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Shoulder MSK Ultrasound (USG)

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Shoulder MSK Ultrasound (USG): Scanning Protocol, Diagnosis & Interventions

Overview

Shoulder musculoskeletal ultrasound (MSK USG) provides real-time, dynamic, radiation-free assessment of rotator cuff tendons, biceps tendon, subacromial-subdeltoid (SASD) bursa, acromioclavicular (AC) joint, and glenohumeral recesses—and safely guides targeted interventions.

Primary keywords: shoulder MSK ultrasound, shoulder USG protocol, rotator cuff ultrasound, ultrasound-guided shoulder injection
Secondary keywords: supraspinatus ultrasound, biceps tenosynovitis USG, SASD bursitis USG, adhesive capsulitis hydrodilatation, suprascapular nerve block ultrasound, calcific tendinitis barbotage

Equipment & Patient Setup

  • Transducer: High-frequency linear 10–18 MHz (hockey-stick optional for small patients).
  • Preset/Settings: MSK preset; adjust depth (3–5 cm), single focal zone at tendon depth; optimize gain to avoid blooming; use compound imaging if available.
  • Position: Patient seated, examiner ipsilateral; arm positions vary by structure (noted below).
  • Technique tips: Keep the tendon fibers perpendicular to the beam to avoid anisotropy; use copious gel; apply gentle probe pressure over bursae.

Standard Shoulder MSK USG Scanning Protocol (Step-by-Step)

1) Long Head of Biceps (LHB) Tendon – Anterior

  • Position: Arm resting on lap, elbow flexed.
  • Probe: Transverse over bicipital groove; then rotate for long axis.
  • Look for: Tendon echotexture, sheath fluid, groove morphology, dynamic subluxation (scan during external/internal rotation).

2) Subscapularis Tendon

  • Position: Arm in external rotation (hand supinated on thigh).
  • Probe: Short and long axes at lesser tuberosity insertion.
  • Look for: Fiber integrity, partial-thickness articular-side defects, dynamic impingement on internal/external rotation.

3) Supraspinatus Tendon (SSP)

  • Position: Modified Crass (hand on ipsilateral hip/back pocket, elbow posterior).
  • Probe: Over greater tuberosity; sweep anterior→posterior; evaluate footprint.
  • Look for: Tendinopathy, partial/full-thickness tears, bursal contour, SASD bursa thickening; perform dynamic abduction for impingement.

4) Infraspinatus & Teres Minor – Posterior Cuff

  • Position: Hand on opposite shoulder or neutral with slight internal rotation.
  • Probe: Posterior greater tuberosity to myotendinous junction.
  • Look for: Tendinopathy/tears, posterior cuff atrophy, posterior recess effusion.

5) Subacromial-Subdeltoid (SASD) Bursa

  • Assessment: Measure bursal thickness; check for fluid, synovial hypertrophy, Doppler hyperemia; compressibility with transducer pressure.

6) Acromioclavicular (AC) Joint

  • Probe: Coronal over AC joint.
  • Look for: Capsular hypertrophy, osteophytes, joint effusion, distal clavicle changes; compress during cross-body adduction.

7) Glenohumeral Joint Recesses

  • Posterior Recess: Probe just inferior to posterior acromion; look for capsular distension/effusion.
  • Axillary Recess (if accessible): Evaluate for capsular thickening (adhesive capsulitis).

8) Rotator Interval & Coracohumeral Ligament

  • Look for: Thickening, adhesions, Doppler signal—supportive of adhesive capsulitis.

Dynamic Tests to Add

  • LHB subluxation/dislocation during rotation.
  • Impingement: Observe SASD bursa and cuff during active/passive abduction.
  • Posterior instability: Posterior translation with gentle stress (expert use).

Ultrasound Diagnosis of Common Shoulder Pathologies

Rotator Cuff Tendinopathy & Tears

  • Tendinopathy: Heterogeneous or hypoechoic tendon with thickening; maintain perpendicular insonation to exclude anisotropy.
  • Partial-Thickness Tear: Focal surface defect (bursal/articular), delamination, fluid at footprint.
  • Full-Thickness Tear: Tendon discontinuity with retraction, exposed humeral head, SASD fluid; assess dynamic gap and residual fibers.

Calcific Tendinopathy

  • USG signs: Hyperechoic foci (arc/fragmented) with posterior acoustic shadow; may be soft/putty-like (mobile with probe pressure).
  • Correlate: Often supraspinatus; candidates for USG-guided barbotage if symptomatic.

