 50 delegates joining for this musculoskeletal webinar and all the credit goes to the needy for making this imaging modality popular. So during the early days of the musculoskeletal ultrasound, the examination was limited to the evolution of the shoulder rotator curve test. However, with the passing of the years and the development of the new transducer technologies and machine having a better hardware, besides rotator curve, people started looking for different structures around the periarticular regions. And if you refer to this book, which is like a bible to most of the musculoskeletal radiologists or artisanologists written by the Bianchi and Martin Orly, there's a vast list of conditions that one can diagnose on musculoskeletal ultrasound. And this list is very overwhelming, but I'm going to restrict my talk to very few subjects. That's the besides the bicep standard methodology. I'm going to talk about the proximal tuberous fractures, frozen shoulder, inflammatory arthropathies, and roll of ultrasound in the shoulder arthroplasty. Up for that matter, any post-operative situation where either complications are suspected. The roll of ultrasound in the suprascapular nerve entrapment was elaborated by Rajesh, but I'm going to talk a little bit about that conditions too. Now, Nidhi in her talk has briefly touched upon the pathologies affecting the long head of the bicep standard. I'm going to deliberate more in detail about the various conditions that affect the long head of the bicep standard. Now the long head of the bicep tendon is a dynamic stabilizer like the rotator cuff. And many times, the pathologies affecting the long head of the bicep tendon mimic that of the rotator cuff pathologies. And hence the evolution of the bicep tendon is of paramount importance when you are looking at the rotator cuff tear. So what are the conditions that one can see on the long head of the bicep tendon examination? Besides the bicep tendon sheath diffusion, it includes the tendonitis or tendonopathy. The instability legions like subluxation and dislocation, you may see a tear which could be a partial tear or a complete tear and to some extent slap legion. However, I would not advise heterosomologists to dwell in the evolution of the slap legions because there are significant number of times that you are not going to evaluate regions completely, except when you are looking at the posterior superior labrum. Now one has to keep in mind that the long head of the biceps has got a very, you know, oblique pores in the interarticular region when it arises from the superior labrum. However, when it enters into the intertubular groove, it becomes the extra articular segment. It runs within the intertubular groove and it ends into the musculoskeletal junction just below the attachment of the pectoralis major tendon. Now, approximately this tendon is stabilized in the intertubular groove by the transverse humoral ligament. At the level of the rotator interval, it is stabilized by the corego-humory ligament and distally, it is stabilized by the tendon of the pectoralis major. Now, as the long head of the bicep exits from the glenohumoryl joint, it carries along with it the bicep tendon shape which is directly in communication with the glenohumoryl joint. So, if there is any pathology like any effusion or loose bodies or synovil loose bodies, one can see indirectly also in the bicep tendon shape and this reflects the glenohumoryl gizzes extension in the bicep tendon shape. So, while keeping the transducer along the transverse axis and connecting the medial and lesser and greater diversity, one can see the bicep standard as an ecogenic structure within the groove. And if you see a halo and equi-halo surrounding the tendon, you can interpret this as a bicep tendon shape infusion and this needs to be confirmed on the longitudinal image. Now, let me tell you the fluid in the bicep tendon shape is a non-specific finding. It is associated with a lot of intra-articular pathologies as well as rotator cuff injuries with the adhesive capsulitis and a lot of other inflammatory arthritis. So, when you see a bicep tendon infusion, don't call it as a tino synovitis, but just describe as a fluid and try to look for the pathologies affecting the resulting into the bicep tendency infusion. Now, you have two cases in contrast to the previous ultrasound image. On the left, we have a complex infusion within the bicep tendon shape, which is the end equi-fluid is replaced with the multiple internal echoes. And this is the bicep tendon, which is pushed along the lateral edge of the lesser tuberosity. This patient had a history of trauma and he had a greater tuberosity fracture. The fluid which was seen in the bicep tendon shape is a reflection of the hemorrhagic effusion in the lino-hemorrhage joint, which had tracked along the bicep tendon shape. In contrast, this is a patient in whom this septic arthritis was suspected. And