Transcript common pathologies seen in ultrasound

COMMONLY ENCOUNTERED
SHOULDER PATHOLOGIES IN
ULTRASOUND
Teena Anderson
Student ID 09734007
BURSITIS & IMPINGEMENT

A bursa of is a small pocket of fluid surrounding muscles
or tendons. Fluid within the bursa is synovium.

The subacromial-subdeltoid bursa is the largest bursa
within the shoulder.

The role of the bursa is to reduce friction and allow
smooth and free movement of the rotator cuff.

Bursitis can be caused by repetitive trauma to the bursa
causing an increased production in collagen and
synovium. The increased size of the bursa increases the
friction which increases the pain (Ishii et al, 1997).

Ultrasound appearances can vary from a thickened
hyperechoic region (which is the thickened walls) or a
hypoechoic stripe within the bursal walls (which is the
increase in synovial fluid).

A bursa with an increase in synovial fluid is indicative of a
tear (due to communication with the joint), whereas a
bursa with oedema is more likely a sign of impingement
or bursitis (Rumack et al, 2005).
BURSITIS & IMPINGEMENT

Impingement occurs when the rotator cuff tendons become
trapped beneath the acromion during movement.

This best assessed during dynamic scanning of the shoulder with
ultrasound.

Impingement is present if during dynamic scanning the bursa or
tendons bunch during abduction.

The bursa acts to reduce the friction to the rotator cuff during
abduction. Impingement is present when the bursa or tendons
are unable to move freely and smoothly during abduction (Ishii
et al, 1997).
JOINT EFFUSIONS

Joint fluid can be found in any of the shoulder
recesses. The most common for site to accumulate
in a patient sitting upright is in the biceps tendon
sheath.

When large fluid collections are found in the
posterior joint recess inflammatory of infective
causes should be considered (Rumack et al, 2005).
The image to the right depicts a posterior joint
recess collection. Aspiration of this collection
indicated the cause to be inflammatory.

Effusions can have different ultrasonic appearances
dependant on what they consist of. If the effusion is
purely synovial fluid the appearance will be
anechoic. Haemorrhage or debris within an effusion
will produce more of a mixed echogenicity, but it
will still be hypoechoic when compared to the
surrounding tendons and musculature (Ishii et al,
1997).
TENDINOPATHY

Tendinopathy is a generalized term used for thickening
or changes within a tendon. It is a useful term as it does
not imply an acute or chronic issue, rather just a
general term of the tendons appearance.

Tendinopathy can be localized, but more often than
not it is seen as more generalized (Rumack et al, 2005).

In acute tendinopathy ultrasound may show an
increased vascularity. Light probe pressure is important
when assessing for colour flow in the tendons.
The images on the left show a normal
transverse supraspinatus tendon (top)
and a tendinopathic tendon.
The image on the right shows a normal
longitudinal supraspinatus tendon (top)
and three images of the same
tendinopathic tendon in its entire
width.
TENDON TEARS

Tendon tears are named according to the amount of tendon that is
involved.

Partial Tendon Tear - these tears only involve one surface of the tendon.
They are called bursal or articular tears.

Intrasubstance tears - do not form on either of the surfaces, rather they
are found within the tendon fibrils.

Full Thickness Tears – involve both surfaces of the tendon (the bursal and
articular), but not the entire width of the tendon. A small full thickness
tear is <5mm and may not show retraction of the tendon.

Complete and Massive Tears – these have a greater extension than full
thickness. Retraction will be seen as there are no intact tendons to hold
the tendon in position. Herniation of the deltoid muscle over the
retracted tendon may be evident. Further assessment of surrounding
tendons is required to asses for extension (Bianchi and Martinoli, 2007).
FULL THICKNESS TEAR

Complete tear of the tendon fibres from bursal surface to the
articular surface. The complete width of the tendon may still be
intact.

The most common site is in the anterior portion of the
supraspinatus tendon at the level of the critical area. This often
leave the posterior portion intact.

Ultrasound appearances vary dependent on how much joint
effusion is present.

There may or may not be tendon fibre retraction, so use of
probe pressure and angle is important (Bianchi and Martinoli,
2007).

