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Diagnostic Imaging of the Shoulder: Introduction
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2
a
Fig. 2.12 (a, b) Transverse image of the bicipital groove. The image demonstrates a tendinopathic long head of biceps (yellow arrow).
In addition, there is synovial thickening within the bicipital sheath (white star) with bowing of the transverse ligament (white curved
arrow). The right hand image demonstrates the associated Doppler signal within the bicipital sheath indicating tenosynovitis.
Humerus
a
Fig. 2.13 (a) Transverse images of the long head of biceps. The image above demonstrates a tendinopathic tendon (yellow arrow)
at the level of the bicipital groove with bowing of the transverse ligament (white curved arrow) and synovial thickening (white stars).
Doppler imaging also demonstrates an associated synovitis. (b) This image is taken distally to the bicipital groove and demonstrates
uid within the sheath (dashed yellow arrow).
b
Humerus
b
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The Shoulder: Diagnostic Imaging
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2.1.2 Subscapularis Tendon
Longitudinal Scan
The patient is seated with the elbow flexed to 90 degrees
and the arm supported on a pillow. The arm should be
placed in slight external rotation. The long head of the
Fig. 2.14 Longitudinal scan of the subscapularis tendon. The
probe is placed in the anatomical transverse plane with its
lateral edge over the bicipital groove which may be used as a
landmark.
biceps may be used as a landmark. The probe is placed in
the anatomical transverse plane to image the subscapularis tendon longitudinally. The arm should be externally and internally rotated to view the greatest extent of
the tendon possible and to assess for anterior impingement (▶Fig. 2.14, ▶Fig. 2.15).
LT
Fig. 2.15 Longitudinal image of the subscapularis
tendon (yellow arrows). The tendon may be seen to extend
from below the coracoid (white arrowhead) and to travel
laterally to insert onto the lesser tuberosity (LT). The bicipital
groove may be used as a landmark and can just be seen to the
left of the image (curved arrow).
Transverse Scan
To view the subscapularis tendon transversely, the
probe is turned through 90 degrees to be positioned
Fig. 2.16 Transverse scan of the subscapularis tendon. The
probe is placed in the anatomical sagittal plane over the
tendon. A better image may be obtained if the probe is angled
in a slight posterolateral alignment.
in the sagittal plane. If the probe is angled in a slight
posterolateral alignment, a better image may be obtained (▶Fig. 2.16, ▶Fig. 2.17).
LT
Fig. 2.17 Transverse image of the subscapularis tendon (yellow
arrows). The tendon may be seen to lay over the lesser
tuberosity (LT). Note the fascicular pattern of the tendon which
is entirely normal.
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Diagnostic Imaging of the Shoulder: Introduction
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2.1.3 Dynamic Examination for
Subcoracoid Impingement
See ▶Fig. 2.18.
Fluid within the subcoracoid bursa
seen with impingement of the bursa
against the coracoid
HH
Fig. 2.18 Longitudinal image of the medial portion of the
subscapularis tendon (yellow dashed arrows) at the level of the
coracoid (white arrowhead). The subject has been asked to
internally rotate the shoulder. A small amount of uid is seen
with in the subcoracoid bursa as it impinges against the lateral
aspect of the coracoid (yellow arrow). HH, humeral head.
Subscapularis: Pathology
See ▶Fig. 2.19a–c.
2
a
b
c
Fig. 2.19 (a) Longitudinal image of the tendon of
subscapularis tendon fails to demonstrate a tendon over the
anterior aspect of the humeral head (HH) in keeping with
a complete rupture (yellow arrows). (b) In addition, there is
retraction of the proximal component of the tendon (curved
) with some uid noted deep to the coracoid (white
arrow
). (c) Transverse image of the subscapularis also failed
star
to demonstrate a tendon over the humeral head (yellow
arrows). White arrowhead, coracoid; yellow arrows, absence of
subscapularis tendon over the humeral head.
15
The Shoulder: Diagnostic Imaging
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2.1.4 Supraspinatus Tendon and
Subacromial Bursa (Including
Dynamic Imaging as Indicated)
Transverse Scan
The patient is asked to place his or her hand on the posterior aspect of the hip while keeping the elbow tucked in.