if you look at this, the bicep tendon effusion appears complex with the internal echoes. The bicep tendon looks to be frayed and thin. And on the aspiration, this was true to be the septic arthritic or pyogenic lino-hemoral arthritis, which had reflected indirectly in the bicep tendon shape as a complex effusion. This is a patient who was a known case of psoriatic arthritis on a transverse image. If you look at this, this is a classical donut sign where there is a central normal tendon surrounded by the complex effusion in the tendon shape with the presence of a sinoval hypertrophy, which also shows an increased vascularity within the shape on the longitudinal images. So this was a tino-sinovitis secondary to the inflammatory arthritis of the bicep tendon shape. So what are the injuries that one can see within the long head of the biceps? One can see, as I said earlier, you can see either tears, you can see the stability lesion in the form of the subluxation and dislocation. Most of these lesions are associated with the spore's injury or rotator cuff disease. These instability lesions are also associated with the injuries to the pulley, which Desi described very well in her talk. And these are also associated with the injury to the supraspatis subscapularis tendon. Other common conditions that one can see the intra-articular tendonosis. So one need to make a serious effort to look at the intra-articular tendon besides looking at the extracurricular tendon in the bicep tendon. But extracurricular bicep tendonosis as well as normal deviates are very well seen on the ultrasound, as one can see on MR. So the most common pathologies that we encountered in day-to-day practice includes the bicep tendonosis. The normal bicep tendon has got a speckled appearance on the transverse image. However, in a patient with the tendonosis, the tendon is enlarged. It is the normal speckled appearance is replaced by the hypoequic ecotexture. And this confirms the tendonosis. However, the continuity of the fibers are maintained. And on a longitudinal image, you can see that the normal hybrillary pattern of the tendon is replaced by the hypoequic ecotexture. But the continuity of the fibers are maintained, suggestive of a tendonosis of the long end of the bicep tendon. This is a case where on the transverse axis, you can see there are two bicep tendon. This is as if they are split into the two parts. This is due to a vertical tear of the bicep tendon. And this can be seen on the longitudinal axis as an end-equic defect which travels within the bicep tendons. So this is a complete tear, vertical tear of the bicep tendon in the proximal part of the tendon. This is a patient. He's a 60-year-old patient while gymming. He came up with a sudden onset of the soft tissue swelling along the anterior arm, which appears as a lump. And this is classically described as called a pop-up sign. And it is a sign of a rupture of the long end of the bicep tendon. So what happens when you scan this patient in the proximal segment at the level of the inter tubercular groove or in the rotator interval, the long head of the bicep tendon, which is seen as an equation of exception, is no longer visualized. You can see the anterior end of the supraspinatus. You can see the Kiffel level of fibers of the subscapularis. But the expected location of the long head of the bicep is empty and it is replaced by the complex fluid. When you scan distally in the region of the inter tubercular groove, this is a symptomatic site where you can see the inter tubercular groove is occupied by the debris, which appears as a hyperequic component and the hyperequic component. However, the normal spectral appearance is lost. If you have a doubt, you can always compare with the opposite side. And this is the classical example of the oval shape hypogenic appearance of the normal bicep tendon. Now if you move your transducer distally and if you keep the transducer along the site of the lump, what you are going to see is the retracted tendon of the long head of the biceps. The muscle belly is contracted. It can appear hyperequic. So this is the retracted distal tendon. And the orthopedicians usually would like to know how much is the distance of the retracted tendon from the bicep's bicepital groove. So they can decide whether this patient can be treated with the tino-dissis or tino-tomy. This is a natural tino-tomy that has already occurred. So if patient is young, they may think of pulling up of the tendon proximally and do a tino-dissis. So at least the normal for a cosmetic purpose, the arm looks normal. And this is usually followed in a young patients. Now, as I said, instability legions like subluxation and dislocation occurs commonly along with the tear of the kefir air fibers of the subscapularis. So what happens along with the tear of the transverse humoral ligament, there is also injury to the pulley system resulting into the destabilization