A massive cuff tear can have several appearances:


When the humeral head is in direct contact with the acromion,

When the deltoid muscle is in direct contact with the humeral head,
or

Only a thickened bursa and fat are seen between the deltoid muscle
and humeral head (Rumack et al, 2005).
The images to the right are of a full thickness tear of the
supraspinatus tendon.
PARTIAL TEAR

Partial thickness tears make up ~18% of all rotator cuff
tears (Bianchi and Martinoli, 2007).

They are more common in younger patients.

They most commonly occur at the anterior third of the
supraspinatus tendon.

The tears will often have a bursal or articular surface
extension.

They can be difficult to visualise. It is important to look
for any defects with hypoechoic fluid within them.

An intrasubstance tear does not extend to either the
bursal of articular surface. It is quite subtle and will
appear with hypoechoic fluid tracking along the
tendon fibrils (Bianchi and Martinoli, 2007).

The image on the right is a articular partial thickness
tear of the supraspinatus tendon.
CALCIFIC TENDONITIS

Refers to the deposit of calcium within the rotator
cuff tendons.

Supraspinatus is the most common site of deposit
(80%), then infraspinatus (15%) and subscapularis
(5%). It should be noted that they can occur
anywhere.

There are four stages:


Precalcific;

Calcific

Resorptive; and

Post Calcific.
The example images show a Stage II deposit with
posterior shadowing (Bianchi and Martinoli, 2007).

Calcific deposits have three types:

Type I – hyperechoic deposit within the tendon with well
defined posterior shadowing.

Type II – A hyperechoic deposit within the tendon which
has faint posterior shadowing.

Type III – may appear as hyperechoic deposit within the
tendon with no posterior shadowing, or as an undefined
hyperechoic/isoechoic structure within the tendon with
mobile internal echoes. This is when the internal structure
becomes liquefied.

Type I relate to the formative stage of the process.

Type II and III relate to the resorptive phase – where
they may be aspirated (Bianchi and Martinoli, 2007).

Ultrasound is very useful in determining the internal
structure of the calcific deposit (Rumack et al, 2005).
BICEP PATHOLOGY

It is important to remember that the bicep tendon
sheath may have a small amount of fluid seen
within the proximal section and be normal. This is
due to its direct association with the shoulder joint.

Pathology that can be encountered include:

Bicipital Tenosynovitis – usually due to impingement.

Bicep Tendon Tear – this results in the Popeye
Deformity due to the retraction of the bicep muscle
towards the elbow. This can be due to chronic
overuse or an acute injury.

Subluxation/Dislocation – usually occurs in
combination with a rotator cuff tear, compromising
the structures holding the bicep within its bicipital
groove (Crane, 2007).

The top and middle image on the right depict a
subluxed bicep tendon. The bottom image shows
biceps tenosynovitis.
(Figure 22: Biceps brachii tendon synovitis.
Gaitini, 2012)
REFERENCES
Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013.
Bianchi S and Martinoli C. 2007. Ultrasound of the Musculoskeletal System. Springer, New York.
Crane, J. 2007. Shoulder:Biceps Tendon Pathology. Faculty of Health Sciences Stellenbosch Hospital. Tygerberg
Hospital. http://www.capetownorthopaedic.co.za/shoulder-biceps-tendon-pathology.php
Gaitini D. Shoulder Ultrasonography: Performance and Common Findings. J Clin Imaging Sci 2012;2:38
Ishii H, Brunet JA, Welsh RP, Uhthoff HK (1997). ""Bursal reactions" in rotator cuff tearing, the impingement
syndrome, and calcifying tendinitis". J Shoulder Elbow Surg 6 (2): 131–6.
Rumack et al. 2005. Diagnostic Ultrasound. 3rd edition. Elsevier Mosby, St Louis.
Wheeless, Clifford. "Subacromial Bursa". Accessed 5/07/2015.
All images, except one, used in this presentation have been produced by myself or a senior sonographer whilst
I was training at Royal Perth Hospital. These images have been desensitised and had all identifying names and
medical numbers removed.
The only borrowed imaged has been credited to the source.