Fig. 2.20 Transverse scan of the supraspinatus tendon.
The medial edge of the probe is placed over the long head
of the biceps tendon within the rotator interval to ensure
that the anterior free edge of the supraspinatus tendon and
midsubstance are both imaged.
Find the long head of the biceps in transverse view and
then move the probe posteriorly to view the supraspinatus tendon in transverse section. It is important to scan
distally as far as the greater tuberosity and proximally
following the tendon of supraspinatus until it disappears
below the acromion (▶Fig. 2.20, ▶Fig. 2.21, ▶Fig. 2.22).
HH
Fig. 2.21 Transverse image of the supraspinatus tendon. Note
the long head of biceps tendon in the rotator interval (white
arrowhead
overlying the supraspinatus tendon (yellow arrows). In this
image the bursa is not thickened.
). The subacromial bursa (curved arrow) may be seen
Clavicular facet
Subacromial bursa
Subdeltoid bursa
Greater tubercle
Intertubercular groove
Lesser tubercle
Supraspinatus
Joint capsule
Humerus
Superior transverse
ligament of scapula
Acromion
Coraco-
acromial
ligament
Coracoid
process
Coracoacromial
arch
Scapula
Fig. 2.22 Superior transverse view of
the right glenohumeral joint. In the
illustration, the clavicle has been removed
to allow visualization of the subacromial/
subdeltoid bursa and the underlying
muscle and tendon of supraspinatus.
Note the extent to which the bursa
extends beneath the coracoacromial arch
formed by the acromium, coracoacromial
ligament, and coracoid. When scanning
the tendon of supraspinatus, the probe
should move as far as the lateral edge
of the coracoacromial arch to ensure
maximum visualization of the tendon.
Note the position of the superior
transverse scapular ligament of the
scapular notch. (Reproduced from
Schuenke, Schulte, and Schumacher, Atlas
of Anatomy, 2nd edition, ©2014, Thieme
Publishers, New York. Illustration by Karl
Wesker/Markus Voll.)
16
Diagnostic Imaging of the Shoulder: Introduction
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Longitudinal Scan
The probe is turned through 90 degrees to find the long
head of biceps running longitudinally through the rotator
interval. Moving the probe in a superolateral direction
Fig. 2.23 Longitudinal scan of the supraspinatus tendon. The
long head of biceps tendon can be found in the bicipital groove
in longitudinal section. The probe is then moved posteriorly to
view the tendon of supraspinatus.
Supraspinatus: Pathology
See ▶Fig. 2.25a,b; ▶Fig. 2.26, ▶Fig. 2.27, ▶Fig. 2.28a,b;
▶Fig. 2.29, ▶Fig. 2.30a,b; ▶Fig. 2.31a–c.
allows the full visualization of the supraspinatus tendon form its anterior free edge through its midsubstance
to the tendon of infraspinatus posteriorly (▶Fig. 2.23,
Fig. 2.24).
▶
DM
GT
Fig. 2.24 Longitudinal image of the supraspinatus
tendon (yellow arrows). The subacromial bursa may be seen
overlying the tendon (curved arrow). In a nonpathological
state, the subacromial bursa appears as two parallel echogenic
lines separated by a low echo central region. DM, deltoid
muscle; GT, greater tuberosity.
2
a
Fig. 2.25 (a) Transverse image of the supraspinatus tendon demonstrating loss of normal tendon structure over the humeral head
in keeping with a full-thickness tear. The overlying subacromial bursa (yellow arrows) has collapsed down onto the humeral head. The
size of the tear can be seen between the white stars measuring 2 cm. The long head of biceps can be seen toward the bottom right
of the image (curved arrow). (b) Transverse image of the supraspinatus tendon. This image is the same as part (a) except pressure
from the probe has been reduced (note loss of contact at the edges of the image). This decreased pressure has allowed uid to ll the
subacromial bursa (yellow arrows) through the full-thickness tear. HH, humeral head.
b
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2
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The Shoulder: Diagnostic Imaging
Deltoid
HH
HH
Fig. 2.26 Transverse image of the supraspinatus tendon (yellow
dashed arrows). There is a low echo foci within the midsubstance
of the tendon with associated bowing of the overlying
subacromial bursa into this region (white arrowhead). In
addition, an “articular cartilage sign” is seen (white arrows).
