 Hey there, my name is Dr. Ankit Shah and I will be talking on ultrasound evaluation of rotator cuff pathologies Ultrasound evaluation of rotator cuff forms a bulk of our work in day-to-day practice of musculoskeletal ultrasound During the course of this talk, we will be focusing on cuff impingement, tendinosis, cuff tears and calcific tendinosis It's important to know that the pathologies of the subacromylsubdeltide bursa, the long head of the biceps and the acromia clavicular joint may often coexist with rotator cuff disorders For instance, if there's a full thickness tear of the cuff, you might end up seeing effusion in the subacromylsubdeltide bursa as well as a biceps tendon sheath So just a quick recap of anatomy, the rotator cuff is formed by the subscapularis, the supraspinatus, infraspinatus and the teres minor tendons from the anterior to posterior direction These tendons go and attach to the greater tuberosity When you start doing shoulder ultrasound, get into the habit of counting the layers from the top These are a series of layers that you will see extending from the skin surface all the way till the humeral cortex. These layers can be seen in the long as well as short axis So the layers are going to be the subcutaneous fat the deltoid muscle belly, the subacromylsubdeltide bursa, the echogenic tendon or the rotator cuff tendon and the hypoechoic cartilage The rotator cuff tendon has two surfaces The one which is close to the joint or along the humeral cartilage that is going to be the articular surface Whereas the surface abutting the subacromylsubdeltide bursa or the acromion is known as a bursal surface Any structure or a pathology which causes narrowing of the coracoacromial arch results in shoulder impingement The coracoacromial arch is a fibrosis tunnel through which the supraspinatus stem passes It is formed by the acromion, the corokite, the acromial clavicular joint, the coracoacromial ligament and the humeral head Subacromial impingement is a painful compression of the supraspinatus tendon The subacromylsubdeltide bursa and the long head of the biceps between the humeral head and the anterior portion of the acromion Now mind you, this is a clinical diagnosis The primary signs of this syndrome are Interrupted gliding of the supraspinatus tendon below the acromion or you might have bunching of the tendon or the subacromylsubdeltide bursa along the lateral edge of the acromion For instance, look at this dynamic image. What we see is that the gliding of the greater tuberosity Or the humeral head is it as smooth as it is supposed to be So once you scan the entire shoulder and you don't find any other pathology It's a good idea to do a dynamic maneuver by placing the probe along the lateral edge of the acromion and Asking the patient to do abduction of the arm The secondary signs are of course tendonosis of the rotator cuff or you might have a Thickened bursa or just simple effusion within the subacromylsubdeltide bursa In this case what we see is that the on the short axis We see thickened anterior fibers of the supraspinatus tendon with an ill-defined hypoechoic appearance of the anterior edge When we look at this tendon on the long axis We see that the normal febrillary pattern is lost and we see some amount of cortical irregularity over the gt However, there's no obvious tear to be seen Multiple criteria have been described in literature to aid us in diagnosis of full thickness tears Now I'm going to talk about the more important ones So the amongst the major criteria that we see in day-to-day practice is non-visualization of the cuff There might be an ecopore defect in the continuity of the cuff You may have cuff atrophy or sometimes you may see a focal hyper-echoic defect Now this focal hyper-echoic defect is something that we don't really see that often It's just seen in acute tears and at least we don't see it that commonly So if you look at this long axis of the tendon We see that there's discontinuity of the fibers and there's some amount of Soft tissue which is over here, but then if you look at it closely There's a clear discontinuation between the articular surface and the bustle surface. So this was a full thickness tear Coming to the minor criteria You might have fluid in the biceps tendon sheath and the subacromyl subdeltoid bursa You might have a concave contour of the bursa Cortical irregularity of the greater tuberosity I think this is really important because if you look at the greater tuberosity and if you feel that there's some cortical irregularity There are almost 79 to 80 percent chances that you might find a tear if not a full thickness at least look for a partial thickness tear and Of course a naked cartilage sign that we commonly seen due to interface between the joint fluid and the articular cartilage Hemorrhoid joint effusion is a very non-specific sign and these findings which have been listed as minor criteria Can be seen in combination with major criteria However, if you see only the minor criteria, you should carefully look for the major findings of a cuffed air For instance, this is a short axis view of the long head of the biceps Wherein we see effusion in the subacromyl subdeltoid bursa along with some sign of a hypertrophy and there's some effusion in the biceps tendon Sheath as well. So this patient ended up having a full thickness tear This is something that you should not miss out You know when I spoke to you about counting the layers from the top what we see is there's a subcutaneous fat That's a deltoid and this deltoid is directly resting on the cortex The supraspinitis tendon has completely torn and it has retracted immediately. So this is something