LHB Tenosynovitis/Subluxation

  • Tenosynovitis: Anechoic/complex sheath fluid ± Doppler hyperemia.
  • Subluxation/Dislocation: LHB moves medially over lesser tuberosity or out of groove during external rotation—often with subscapularis injury.

SASD Bursitis / Impingement

  • USG signs: Thickened bursa with fluid and synovial proliferation; impingement if bursa/cuff bunch against acromion on dynamic abduction.

AC Joint Osteoarthritis / Synovitis

  • USG signs: Capsular thickening, osteophytes, joint fluid; point tenderness guides injection.

Adhesive Capsulitis (“Frozen Shoulder”)

  • USG clues: Thickened coracohumeral ligament/rotator interval, reduced gliding with dynamic scan, painful capsular stretch; axillary recess thickening where visible in frozen shoulder.

Glenohumeral Effusion & Synovitis

  • USG signs: Posterior recess distension; viscous synovial fluid; evaluate for inflammatory or degenerative arthropathy.

Ultrasound-Guided Shoulder Interventions (Practical Mini-Manual)

General principles: Informed consent; asepsis; probe cover; in-plane needle visualization preferred; avoid intratendinous steroid; aspirate before injectate; consider Doppler to map vessels; post-procedure instructions + rehab plan.

1) SASD Bursa Injection (for bursitis/impingement)

  • Position: Seated, arm neutral.
  • Probe: Over lateral acromion in coronal plane.
  • Needle: In-plane lateral→medial into bursal space (watch spread separating deltoid from cuff).
  • Injectate (example): 3–5 mL local anesthetic ± small-dose corticosteroid; consider saline for hydrodissection.

2) LHB Tendon Sheath Injection

  • Probe: Transverse over bicipital groove.
  • Needle: In-plane lateral→medial; tip within sheath, not tendon.
  • Injectate: 1–3 mL LA ± corticosteroid or PRP

3) AC Joint Injection

  • Probe: Coronal over AC joint.
  • Needle: In-plane into joint cleft.
  • Injectate: 0.5–1 mL LA ± corticosteroid or PRP

4) Glenohumeral Joint Injection – Posterior Approach

  • Landmark: Posterior recess just inferior/medial to posterolateral acromion.
  • Needle: In-plane lateral→medial into capsule; confirm intra-articular spread.
  • Injectate: 5–10 mL LA ± corticosteroid or, PRP
  • For Hydrodilatation (Adhesive Capsulitis): Gradual capsular distension with saline + LA (± steroid) to patient tolerance; follow with immediate physiotherapy.

5) Calcific Tendinopathy Barbotage (Needle Lavage)

  • Target: Calcific focus in SSP (commonly).
  • Technique: Single or two-needle in-plane; puncture calcification, lavage with saline (aspirate chalky material), then consider small SASD bursal injection for post-procedure pain.
  • Pearls: Keep needle within deposit; avoid aggressive intratendinous steroid.

6) Suprascapular Nerve Block

  • Probe: Transverse over suprascapular notch (posterolateral neck of scapula).
  • Needle: In-plane towards notch; avoid suprascapular vessels (use Doppler).
  • Injectate: 5–10 mL LA ± corticosteroid for chronic shoulder pain.

7) PRP / Dry Needling for Tendinopathy (Specialist Use)

  • Approach: In-plane “peppering” along tendinopathic zones; PRP per protocol; avoid steroid inside tendon.

Safety notes: Check anticoagulation status and diabetes (if steroid planned); sterile technique; continuous needle tip visualization; be mindful of pleura posteriorly.

FAQs

Q1. Can ultrasound replace MRI for rotator cuff tears?
USG detects most partial and full-thickness cuff tears and guides care; MRI is reserved if labral pathology, complex re-tear, or surgical planning is needed.

Q2. Which probe is best for shoulder MSK USG?
A high-frequency linear (10–18 MHz) probe; hockey-stick probes help with small/narrow windows.

Q3. How do I avoid false “tears” from anisotropy?
Keep tendon fibers perpendicular to the beam; heel-toe the probe and repeat in long/short axes.

Q4. Are USG-guided injections painful?
Discomfort is brief; real-time guidance minimizes tissue trauma and places medication precisely.

Q5. What is hydrodilatation?
Capsular distension of the glenohumeral joint under USG to improve pain and range in adhesive capsulitis, followed by immediate physiotherapy.

Q6. What is barbotage for calcific tendinitis?
Needle lavage of calcium under USG to reduce pain and speed recovery, often with excellent outcomes.