of the tendon of the long head of the bicep. So tendon can move medially, can lie over the lesser tuberosity, suggestive of a subluxation. Occasionally, tendon can move along the superior aspect of the torn subscapularis or it can move inferiorly and can lie within the glenohumeral joints. And there are various classification of the subluxation and dislocation of the long head of the biceps instability legions, which is beyond the scope of this lecture. So if you look in the inter tubercular groove on the long axis, the inter tubercular groove will be empty. But when you move your transducer more medially, you will see that the long head of the bicep tendon is displaced medially, suggestive of subluxation or dislocation of the biceps tendon. Occasionally, tendon can also dislocate laterally, but this is a very, very rare situation. Most of the time, the tendon dislocates medially and it could be above the subscapularis or it could be below the subscapularis. Now let's come to a very important topic of the frozen shoulder. This is the bread and butter for the musculoskeletal radiologist and for the ultrasonologist. Let me tell you the diagnosis of the frozen shoulder is made clinically and clinicians ask imaging studies just to support their, to protect them from the medical legal issues or they want to rule out any other associated conditions in the patient with the frozen shoulder or an adhesive capsule like this. Most of the time in patient with the frozen shoulder, you are going to see a normal radiogram and that's what is expected. Now what is the basic pathology in the patient with the adhesive capsule like this? So what happens? This condition is more commonly seen among the diabetics or those patients who have a thyroid issues and commonly seen among the females in the middle age. However, it can be seen even the male too. So what happens? There's the initial stages, there's the intense inflammatory changes in the joint capsule resulting into the global fibroplasia which is associated with the severe pain. And if you look at the gross pathology, there's a thick, congested and inflate joint capsule. You can see a thickened cortico-humeral ligament and there could be a thickened glenohumeral ligaments and all these structures can be seen on ultrasound very well. So what happens? During the initial stage where there is an inflammation is very severe, patient has got a pain. But if this over a period of time, this inflammation settles and there's a fibrotic contraction of the capsule happens and this results in the significant restriction of the shoulder moments. So adhesive capsulitis goes through the three different phrases. You have a first phase which is a phase of the freezing stage where there is a usually a moderate to severe pain. The pain is more significant at the night which disturbs the lifestyle of the patient. This phase is followed by the frozen stage which is associated with the pain and the stiffness. And this is a last stage or the terminal stage where is a thawing phase stage where there is a pain receptors but there is a gradual stiffness and the restriction of the moments occurs. Now frozen shoulder is a self-limiting disease and it can last from six weeks to two years and during the early stages patient is treated with the rest and anti-inflammatory agents but if patient if they don't respond then the steroid is the injection in the glenohumeral joint is the treatment of the choice. Still if the patients are refractory to this condition the hydro dilation of the joint capsule is of the treatment of the choice. So if you look at this patient who presented with the history of the left shoulder joint on clinical examination if you look at the external rotation the left side shoulder shows the limited external rotation while the right side there is a normal rotation seat. So this is one of the important criteria for the diagnosis of the frozen shoulder. Along with this there is also restriction of the internal rotation. We are clinical radiologists so we need to examine the patient as long as possible and also try to evaluate certain signs which can lead us to a certain diagnosis of the periatvular soft tissue pathology. As I said most of the time X-ray is going to be the normal and if the next imaging modality should be ultrasound because it is quick it is very cost effective and can be easily performed in a patient who has a painful shoulder. These patients find it very difficult to lie down for about 40 45 minutes in the MR scanner without moving which may lead to the sub optimal imaging of the rotator cuff. So ultrasound is a primary diagnostic tool in establishing diagnosis of the frozen shoulder. So what do you find in the patient with the frozen shoulder? You will see a thickened coreco humeral ligament. The normal thickness of the coreco humeral ligament is 1.3 millimeter. Anything more than that can be interpreted in the proper setting as