 Hey there, my name is Dr. Ankit Shah and I am a practicing radiologist at Wille Parle West and I practice at Eglad polyclinic. I also happen to be the general secretary of Muscular Skeletal Ultrasound Society. Today, I will be demonstrating the ultrasound scanning technique of the shoulder joint. From the anterior aspect, we will be evaluating the long head of the biceps, the subscapularis tendon and the acromioclavicular joint. Now, we identify the long head of the biceps on the transverse view by placing our probe along the anterior shaft of the humerus and as we scan upwards, we see the bicepital groove which is formed medially by the lesser tuberosity and laterally by the greater tuberosity. The long head of the biceps is seen as an echogenic oval structure which is prone to anisotropy. So, as I rock my probe anterior and posteriorly, you see that the appearance of the long head of the biceps changes. So, once I have scanned the long head of the biceps, I go all the way from the rotator interval superiorly till all the way down till I keep on scanning down till I see the pectoralis major tendon coming into view and that is where I stop. So, on the short axis, what we see is the biceps tendon is flush with the bicepital groove and it is located within the groove itself. It is neither dislocated nor subluxed and what we would like to look for is a possibility of a hypoechoic halo which would represent effusion within the biceps tendon sheath. Once we have seen the biceps tendon on the short axis, what I do is I carefully turn my probe 90 degrees or perpendicular to the perpendicular to what my previous position and I align myself with the long axis of the biceps tendon. So, once I have seen what I do is I scan upwards, I go all the way down, I go all the way down, I look at the long head of the biceps, go all the way down and this is the muscular tendinous junction of the biceps tendon that we see over here. Now that we have evaluated the long head of the biceps, what we do is we ask the patient to externally rotate his arm and as much as possible. So, what this maneuver does is it brings out the sub scapularis tendon. So, what I do is from the bicepital groove, I slide medially and I identify my bony landmark which is the coracoid process that I see over here. Now in this view, what we see is we see that the coracoid process is medially and as I slide my probe laterally, as I slide my probe laterally, what I see is this is a sub scapularis tendon which is forming and it goes all the way and it attaches over the lesser tuberosity. Once again I slide medially, I go all the way, I identify the muscular tendinous junction of the sub scapularis tendon in the long axis and this is a coracoid process that I see. So, while we are scanning the long head of the, while we are scanning the sub scapularis tendon in the long axis, what we do is it is important to know that it is a broad and flat tendon. So, make sure that you make these micro movements and scan the tendon from superiorly to inferiorly and the other way around. So, what I am doing over here is I am scanning the tendon along its long axis from superior to inferior over here and we make sure that you know we scan the entire length and breadth of the tendon. Once I have scanned the tendon on the long axis, what I do is I turn my probe 90 degrees from what it was initially and this is what the sub scapularis tendon looks like. It typically has a multi-penet appearance that we see its alternate areas of echogenic and hypoechoic bands that we see. So, this is the superior edge and this is the inferior edge of the tendon. While I am identifying the sub scapularis tendon, what I do is I scan the entire tendon from its cranial edge over here that I see till all the way down all the way down till its inferior edge which makes sure that I have scanned the entire length and breadth of the tendon. Once again, let me repeat it has a multi-penet appearance with alternating areas of echogenic and hypoechoic bands so do not mistake it for tendinosis or an interstitial tear. Make sure you have sweeping movements which go all the way from medial to lateral and superior to inferior. So, this way we have scanned the entire sub scapularis tendon in the short axis as well. So, from the anterior aspect one more structure that you can easily see is the coracoacromial ligament. After you scan the sub scapularis tendon, once again you come to your bony landmark which is your coracoid process and you angle your probe gently towards the acromion. So, what you see over here is this nice thick band-like structure that we see over here that is your coracoacromial ligament. So, you scan medial to lateral and this is an entire thing is a coracoacromial ligament which is really seen as an echogenic linear structure over here. Third structure that we see from the anterior aspect is your acromioclavicular joint. So, the acromioclavicular joint is seen either by the palpation or what you can do is you can place your probe over the bicepital groove over here and you go all the way up you go scanning all the way up all the way up all the way up all the way up and you come to the acromioclavicular joint over here. So, laterally what you have is the acromion and medially what you have is z-clavicle. Alternatively what you can do is you can identify the acromioclavicular joint by palpating the acromioclavicular joint around the superior aspect of the shoulder or what you can do is directly drop your probe over the most bony most prominent bony protuberance along the superior