European Society of MusculoSkeletal Radiology
Musculoskeletal Ultrasound Technical Guidelines I. Shoulder
Ian Beggs, UK Stefano Bianchi, Switzerland Angel Bueno, Spain Michel Cohen, France Michel Court-Payen, Denmark Andrew Grainger, UK Franz Kainberger, Austria Andrea Klauser, Austria Carlo Martinoli, Italy Eugene McNally, UK Philip J. O’Connor, UK Philippe Peetrons, Belgium Monique Reijnierse, The Netherlands Philipp Remplik, Germany Enzo Silvestri, Italy
Shoulder
1
Although patient’s positioning for shoulder US varies widely across different Countries and Institutions reflecting multifaceted opinions and experiences of different examiners, we strongly recommend to examine the patient while seated on a revolving stool. This position allows the examiner to reach the anterior, lateral and posterior aspects of the shoulder with the probe by simply asking the patient to rotate on the chair.
2
Place the arm in slight internal rotation (directed towards the contralateral knee) with the elbow flexed 90°, palm up. Start by finding the long biceps tendon in between the greater and lesser tuberosities – Use short and long (more limited utility) axis planes to examine the biceps.
SubS
GT LT
Shift the probe up to examine the biceps in its intraarticular course and down to reach the myotendinous junction (level of the pectoralis major tendon).
SubS
SupraS
SH
LH
H
Legend: SubS, subscapularis tendon; SupraS, supraspinatus tendon; Arrow, long head of the biceps tendon; LT, lesser tuberosity; GT, greater tuberosity; SH, short head of the biceps; LH, long head of the biceps; H, humeral shaft; Arrowheads, pectoralis major tendon
1
Shoulder
3
Rotate the arm externally fixing the elbow on the iliac crest to show the subscapularis tendon and its insertion on the lesser tuberosity (slight supination of the hand may be helpful to neutralize the tendency to lift and abduct the elbow from the lateral chest wall).
Del Co SubS
LT
This tendon should be evaluated along its long- (transverse planes) and short- (sagittal planes) axis during passive external and internal rotation with hanging arm. Sweep the transducer up and down over the subscapularis until its full width is demonstrated.
SubS
LT
LT
Legend: Arrow, long head of the biceps tendon; dashed line, insertion of the subscapularis tendon; Co, coracoid; Del, deltoid muscle; LT, lesser tuberosity; SubS, subscapularis tendon; void arrowheads, tendon fascicles of the subscapularis; white arrowheads, muscle tissue interposed between tendon fascicles
2
Shoulder
4
Moving the probe toward medial on transverse planes, look at the coracoid process, the coracoacromial ligament (the medial margin of the transducer is on the coracoid process and the lateral edge is shifted upward and laterally towards the acromion), the conjoined tendon and the anterior aspect of the subacromial subdeltoid bursa. Then, check the subscapularis recess and the subcoracoid bursa for effusion. External and internal rotation may also used to demonstrate anteromedial impingement (distance between coracoid process and lesser tuberosity measured in internal rotation).
CoBr
SubS
Co SupraS
Acr
HH
Legend: Acr, acromion; Arrows, short head of the biceps; Arrowheads, coracoacromial ligament; Co, coracoid; CoBr, coraco-brachialis; HH, humeral head; SubS, subscapularis tendon; SupraS, supraspinatus
5
Place the patient’s arm posteriorly, placing the palmar side of the hand on the superior aspect of the iliac wing with the elbow flexed and directed posteriorly. The supraspinatus tendon should be evaluated along its long- and short-axis.
3
Shoulder
5
Refer to the intraarticular portion of the biceps as a landmark to obtain proper transducer orientation for imaging the supraspinatus. In fact, these tendons run parallel one to the other and the intraarticular portion of the biceps is easy to be recognized due to a more clearly defined fibrillar pattern. One should rotate the transducer until the biceps is depicted as more elongated as possible in the US image. Then, the probe is shifted upward and posteriorly over the supraspinatus without changing its orientation. The resulting image is in axis with the supraspinatus. Between the supraspinatus and the deltoid, the normal subacromial-subdeltoid bursa appears as a thin hypoechoic band.