Findings in keeping with a full-thickness tear. The tear measures
approximately 7 mm in length (calipers 2) and is situated 9 mm
posterior to the anterior edge of the tendon (calipers 1). Yellow
curved arrow, long head biceps; HH, humeral head.
DM
GT
a
GT
Fig. 2.27 Transverse image over the humeral head. The
tendon of supraspinatus cannot be clearly seen. The
overlying deltoid muscle is in direct contact with the humeral
head. Findings in keeping with a complete rupture of the
supraspinatus tendon with retraction of the tendon proximally.
HH, humeral head.
HH
Fig. 2.29 Transverse image of the tendon of
supraspinatus (yellow arrows). A low echo region is
demonstrated within the midsubstance of the tendon
toward its insertion onto the greater tuberosity measuring
approximately 1.3 cm (white stars). Findings in keeping with a
full-thickness tear. The overlying subacromial bursa appears to
indent the torn tendon (white arrowhead). HH, humeral head.
b
Fig. 2.28 (a) Longitudinal image of the greater tuberosity. The
subacromial bursa is seen to be distended (yellow arrows) as it
overlays the lateral aspect of the greater tuberosity (GT). (b)
MRI (coronal STIR). The image is of the same shoulder
as in part (a). The image demonstrates high signal in the
subacromial bursa (yellow arrow). DM, deltoid muscle.
18
HH
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Diagnostic Imaging of the Shoulder: Introduction
2
a
Fig. 2.30 (a) Longitudinal image of the tendon of supraspinatus (yellow arrow). A relatively large calcic region measuring
approximately 0.8 mm can be seen within the distal part of the tendon toward its insertion on the greater tuberosity (white crosses).
Note the posterior shadowing (curved arrow). (b) X-ray of the same shoulder as in part (a) demonstrates the calcic foci (dashed yellow
arrow). HH, humeral head.
a
b
Fig. 2.31 (a) Transverse image of the
tendon of supraspinatus. The tendon
cannot be seen over the humeral head
in keeping with a complete rupture. In
addition, there was a large subacromial
bursal eusion with associated bursal
thickening (dashed arrows). (b) X-ray of the
same shoulder demonstrates a marked
reduction in the acromiohumeral space
in keeping with a complete rupture of the
supraspinatus tendon (curved arrow). (c)
CT of the same shoulder demonstrating
an advanced osteoarthrosis involving the
glenohumeral joint with marked loss of
joint space, large osteophyte formation,
subchondral sclerosis and cyst formation,
and a decreased acromiohumeral
space (curved arrow). HH, humeral head.
b
c
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2
PG
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The Shoulder: Diagnostic Imaging
2.1.5 Infraspinatus Tendon
Longitudinal Scan
The patient is asked to place the hand of the shoulder to
be imaged on the opposite shoulder with the elbow resting on the chest. In this position the tendon of infraspinatus runs horizontally and is parallel to and immediately
below the spine of the scapula. Scan from the musculotendinous junction posterior to the humeral head to the
insertion of the tendon onto the greater tuberosity which
is situated relatively laterally (▶Fig. 2.32, ▶Fig. 2.33a,b).
Infraspinatus: Pathology
See ▶Fig. 2.34, ▶Fig. 2.35.
a
Fig. 2.33 (a) Longitudinal image of the posterior aspect of the shoulder joint. Both the tendon (yellow arrows) and muscle of
infraspinatus (IM) can be seen deep to the posterior deltoid (PD) muscle. Note the posterior glenoid labrum demonstrated here as a
hyperechoic triangle (dashed yellow arrow). (b) Longitudinal image of the tendon of infraspinatus (yellow arrows). The tendon can be
seen to insert onto the posterior aspect of the greater tuberosity. HH, humeral head; IM, infraspinatus muscle; PD, posterior deltoid;
PG, posterior glenoid.