aspect of the shoulder and what you see over here is the acromioclavicular joint. Once you identified the joint once again this is the cortex of the acromion along the lateral aspect medially you have the medial edge of the clavicle and between the two bones what you see is the acromioclavicular joint this echogenic structure that we see over here that is the fibrocartilaginous disc. The superior edge of the acromioclavicular joint is formed by a capsular ligament which is just superior acromioclavicular ligament. So, we scan the ac joint from anterior to posterior and smooth sweeping movements and look for any cortical irregularities which might be over there. So, now we are going to examine the shoulder from the lateral aspect over here what we are going to do is we are going to evaluate the supraspinitis tendon the infraspinitis tendon and the rotator interval along with the subacromil subdeltaid bursa. So, what we do is we ask the patient to flex his elbow and extend his shoulder. So, take it all the way back and ask him to touch his right right lower back or the right gluteal region or ask the patient to reach for the back pocket and while we are doing this make sure that the elbow is tucked in or as close to the spine as possible. This is typically known as the modified crass position so that when the patient does this maneuver what happens is the entire supraspinitis tendon comes out below the acromial edge and we can assess the entire supraspinitis as well as the infraspinitis tendons. Once the patient is in the modified crass position what I do is I place my probe along the long axis of the supraspinitis tendon. So, what I see is the rotator cuff is seen as a beak shaped appearance birds beak appearance that we see over here. So, as a beginner it is always a good idea to count all the layers from the top. So, on top you have the most echogenic layer which is your skin and the subcutaneous tissue followed by you have the deltite muscle you have the subacromial sub deltite bursa below the muscle and this is seen as a thin echogenic line it is a potential space. So, it will be collapsed and because of the peri bursal fat it is seen as an echogenic line and below the subacromial sub deltite bursa is your echogenic supraspinitis tendon which has a fibrillary pattern below that you have the hypoechoic articular cartilage and just below that you have the below that you have the echogenic cortex of the humeral head. The supraspinitis tendon is seen as an echogenic beak like structure as I had said. So, how do I make sure that my tendon fibers are seen absolutely parallel without any anisotropy what I do is you take a look at the fibers of the deltite muscle belly superiorly. So, if you see these echogenic lines which are parallel that means you your probe is parallel to the supraspinitis muscle fibers or alternatively you come anteriorly you identify the long head of the biceps and try and scan in the long axis in that plane. So, what we do is we scan the tendon from anterior to posterior this is a cuff as we go as we go as we go posteriorly we see that the supraspinitis ends and infraspinitis tendon that we see. Again I come anteriorly and this is what this is how we scan the entire cuff and the long axis often at times it is difficult to identify on the long axis which is a supraspinitis tendon and from where does the infraspinitis begin. So, what we do is we can have a look at the greater tuberosity. So, look at the morphology of the greater tuberosity anteriorly anteriorly it is a little bit more sharp and as we go posteriorly the morphology of the greater tuberosity changes and it becomes more rounded. So, when the greater tuberosity appears a little bit more rounded you are more likely to be in the space of the infraspinitis and as you come anteriorly it is more likely to be supraspinitis due to the sharp edge of the greater tuberosity. One more thing to note is as this supraspinitis tendon fibers reach the greater tuberosity what you see is that this there is this little bit of anisotropy which is happening and the tendon may appear hypoechoic because this is because there is curving of the fibers. So, one way to reduce that anisotropy is you go a little bit laterally and you angle the probe and reduce the anisotropy as much as possible. So, what we see over here is we have reduced the anisotropy and we kept the tendon appears ecogenic with this normally normal fibrillary pattern all the way till the greater tuberosity. Now as the tendon approaches the greater tuberosity along the footprint you see a small hypoechoic area and this is a fibrocartilage because this is where the tendon attaches over the greater tuberosity. So, once we have identified the rotator cuff tendon in the long axis what we do is I turn my probe 90 degrees gradually very carefully I turn my probe 90 degrees and I evaluate the rotator cuff in the short axis. So, this is what the cuff looks like. So, this is a anteriorly what I see is a biceps and posteriorly what I see is a supraspinitis a little bit more anteriorly I see the kefalate fibres of the subscapularis tendon. So, as I go a little bit more posteriorly once again that is the subscapularis tendon that is the biceps tendon at the rotator interval this is the supraspinitis tendon all right and this is the infraspinitis tendon coming in. Now how do I differentiate between the supraspinitis and infraspinitis on the short axis it is a little bit simpler than doing it on the long axis. So, as I go laterally as I go laterally you see the humerus is gets divided