocatesmedially,eitheranteriororposteriortothesubscapularistendon. Thisiscommonlyassociatedwithtendonitisandtearsofthetendonduetomechanicalabrasionofthetendononthelessertuberosity.

55. •Anemptybicepitalgroove(Bewareofincorrecttransducerangle)
•Thetendonisvisualizedinadislocatedposition.
•Thetendonmaybeseentodislocatewithexternalrotationorwithflexion/extension.
•Underlyingcorticalirregularity
SonographicSigns:

56. •Subaciornial-subdeltoidbursa
•Fluid in this bursa is highly suggestive of a rotator cuff tear.
•It may also be seen in impingement or in inflammatory arthritidessuch as rheumatoid arthritis, which is often associated with synovial thickening.
•Always check laterally down to the deltoid tubercalas this bursa is quite extensive.

57. This may communicate with the shoulder joint.
In these cases fluid will be seen at this site with a joint effusion
Sub-coracoid bursa
This bursa may also communicate with the shoulder joint
Isolated fluid may be seen in the subcoracoidbursa with subscapularisimpangment.
Infraspinatus bursa

58. Ultrasoundissensitivefordetectionoffracturesinthevisiblebonysurfaces, especiallythegreatertuberosity.
Undisplacedfractures of the greater tuberosity are commonly missed on plain films.
FRACTURES

60. The capsule of the A-C joint normally has a convex superior surface Abnormal findings include:
Widening of the joint
Fracture fragments
Degenerative change
Ganglion cysts
A-C JOINT

62. Comparison views of the right and left AC joints in this patient reveal separation of the AC joint on the right side as demonstrated by the increased distance between the acromion and the clavicle (curved arrow).
AC Joint Separation

63. Hematomas,tearsandtumorsinthemusclesandsofttissuessurroundingtheshoulderjointareusuallybevisible. Detectionoftheseabnormalitiesisassistedbytheabilitytoexaminetheexactsateofswellingortenderness
PERI-ARTICULAR ABNORMALITIES

65. Manydifferenttechniquesforevaluatingtheshoulderbyultrasoundhavebeendescribed.Theidealseemstobeexaminationofeachcomponentoftherotatorcuffmorphologicallyandfunctionally.

66. •Ahighfrequency,lineararray,smallpartstransducerwithgoodnearfieldisESSENTIAL.
•Adjustoutput(power)toavoidoversaturation—rememberallstructuresaresuperficial.
•Selectappropriate2Dgreyscalemap, persistence,framerateandlinedensitytooptimisetheimage.
•Hardcopyimagesaretakenaccordingtodepartmentprotocol,withadditionalviewsofrelevantpathology.
•UsefultorecorddynamicassessmentonVCR.
EQUIPMENT:

67. TECHNIQUE:
BOTH SIDES ARE EXAMINED, THE NORMAL FIRST this "sets up the
equipment, the patient, and yourself. A formal routine is followed to ensure that
no abnormality is overlooked. Each phase leads onto the next, making it easier
for the novice to maintain their anatomical bearings.

68. The routine is, in order
BICEPS
Transverse,longitudinalanddynamic(internalandexternalrotation).SUBSCAPULARIS
Longitudinalanddynamic(internalandexternalrotation).
CORACO-ACROMIALLIGAMENT
Longitudinalanddynamic(internalandexternalrotation)
SUPRASPINATUS
Transverse,longitudinalanddynamic(passiveandactiveabduction)

69. INFRASPINATUS -Longitudinal and dynamic (internal and external rotation). TERES MINOR - Longitudinal and dynamic (internal and external rotation).
ACROMIO -CLAVICULAR JOINT Longitudinal and dynamic (abduction, adduction and forward flexion).
AREA OF PATIENT'S CONCERN ASK the patient what movements are difficult or painful, and if they have any "sore spots". Throughout the examination, if an area of concern is encountered, reference is made back to the normal side.

70. Bonylandmarksareparticularlyusefulinlocatingthevarioustendons.Whenstructuresofuncertainoriginareencounteredtherule"whenindoubt,moveit"isveryuseful,providedthesonographerhasasoundknowledgeofanatomy.

71. Itistransverseviewatthelevelofthelongheadofthebicepstendonatitsintra- capsularlevel.Notetheechogenictendonseparatingthesupraspinatus(laterally)andsubscapularis(medially)tendons.Thisregioniscalledtherotatorcuffintervalanditisimportantnottoconfusethisechogenicfocus,oftenflankedbytwohypoechoicareas,witharotatorcuffabnormality.
The Rotator Cuff Interval

73. The patient sits facing the monitor, preferably on an adjustable chair, with their arm by their side, hand resting on the outer thigh. In this position the bicipitalgroove lies anteriorly —(if the hand lies in the lap, the groove is quite medial, and can be difficult to located. Placing the transducer horizontally on the anterior upper shoulder, the bicipitalgroove can be seen —this is a VERY IMPORTANT bony landmark.
BICEPS:

74. TRANSVERSE—slidethetransducerfromsuperiortoinferiorintheaxial(horizontal)position,fromtheacromiontothebellyofthebicepsmuscle,keepingthetransducerperpendiculartothetendon."Heelandtoe" movementswiththetransducermaybenecessarytoshowtendontextureand/orfluidinthegroove.Thebicepstendonisusuallyovalandoftenlieseccentricallywithinthegroove.Thetransversehumeralligamentcanbeseensuperficialtothetendonasathinechogeniclineandisacontinuationofthefasciaoverlyingthesubscapularistendon.