a thickening of the ligament and the best place to look for this ligament technique is in the rotator cuff interval in the intra-articulation. Now whenever if you have a doubt about the signs you can always compare with the contralateral side compare whether the ligament is really thickened that could be an abnormal soft tissue in the region of the rotator interval. The coreco humeral ligament can appear hyper-equic. So if you connect the probe from the coreco process and the humeral in greater tuberosity and perform the internal and external rotation you will be able to see the coreco humeral ligament which is hyper-equic and usually measures more than 1.3 millimeter in size. Also this during the acute stage or the freezing stage there is an associated hyperemia within the thickened soft tissue in the region of the rotator cuff interval. So this is a technique who had abnormal thickening in the rotator interval which was associated with the hyperemia, suggestive of possibility of the inflammatory tissue within the rotator interval. One can also see the thickened axillary pause. One can look at this region from the posterior aspect at the level of the TV's minor and one can see there is a thickening of the normal inferior axillary recess. Also one can see from the anterior aspect at the anterior in the patient who have a painful shoulder evolution from the anterior aspect becomes sometimes difficult. So the posterior evolution is preferable over the anterior aspects. So if you have inferior glenohumeral recess more than 4 millimeter in size you can think in the possibility of the thickening of the recess. And this is how the recess appears. So if this is the humerus that's the glenohumeral joint and that's the recess which is thickened along the posterior recess. Bicep stentative diffusion as I said earlier is a nonspecific finding and many times it is seen in the patient with the frozen shoulder. So this is the spectrum of different patient who are showing the abnormal thickening and the soft tissue in the region of the rotator interval. That's the patient who have 3.1 millimeter and this is a patient who had 3.2 millimeter thickening of the auricohumeral ligament in the interval. So as I said the frozen shoulder diagnosis is clinical. Usually diagnosis is made by this where the patient comes with the restriction of external rotation and the internal rotation which is painful and the imaging is performed just for the medical legal purpose. So when you put your so radiographs usually are normal and this is a case of classical frozen shoulder. On ultrasound you may find a normal ultrasound or you can see you may see associated rotator cuff tear, tendinosis that could be a calcification and the arthritis. So many times the orthopedic surgeons refer the patient with a rotator cuff tear when their diagnosis is not sure particularly this happens in the early stage where the clinical picture mimics like that of the impingement syndrome or a rotator cuff tear and if you find this findings your diagnosis is clinched. Now as usual we teach that the ultrasound is not good for the evolution of the bone and the intra medullary cavity. However ultrasound is excellent for the evolution of the surface superficial cortex of the bones and one of the common application of ultrasound is for the detection of the fracture of the proximal humerus. So this is a patient who had a fracture of the greater tuberosity and ultrasound can diagnose occult fractures which are undetected by the previous radiograph. This happens very commonly when there is acute injury obtaining optimal images of the rotator cuff in a different position is not possible. Patient most of the time ends up with a single radiograph. This may not be adequate for the diagnosis. In this cases if you perform ultrasound many times ultrasound is excellent for the detection of the fracture of the greater tuberosity. So on the left you have a 48 year old patient who had a history of fall and in his case the protractor cuff tear was suspected. However on ultrasound if you can see there is a classical step of defect which is seen at the level of the anatomical neck of the humerus. This is a proximal, this is a humeral head which is lined by the high line cartilage. This is the greater tuberosity which is lined by the fibrocartilage and there is a defect suggestive of a undisplaced fracture of the greater tuberosity. On the right there is a patient who is a young 27 years old who had a history of a food traffic accident and if you look at this there's a multiple defects in the normal smooth outline of the cortex suggestive of a difference fracture of the greater tuberosity. Again if you look at this patient who is a 39 year old had a shoulder pain and had an injury while doing a snowboarding about the six weeks back. If you look at this image which is obtained from the posterior aspect you can look at this is the bony glenoid. This is a