into at least two facets over here. The facets of the greater tuberosity have typically a configuration wherein anteriorly you have the more flattened facet which is where your supraspinitis tendon attaches a little bit more posteriorly you have an oblique orientation of the facet where your infraspinitis tendon attaches and as you go a little bit more posteriorly you have a vertical facet where your teres minor tendon attaches. So, this is how the tendons attach over the greater tuberosity and as we go anteriorly as we scan anteriorly just anterior to the supraspinitis tendon what we have is a rotator interval. The rotator interval is formed between the supraspinitis tendon superiorly the subscapularis tendon inferiorly and the floor of the rotator interval is formed by the head of the humerus. Now looking at the rotator interval it consists of three structures which is the coracohumeral ligament, the biceps tendon and the superior glenohumeral ligament. It is important to know the contents of the rotator interval and its clinical significances that it is one of the dynamics stabilizers of the shoulder joint and it is commonly involved during adhesive capsulitis or frozen shoulder. So, what you see over here is the at the rotator interval is the biceps tendon is kind of enveloped by a C-shaped structure that we see over here and this C-shaped or the inverted C-shaped structure is formed by superiorly by the coracohumeral ligament and inferiorly by the superior glenohumeral ligament and this entire structure what we see over here that is known as a biceps pulley. So, from the posterior aspect what we will be covering is the supraspinitis muscle belly, the infraspinitis muscle belly, the teres minor muscle belly and the tendon as well as the posterior joint recess. Apart from that we will also be looking at the suprascapular nerve at the level of the suprascapular notch and the spinal glenoid notch. So, for that the most important bony landmarks that we need to remember is one thing is a scapular spine. If it is a bony or if it is a thin individual what you can do is you can you will be able to palpate the scapular spine because it is important because it divides the rotator cuff muscle bellies into the supraspinus fossa and the infraspinus fossa and so your supraspinitis muscle belly arises from the supraspinus fossa, infraspinitis muscle belly arises from the infraspinus fossa. So, that is a good way of remembering. So, what I do is I begin scanning the posterior shoulder by placing my probe along over the spinus process and what I see is inferior to the spinus process I have the infraspinitis muscle belly whereas superior to the spinus process what I see is a supraspinitis muscle belly. So, once again supraspinitis this is a infraspinitis and as I go a little bit more below I see is a teres minor muscle belly over here. The lateral part is not well visualized because of the shadowing of the acromion and now what I do is I gradually turn my probe 90 degrees and evaluate the muscle belly in the long axis as well. So, this is how the muscle belly looks like you see the nice muscular tendon is junction and as I go laterally like I said because of the shadowing of the acromion and the coracoacromion arch you do not see the entire supraspinitis tendon. Once I have evaluated the supraspinitis muscle belly what I do is once again I come back to the scapula spine and as I go inferior to this scapula spine what I see is this is the infraspinitis muscle belly. As I screen in the short axis from medial to lateral as I am coming laterally as I am coming laterally I see the infraspinitis muscle forming into a tendon and it forms the proper tendon of the infraspinitis. After I have identified the infraspinitis muscle belly on the short axis I turn my probe 90 degrees I evaluate the infraspinitis muscle belly go all the way laterally all the scan laterally and this is what the infraspinitis tendon which forms it crosses the glenohumeral joint and it goes and inserts over the greater tuberosity over here. Below the infraspinitis what you have is a teres minor muscle belly which starts along closer to the lateral aspect of the scapula. Now it might as a beginner it might be difficult to identify or differentiate between the supraspinitis and the teres minor muscle bellies. So, what you can do is you can scan from medial to lateral and as you go laterally as you go laterally you see that both the tendons are forming. So, that is the infraspinitis tendon on top and this is a teres minor tendon which is forming over here and it attaches over the lesser tuberosity. So, that is the infraspinitis tendon and that is the teres minor tendon. So, as once again as I go scanning medially I see that they are forming into a muscle. So, as a practical point it is much more easier to identify the infraspinitis and teres minor muscle bellies on the short axis along the lateral as far lateral as possible. So, we identify the glenohumeral joint either by scanning through the infraspinitis muscle belly or what we do is we identify the inferior axillary fold and what we do is I put my probe on that and as I go up I go scanning up I go scanning up and I identify two bony landmarks. So, medially my bony landmark is a glenoid which I see over here and laterally what I see over here there is a humeral head the echogenic humeral head which is covered by the hypoechoic cartilage. So, between the humeral head and the echogenic glenoid what we see is a triangular structure which is which has an echogenicity which is slightly less than