75. Biceps Tendon -Transverse View

76. Longitudinal-Rotatingthetransducerthrough90degrees,thetendonisanechogenicfibrillarstructurelyinganteriortothestronglyechogenichumeralshaft.Again,"hee/andtoe" movementswillcompensateforanisotropy.Examinetendonfromacromiontomusclebelly.

77. Biceps Tendon Long axis
Demonstrate the biceps tendon in a sagittal view (white arrow) Note the
Classic fibrillar echo pattern evident within the tendon
also note the transverse humeral ligament in this plane (small white arrow)
Dynamic —The oiclpitaigrocyi-e is scanned transversely as the arm is Inter-sally
anaexternally rotated. any subluxation of the tendon should be visible on the
screen —t is usually obvious to the patient as a palpable and often audible
cli ,kScannincthe tendon longitudinally with it under tension (patient to pull
up the -forearm agaulstyour pushing)also show movement of the tendon
fibres

78. Lonoitudinai—From tnetransverse vie■A" of the e biceps. the insertion of tne
subsoapulanstendon can be seen on the medial aspect of the lesser
tuberosity The insertion is the apex of a somewhat triangular tendon. so care
should be taken to observe the whole insertion —it can be 3 to 6 ems wide.
With the arm in external rotation. the whole length of the tendon can be seen
under the subdeltoidbursa
SUBSCAPULARIS

79. -Short Axis
Figure illustrates a normal subscapularistendon (arrows) in a short axis, or transverse plane. Note the deltoid muscle labeled 0) superficially, as well as the humeral head (labeled H) and lesser tuberosity (labeled LT). Remember, the transducer must be oriented almost longitudinally in order to visualize this tendon in a transverse plane
SubscapittarisTendon

80. SubscapularisTendon -Long Axis

81. Dynamic—Internalandexternalrotationofthearmwilldemonstratethepassageofthetendonandverybroadmusclebellyunderthecoracoidprocess. Bursalfluidmaybecomemoreevident, andimpingementofthebursaormuscleonthecoracoidcanbeseen.

82. Attheendoftheexaminationofthesubscapularis,thetransducershouldbehorizontalwiththecoracoidprocessandsubscapularistendonvisible.Fixthemedialendofthetransducerandrotatethelateralendsuperiorly,sothatalinedrawnthroughthetransducerwouldpassthroughthenippleontheothersideofthebody.Thecoraco-acromnialligamentisvisibleasapairofechogenicthinlineswithaninterveningthinsonolucentline,runningbetweenthecoracoidandtheacromion.Atthecoracoidtheligamentappearstopasssuperficiallybutattheacromiontheligamentpassesdeeptothebone,andisoftennotwellseen.Ifthepatienthashadprevioussurgeryoftheshoulderthelateralpartofthe
ligamentmaywellhavebeenremoved.
CORACO -ACROMIAL LIGAMEN

83. Dynamic-OninternalandexternaliotationtIieiotatorcuffisseenglidingbeneaththeligamentandthedeltoidmusclemovesslightlyfromsidetosidesuperficialtoit-theligamentshouldbeassessedforflexibility, fluidinthesubdeltoidbursaquiteoftenbeingseenbeneathit.

84. Transverse-thesupraspinatustendoninsertsontothegreatertuberosityandformsthesuperiorandlateralportionsofthecuff:normallyitiscoveredbythebonyacromion,sohastobeputLindertensiontoobserveitinitsentirety,thisinvolvesmovingthearmintovariouspositions.Theeasiestpositionistoflextheelbow,placethepalmofthehandontothehip,andtucktheelbowintothesideorextendthearmdownbythesideandturnthethumbinward:orplacethearmbehindtheback,makingsurethereisno"gap"betweentheelbowandthetorsothiscanbequitedifficultforelderlypatients.Acombinationof.thesethreemanoeuvrescanbeattempted.
SUPRASPINATUS

85. Thetransducerisplacedontheacromioninthecoronalplane,andslidlaterallytheacousticshadowoftheacromionisreplacedbyapairofparallelcurvedechogeniclinesTheanteriorlineisthesubdeltoidbursaandtheposterior,thehumeralhead. Articularcartilageisseenasathinhypoechoiclineanteriortothehumeralhead.Movethetransducerinthisplaneanteriorlyuntilthebicepstendonisseenasanovalechogenicstructure-THISISAVERYIMPORTANTLANDMARK-asthesupraspinatustendonimmediately

86. posteriortoitisknownasthecriticalzoneofthetendon, ie.,itismorepronetodegenerativechangebecauseofpoorvascularity.Movingthetransducerposteriorlywilldelineatethejunctionofthesupraspinatusandinfraspinatus,seenasanobliqueechogenicline,neartheposterioredgeoftheacromion.Scanthetendondownontoitsinsertionontothehumeralhead,notinganypittingorbonychangesonthehumeralhead.possiblyindicativeoftears.Continuescanninginthesameplaneontothehumeralhead,toruleoutfluidinthesubdeltoidbursabeyondthetendoninsertion-•careshouldbetakentoscanverylightly,asfluidcanbeveryeasilydispersed.