what we call is as a As a bald head sign. There's one entity known as a massive tear. They are described as Complete detachment of two or more tendons. So this is Most commonly, it's a supraspinitis and the infraspinitis Get completely detached and this results in superior migration of the humeral head Another case this is a full thickness tear of the of the rotator cuff from the footprint We see that there's a concavity of the subacromyl subdeltoid bursa and if we look at the video in the short axis There's a communication between the articular surface and the bursal surface over here So the tendon whenever you evaluate make sure that you see it in the long axis as well as a short axis Another case where we see a combination of both major as well as minor criteria You see a clear Full-thisk thickness defect within the rotator cuff. You see some effusion as well And when you evaluate the tendon and the short axis or the joint in the short axis We see effusion and the subacromyl subdeltoid bursa along with senovial hypertrophy Sometimes you might see some tendons which may or are tears which might actually look as partial thickness tear But you really need to follow them and all the planes and to make sure that it's not a full thickness tear For instance the image on the left we see a tear which looks like a partial thickness articular surface tear But as we trace it you can see it going all the way to the bursal surface Another patient which we see on the right side this look more like a chronic tear. This was The tear was old so there was some amount of granulation tissue along the edges But then the defect is when we look at it closely the defect goes all the way from the articular to the bursal surface Once you've identified a full thickness tear, what else do you tell that orthopedic surgeon How much is the tendon retraction because this is going to have a lot of bearing on the how difficult or easy the surgery is going to be So stage one and it is just seen adjacent to the tendon Insertion of the greater tuberosity stage two the tendon will lie At the level of the humeral head and of course stage three is retraction probsiment to the glenoid margin Stage three tendons, you know They are a little bit difficult to operate because they have to pull it back and attach it to the greater tuberosity So these kind of surgeries are going to be high tension repairs, which have a high probability of failing So what I said is this is stage one where we see that the there's a full thickness tear But the tendon is lying more or less close to the greater tuberosity Another patient with a stage two retraction the greater tuberosity is Bear and the deltoid is lying just on top of it And there is medial retraction of the torn edge at the level of the humeral head another important Thing that we need to mention in our report in case of a full thickness tear is how much is the atrophy of the Muscle belly because if there's significant muscle atrophy the Operative outcomes aren't going to be that great. So you need to give this. This is very very important Now the classification is based on the Bortelia classification, which was initially based on CT but now we can actually Apply them to ultrasound as well. So this image on the left shows a normal appearance of the Supraspinatus muscle belly Whereas the image on the right on the short axis shows market fatty atrophy with volume loss and sometimes Extended field of view image helps you in giving a good overall appearance You know estimation of the muscle atrophy Partial thickness tears are characterized by discontinuity of the tendon Either along the articular surface of the tendon or along the bursal surface of the tendon or sometimes You might have discontinuity of fibers only within the substance of the tendon Meaning which these tears they do not communicate either with the articular or the bursal surfaces So this is another example of a partial thickness tear This is an intra substance tear as we sweep from the anterior to posterior We see a tear along the footprint, but it is neither communicating with the articular surface or the bursal surface Another patient we look at the tear on the short axis and Of the tendon and we see that this is a curvilinear tear Which is going from the articular surface and stops right at the midway Of the tendon substance. So this is an articular surface tear Now mind you these kind of tears can be completely missed if you look at the tendon only on the long axis Hence you should try and look at the tendon or you must always evaluate the tendon and the long as well as the short axis Quite often partial thickness articular surface tear may not be that obvious That's when we need to use some secondary signs like you know I mentioned about the naked cartilage sign to identify a tear So if you look at this this patient we had you know when we evaluated the patient on the long axis We really didn't find anything much, but then when you look over here You see that the cartilage is seen really nice and well. It's quite prominent So this is known as a naked cartilage sign going back to the long axis We see that there is a partial thickness articular surface tear involving around 50% of the cuff thickness So what all do you report while you report the tear you report the type of tear is it full thickness Partial thickness articular bursal surface. What is the size of the tear you report? What is the distance of the tear from the rotator interval? This will give the the orthopedic surgeon an idea of Which tendons are involved? Is it only the supraspinitis? Is it supras plus infra and so on? You have to give them the degree of retraction and muscle atrophy