that of the cortex and this is the glenoid labrum that we see and just above the labrum there is a muscle that we seeing over here and this is your infraspinitis muscle that we see over here. So, when we are looking at the glenohumeral joint what we do is we scan the entire joint recess from superior to inferior and as we go up. So, if at all you have to inject within the glenohumeral joint your needle would come from lateral angle towards the glenohumeral joint and between the glenoid and the humerus. The posterior joint recess is a great way to demonstrate glenohumeral joint effusion. So, what you do is you ask the patient to gently internally and externally rotate the humerus or his arm and what we see over here is if at all if there is any joint effusion it will pop up through the posterior joint recess. So, what we are seeing over here is we are seeing a humeral head which is rotating internally and externally this is the glenoid and that is triangular structure that we see just lateral to the glenoid that is your glenoid posterior glenoid labrum. So, from the posterior aspect now what we are going to do is we are going to evaluate or we are going to try and trace the path of the suprascapular nerve. We in the standard shoulder examination we evaluate the suprascapular nerve which starts from the brachial plexus courses along the posterior triangle and then it enters the shoulder girdle where the suprascapular notch it travels through the supraspinus spina sphosa gives a branch to the supraspinatus and it winds around the spina glenoid notch and gives a branch to the infaspinatus. So, we evaluate the suprascapular nerve at the level of the suprascapular notch and at the level of the spina glenoid notch. One way to identify the suprascapular notch along the superior border of the spinus you identify the spine of the scapula and what we do is we gradually walk your probe walk your probe anteriorly walk your probe anteriorly and you look at the notch over the scapular spine. So, what we see over here that there is a notch that we see over here and there is a defect in the superior cortex of the scapular spine and this is your suprascapular notch. If you are unable to see the nerve at least what you can see is there will be a certain structure that you see pulsating over here that is the suprascapular artery and the suprascapular nerve is right next to the suprascapular artery that we see. You may or may not be able to see the signal on color Doppler but that is not a problem what you can do is you can just even on your grayscale you will be able to see the pulsations of the artery. So, we evaluate the spina glenoid notch below the level of the suprascapular notch and that is where we see the suprascapular nerve after it has given a branch to the supraspinates. So, what you do is you evaluate you identify the glenohumeral joint and gently slide your probe medially and right below the infaspinates muscle belly you see this valley like structure and that is your spina glenoid notch. So, laterally you have the glenoid medially you have the spinous process and nestle between them that is your suprascapular nerve. If you are unable to identify the suprascapular nerve just look for the pulsating suprascapular artery and your nerve will be right next to that. So, sometimes what happens is if there is a small tear in the posterior superior labrum you might have a parallel cyst forming which courses medially which courses medially and which ultimately comes to the spinoglenoid notch and it will compress the nerve resulting in infaspinates atrophy. To look for subacromial impingement we do dynamic evaluation with the patient standing we place a probe along the lateral aspect of the acromion and ask the patient to abduct the arm and take it down again abduct the arm take it down. So, what we do is we look for sliding of the supraspinates below the lateral edge of the acromion and look for sliding of the bursa as well. So, what I am seeing over here is that there is smooth sliding of the greater tuberosity as well as a supraspinates standard below the acromion edge. We evaluate acromion clavicular joint in dynamic imaging by asking the patient to touch his opposite shoulder repeatedly and extending the shoulder with his elbow flex. So, this is what is known as the SCARF test. So, what we look for is if there is widening of the acromion clavicular joint space or if there is abnormal movement between the acromion and the clavicle that we see over here. So, if we see over here although that the patient is moving that there is no significant movement which is happening at the level of the acromion clavicular joint. There are a lot of pain generating structures within the shoulder. Hence, shoulder is one of the very few joints in muscular skeletal system which requires a standard protocol based approach. Hence, it is a good idea to do a systematic examination doing scanning the shoulder from the anterior aspect looking at the biceps, the subscapularis, the acromion clavicular joint from the lateral aspect looking at the supraspinates and the infraspinates tendon the subacromial subdeltoid bursa and from the posterior aspect to assess the muscle bellies of the supraspinates infraspinates and the teres minor and of course, do not forget to have a look at the glenohumeral joint as well. Before you go ahead with the shoulder examination it is always a great idea to have a look at the radiographs and maybe a little bit of clinical examination for whatever you know a little bit it will help you in a big big way.