part of the glenoid which was fractured and on top of this fracture you have a calf leg structure which is a posterior superior labrum and on anterior aspect you have the intraspinus tendon. This is the glenohumeral joint and this was very well depicted by Rajas on his how to look at the posterior recess and this spinal glenotinoch on the ultrasound and if you look at this dynamic image you can see the labrum is moving very smoothly while this fragment does not move that freely so on the basis of real-time imaging the fracture of the glenoid was diagnosed and this was later on confirmed on the auxiliary image. So initial stages to obtain this kind of image is very difficult and the fracture of the glenoid labrum can be glenoid, bony glenoid can be missed and ultrasound plays a very important role in the diagnosis of this kind of condition. Another patient 52-year-old who had met with the road traffic accident two months ago and there was a clinical suspicion of the rotator cuff injury if you look at this image it one can see that there is a multiple discontinuity in the sorry in in the greater tuberosity in the cortical margin suggestive of a greater tuberosity fracture this is the same patient who's a panoramic view was obtained one can see that that's the that's the anatomical neck and that's the anatomical neck and this is the step of deformity in the greater tuberosity suggestive of a greater tuberosity fracture and there was abnormal soft tissue suggestive for healing process this many times the healing fracture may appear like a hyperequic foci within the uh within the tendon and this can be mimicked as a crystal deposit disease so keep in mind healing fracture this is a corresponding radiograph of the same patient showed that there is a palace formation at the site of the fracture and transverse ultrasound shows that a hyperequic foci within the supressor tendon should not be mistaken as the crystal deposit disease this is a 60-year-old female patient who had a road rheumatoid arthritis presented with the soft tissue swelling along the anterior as a aspect of the shoulder and it was thought that probably this is the distended sub-dactyroid subacrobial bursa ultrasound is an ideal imaging modality for the evolution of the patient who have a inflammatory arthritis so what do you expect in a patient with the inflammatory arthritis you can pick up the joint diffusion with the associated sinus hypertrophy you can look at the tino sinovitis bursitis cortical erosions associated with the inflammatory orthopathy and the anesthetist changes the patient with the inflammatory so this was a patient who had on the anterior aspect there is a on the posterior aspect there is a effusion in the glenohumeral joint when the ultrasound is performed from the posterior quadrant that's the tereis minor muscle and that's the intraspinatus along the short axis also one can see the thickened sinovium which can appear as a nodular hypertrophy of the sinus tissue and if you put a colored Doppler you will see that there is an intense vascularity suggest you have a new vascularity in the intram sinovium one can also see the tino sinovitis which can seen around the bicep tendon because there is a here there is a significant hypertrophy of the sinovium and the any quick component is very little and of course along with that you can see an increased vascularity when you look at this tendon and the bicep tendons in the longitudinal axis subdeltor subacromial bursitis can appear as a any quick structure or it can appear as a complex structure and the most common site where one can see is at the level of the of the proximal humeral metaphasis because that is the area where early cases you can see the subdeltor subacromial bursitis cortical superficial cortical erosions and we very well identified until showed some of the cases of isizontal arthritis this is the patient who had a cortical irregularity along the lateral and the middle edge of the lateral end of the clavicle at the middle edge of the acromyls suggest you offer cortical erosion associated with the inflammatory arthritis and the enthesopathic changes in the form of the tendon enlargement for abnormal enthesophyte and the cortical irregularly can be picked up on the ultrasound in a patient with the inflammatory arthritis ultrasound plays a very important role in the evolution of the postoperative shoulder very in this cases with a patient with the metallic hardware the MRI is associated with the significant metallic artifacts and the interpretation becomes problematic since this patient ultrasound should be a first imaging modality what we are expected to see in a patient in a postoperative complication is the periodicular collections sinus drag joint effusion deltoid dehesions and the implants dislocation so if you look at this patient who had undergone hemorrhagic processes about one and a half month back presented with the pain and swelling