Acr
Del
Del SupraS
*
SupraS
GT
Tilt the transducer gently in the area overlying the tendon insertion to avoid anisotropy. Remember to scan the lateral pouch of the subacromial subdeltoid bursa along the lateral edge of the greater tuberosity. When looking for the supraspinatus on short-axis, the normal cuff must have almost the same thickness from the biceps tendon landmark until 2cm backwards: from this point backwards the tendon seen is the infraspinatus.
Legend: Acr, acromion; asterisk, myotendinous junction; Del, deltoid muscle; GT, greater tuberosity; void arrow-head, articular cartilage; curved arrow, hypoechoic artifact related to anisotropy; straight arrow, long head of the biceps tendon; SupraS, supraspinatus tendon; white arrowhead, subacromial subdeltoid bursa
4
Shoulder
6
Place the dorsum of the hand over the opposite back pocket (forced internal rotation, stress manoeuvre). There should not be any space gap between the elbow and the lateral chest wall. Using this position, the supraspinatus becomes a more anterior structure and the transducer should be oriented almost vertically to be in axis with it. Consider that the tendon fibers are more stretched than in the position described at point -5. This may be possible cause of overestimation of tear size. Due to an excessive internal rotation, the long head of the biceps tendon may be difficult to be visualized in this position.
Neutral
Internal Rotation
7
Dynamic assessment of subacromial (antero-superior) impingement can be attempted by placing the probe in the coronal plane with its medial margin at the lateral margin of the acromion. The patient abducts his arm while in internal rotation. With this manoeuvre, the supraspinatus and the bursa can be seen passing deep to the coracoacromial arch.
Acr GT
Acr GT
Legend: Acr, acromion; GT, greater tuberosity; arrows, supraspinatus tendon
5
Shoulder
8
Place the transducer over the posterior aspect of the glenohumeral joint with the arm in the same position described at point-2 (or with the hand on the opposite shoulder) and increase the depth to include the structures of the posterior fossa within the field-of-view of the US image. Use the spine of the scapula as the landmark to distinguish the supraspinous fossa (transducer shifted-up) from the infraspinous fossa (transducer shifted-down) on sagittal planes.
1 2
Legend: a, supraspinatus; arrow, spine of the scapula; b, infraspinatus; c, teres minor; dashed line, spine of the scapula; 1, supraspinous fossa; 2, infraspinous fossa; void arrowheads, deltoid; white arrowheads, trapezius
Look at the infraspinatus and teres minor muscles as individual structures filling the infraspinous fossa deep to the deltoid. After scanning these muscles, sweep the transducer toward the greater tuberosity on sagittal planes. The two tendons can be appreciated as individual structures arising from the respective muscles.
*
Del
InfraS Tm
*
Del
GT
Legend: asterisk, spine of the scapula; dashed line, spine of the scapula; Del, deltoid muscle; GT, greater tuberosity; InfraS, infraspinatus muscle; Tm, teres minor muscle; void arrow, teres minor tendon; white arrows, infraspinatus tendon
6
Shoulder
9
Examine these tendons separately on their long-axis (transverse planes) during external and internal rotation of the arm (same position as in point-2) by placing the probe over the posterior aspect of the glenohumeral joint.
HH
HH
Look at the posterior labrum-capsular complex and check the posterior recess of the joint for effusion during scanning. In thin subjects the posterior labrum can be clearly seen. Move the transducer medial to the labrum on transverse plane to visualize the spinoglenoid notch. It is often necessary to increase the depth of the field-of-view not to miss this area. A paralabral cyst originating in this area should be sought.