Fig. 2.32 Longitudinal scan of the tendon of supraspinatus
tendon. Place the probe parallel to and immediately below
the spine of the scapula. The tendon insertion itself is situated
relatively laterally.
b
HH
Fig. 2.34 Longitudinal image of the posterior aspect of the
humeral head (HH) and glenohumeral joint. The tendon of
infraspinatus cannot be seen in keeping with complete rupture
and retraction of the tendon proximally (yellow arrows). In
addition, there is a signicant eusion extending out from the
posterior aspect of the glenohumeral joint which is lifting the
posterior deltoid muscle away from the humeral head (white
star). PD, posterior deltoid; PG, posterior glenoid.
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PD
PD
HH PG
Fig. 2.35 Longitudinal image of the posterior aspect of the
humeral head (HH) and glenohumeral joint. There is an
eusion deep to the infraspinatus tendon which can be seen to
extend to the supercial aspect of the tendon (white star). The
tendon itself appears intact (white arrowheads). PD, posterior
deltoid; PG, posterior glenoid.
Diagnostic Imaging of the Shoulder: Introduction
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2.1.6 Suprascapular Notch and
Suprascapular Nerve
The patient sits with his or her arm by the side. The probe
is placed in a coronal oblique plane over the supraspinous
Fig. 2.36 Longitudinal scan over the suprascapular notch
and nerve. The probe should be positioned in a coronal
oblique plane so that it lies over the supraspinous fossa. The
suprascapular notch may be seen deep to the upper trapezius
and supraspinatus muscles.
fossa. The suprascapular notch and nerve may be seen in
longitudinal view immediately medial to the acromioclavicular joint deep to the upper trapezius and supraspinatus muscle (▶Fig. 2.36, ▶Fig. 2.37, ▶Fig. 2.38).
UT
SST
Fig. 2.37 Longitudinal image of the suprascapular nerve (white
arrowhead
arrow). Overlying the nerve can be seen the muscle bellies of
supraspinatus tendon (SST) and upper trapezius (UT).
) lying within the suprascapular notch (yellow
2
Vertebra
prominens
(C7)
Supra-
spinatus
muscle
Scapular
spine
Infra-
spinatus
muscle
Suprascapular
nerve
Superior transverse
ligament of scapula
Suprascapular nerve in
the scapular notch
Acromion
Greater
tubercle
Fig. 2.38 Posterior coronal view of
the right glenohumeral joint and
suprascapular notch. Note the superior
transverse ligament and underlying
suprascapular notch containing the
suprascapular nerve. The suprascapular
artery travels superiorly to the superior
transverse ligament. The superior
transverse ligament may be ossied.
Injection here can provide symptomatic
relief in painful shoulders related
to degenerative change and large
rotator cu tears when conservative
treatment has failed and surgery is not
an option. (Reproduced from Schuenke,
Schulte, and Schumacher, Atlas of
Anatomy, 2nd edition, ©2014, Thieme
Publishers, New York. Illustration by Karl
Wesker/Markus Voll.)
21
2
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The Shoulder: Diagnostic Imaging
2.1.7 The Acromioclavicular Joint
The patient is positioned with the arm by the side. The
acromioclavicular joint is viewed longitudinally with
the probe placed in a coronal oblique plane (▶Fig. 2.39,
▶Fig. 2.40, ▶Fig. 2.41).
Distal clavicle
Acromium
Fig. 2.39 Longitudinal scan of the acromioclavicular joint. The
probe is placed in a coronal oblique plane over the joint.
Fig. 2.40 Longitudinal image of the
acromioclavicular joint. The acromium is
seen to the right of the image and appears
inferior to the distal clavicle positioned
to the left of the image. The joint capsule
is indicated by the curved arrow. Curved
arrow, acromioclavicular joint capsule.
Superior transverse
ligament of scapula
Scapular
notch
Infraspinous
fossa
Coraco-
clavicular ligament
Axillary
recess
Scapular
spine
Clavicale
capsule
clavicular ligament
Joint
Axroio-
Acromion
Greater
tubercle
Humerus
Fig. 2.41 Posterior coronal view of the
right glenohumeral and acromioclavicular
joints. The illustration also demonstrates
the scapular notch through which the
suprascapular nerve passes deep to
the superior transverse ligament. The
suprascapular artery travels superiorly
to the ligament. (Reproduced from
Schuenke, Schulte, and Schumacher, Atlas
of Anatomy, 2nd edition, ©2014, Thieme
Publishers, New York. Illustration by Karl
Wesker/Markus Voll.)
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