the this is a plain radiograph showing the metallic implant with the evidence of the osteolysis around the proximal humerus and on the ultrasound there was complex collection which was seen at the site of the implant and this was also the root attack of was intact so this was a suggestive of a presence of a probably infective etiology I've everyone cannot confidently tell that this is an infection or inflammatory process the best thing is to do a biopsy or aspiration and when this patient was aspirated the virulent material was aspirate suggestive of a septic infection of the joint so I'm not going to dwell upon too much on the supra scapular now pathology because Reyes has covered very well but one of the most important application of ultrasound is to find where the the role of ultrasound in the patients with the supra scapular now pathology is to rule out the rotator cuff there to look at the muscle equal texture and volume to see whether there is a denervation injury what is the pattern of muscle involvement this is the only supraspinatus or infraspinatus involved potential site of the supraspin now entrapment you can characterize the lesion whether it's a cystic lesion or a vascular lesion or a thickening of the transverse scapular ligament and once the diagnosis is great you can use guided intervention for the aspiration of the glenoid assist or for the injection of the injection of the serum so this is a patient who had a cyst in the spinal glenoid notch resulting into the infiltration of the infraspinatus and this patient was aspirated and this is like a classical mucous material that one can aspirate on the ultrasound guidance I will end my talk with the few cases of pectoralis major lesions so this is a patient who presented with the acute pain on the anterior aspect of the proximal humerus and if you look at this radiographs but can see that there is a calcific deposit which was in however this was it was very difficult to interpret and localize this calcification when the ultrasound was done at the level of the pectoralis major tendon one can see a semilunar hyperequation with a mild distal shadowing suggestive of a calcification this is the extended field of you confirming the same findings on the logic interview so this was a calcific tendinosis of the pectoralis major this is another patient 34-year-old male patient presented with the painful swelling since last five days and had a history of injury during the bench press exercises and there was a chemosis on the clinical examination at the level of the proximal humerus which is look at this longitudinal ultrasound there was a myofascial injuries of the pectoralis major tendon which was extending all the way from the attachment of the pectoralis tendon approximately at the level of the myotendinous junction so this was a case of the pectoralis major tendon of course let me tell you this is a very very rare injuries but in a proper clinical setting and if a patient is athletic and has developed injury during the athletic activity you can think of the possibility of the injury to the pectoralis major so I would like to conclude by the take home message the clinical correlation is absolutely must when you are looking at the periarticular soft tissue pathology of the shoulder particularly non-rotator cuff pathology knowledge of the relevant anatomy we again and again emphasize that the muscular skeletal ultrasound knowledge of the anatomy relevant anatomies of paramount importance the usual conditions for which the ultrasound is referred is the frozen shoulder and the occult fractures ultrasound is more sensitive than radiographs in detecting the acromecal good joint injuries as Ankit has spoken in his previous lecture review of the posterior radiographs this is a very very important topic when you are evaluated to patient with the postoperative complication don't start examination without looking at the radiographs which is very important ultrasound has limitation in evolution of the labrum glenohumeral ligaments and the cartilage so if you are suspecting slab lesion don't evaluate this patient with ultrasound directly send them to the MRI so thank you for your patient listening and this is my quiz this is a 54 year female patient who presented with the who is a known case of arthritis presented with the anterior shoulder pain and these are the transverse images obtained at the level of the intertubercular group and this is obtained with the power Doppler on the longitudinal axis so please answer the questions and there are more than two answers in this slide so have a look more carefully and answer the question so Sanjay why are we all right yes that was wonderful it's a superb presentation of all pathology it was like a wonderful end to this shoulder session and I hope the faculty is here so we can actually go ahead and take questions for the faculty so you could stop your screen sharing as well yeah I have that