87. Lorigi_tudinal-Rotate the transducer through 90 degrees, and use the acromion as a landmark.
The anterior part of the supraspinatus lies anterior to the acromion. The tendon has a sickle shape Often the coraco-acromial ligament is seen in cross-section immediately superficial to the tendon The ligament is iistrallyan echogenic dot. often with a sonolucentcentre. Sliding the transducer slightly anterior to the supraspinatus the tendon of long head of biceps is again encountered.
The mid portion of the tendon has an "eagles beak" appearance. 1 he acoustic shadow of the acromion resembles the head of the eagle, the smooth convex upper border of the tendon is the top of the beak, and the top of the humeral head is the bottom of the beak The hook of the beak is the greater tuberosity.

88. Slidingthetransducerslightlynioreposteriorly,thehookofthegreatertuberosityislostandthebeakhasaflatterappearance,resemblingmorea"crow'sbeak".

89. Supraspinatus Tendon -Long Axis

90. Supraspinatus Tendon -Short Axis

91. Dynamic---Withthetransducerparalleltothelongitudinalplaneofthesupraspinatustendon, abductthepatient'sarmwhilstwatchingthetendonmovementonthescreen.Thetendonandsubdeltoidbursashouldslidecompletelyundertheacromionorcoraco-acrornialligament.Themovementshouldbeperformedbythepatient(active)andbythesonographer(passive)withthearmindifferentdegreesofinternalandexternalrotation.

92. Thedynamicprocedureshouldbeperformedsothattheanteriorandmid(andoccasionallyposterior)portionsofthetendonareexaminedaspathologycanoccurinanyregionwithanymovement,dependingontheclinicalsituationeginsomeoccupations,wheremanymovementsareperformedwiththearmsoverthehead,theposteriortendonsuffersmorethantheanterior,andviceversa.Itshouldbenotedthatwhenthc,armisinmarkedinternalrotation,thereisanaturallimittotheamountofabductionthatcanoccur(approximately90degrees)

93. Longitudinal—Withthepatient'sarmininternalrotation,placethetransduceronthespineofthescapula,alignedtoitslongitudinalaxis.Slideinferiorlyandlaterallytodemonstratetheinfraspinatustendoninsertionontothegreatertuberosity. Thenmovebackmediallytothemusculotendinousjunction.
INFRASPINATUS

94. Infraspinatus Tendon -Short Axis

95. InfraspinatusTendon Tendon-Long Axis

96. Dynamic —Moving the arm through external and internal rotation demonstrates
the tendon moving over the humeral head. Deeper to the tendon the posterior

97. glenoid labrum can be seen as a thin echogenic triangular structure "leaning“ on the humeral head. Effusions in the gleno-humeral joint are easily identified in this position as sonolucentcollections adjacent to the glenoid labrum. These collections change shape with the movement of the humerus.

98. Longitudinal-Fromtheinfraspinatusposition,slidethetransducerinferiorly,approximately1cm.ThethickerTerestendonresemblesaship'sprow.becomingmoreelongatedasthearmisinternallyrotated.Thetendonitselfismoreobliquethaninfraspinatus—toviewlongitudinally,rotatethemedialend/,ofthetransducerslightlyinferiorly.
TERES MINOR

99. Dynamic--Again,oninternalandexternalrotation,thetendonassessed,ascanbeanyfluidcollectionsintheposteriorjointspace.

100. hisisusuallyeasilypalpable.Ifnot,inthelongitudinalsupraspinatusposition,slidethetransducerslightlyantero--mediallyacrosstheacromionandthejointshouldbecomeobviousasasonolucentinvertedtrianglebetweentheacousticshadowsoftheacromionandtheclavicle("Thefatseagullsign").Scanfromanteriortoposterior.
ACROMIO-CLAVICULAR JOINT

101. Dynamic—Frorntlierestingposition(armextendeddownbythepatient'sside), abductandadductthearm,observinganychangeintheshapeofthejointcapsule. Alsoobserveanymovementsofthebonesthemselves--especiallyintheforwardflexionposition.

102. •ThisistheBASICexamination:otherareasofconcerninclude-
•thesuprascapularnotchandspino-glenoidnotch(affectingthe
•suprascapularnerve),
•theshortheadofbiceps,
•muscletextureindisusesyndromes(especiallyinfra-andsupraspinatus)
•rhomboids,
•deltoidoriginandinsertion
•pectoralismuscles
•triceps