InfraS
HH
*
Legend: asterisk, spinoglenoid notch; curved arrow, bony glenoid; HH, humeral head; InfraS, infraspinatus; void arrows, teres minor tendon; white arrows, infraspinatus tendon; white arrowheads, posterior labrum
10
Place the transducer in the coronal plane over the shoulder to examine the acromioclavicular joint. Sweep the transducer anteriorly and posteriorly over this joint to assess the presence of an os acromiale. Shifting the probe posterior to the acromioclavicular joint, it is possible to assess the status of the supraspinatus muscle.
Legend: Acr, acromion; arrowheads, superior acromioclavicular ligament; asterisk, acromioclavicular joint space; Cl, clavicle
Cl
*
Acr
7
肩关节体格检查概述 华山运动医学 与传统骨科的体格检查程序类似，对于肩关节疾患也是从“视、触、动、量(包括特殊 试验)”等方面进行检查。 一、 “视”：患者双肩应充分暴露， 观察肩关节的轮廓， 有无外伤、手术改变，有无肌肉萎缩， 畸形、肿块等。 二、 “触”：分别于肩锁关节、喙突、喙肱韧带、肱骨大结节、肱二头肌长头腱、 Ban kart 点 (盂唇前缘中点)等部位检查有无压痛。为了与颈椎病鉴别，还需了解颈椎有无压痛。 三、 “动”：主要观察肩关节的主动和被动活动度( range of motion , ROM 。肩关节活动度 受盂肱关节、肩锁关节、 胸锁关节、肩胛骨胸壁活动度的共同影响。其中盂肱关节属于球窝 关节，有很大的关节活动度。 为了简化临床检查程序， 通常检查肩前屈(forward flexion )、 夕卜展(abduction )、夕卜旋(external rotation )、内旋(internal rotation )四个方向的 活动度。 正常肩关节的活动度： (Ma nual of Orthopaedics, Fifth Editi on ) 冠状面 矢状面 水平面(前屈90°) 内收 0-75 ° 前屈0-180 ° 0-130 ° 外展 0-180 ° 后伸0-60 ° 0-40 ° 屈肘90°，肩外展90°：旋前：0-90 °;旋后：0-90 ° 肩胛骨 闿锁关节
前屈活动度 上肢保持内收位，肘关节伸直，上肢自前方向上举直至超过头顶，前屈至最上方时掌心向前。 外展活动度 上肢保持肘关节伸直，自身体侧方向上举直至超过头顶，外展至最上方时掌心向外。 外旋活动度 内收位外旋：患者肩内收位，肘部贴紧身体，屈肘90度，前臂旋转中立位。肩关节外旋使手向侧方移动。
超声对类风湿性肩关节炎的早期诊断价值分析 摘要目的对比高频超声与传统临床检查方法对类风湿性肩关节炎诊断的差异性，评价超声的诊断价值。方法27例类风湿性肩关节炎患者，应用高频超声检查对經临床和实验室检查确诊的肩关节进行扫查，观察肩关节腔腋囊侧及后隐窝侧、肩峰下滑囊、肱二头肌长头肌腱鞘4个区域内滑膜厚度、积液深度；利用彩色多普勒观察滑膜血流显示情况。结果5例患者出现肱二头肌长头腱肌腱炎表现，其声像图表现为肌腱肿胀，纹理紊乱，可见片状低回声，肌腱滑膜增生，腱鞘积液，彩色多普勒血流显像（CDFI）于部分病例可见较多短线状及树枝状血流信号。9例患者出现滑膜炎表现，其声像图表现为肩关节可见滑膜增生，CDFI显示部分增生的滑漠内可见较多点状及短线状血流信号。6例患者出现关节腔积液表现，其声像图表现为关节腔内可见不规则液性区。12例患者出现骨侵蚀表现，其声像图表现为骨表面连续性中断。不规则隆起，可见于关节的任何部位。2例患者出现肩袖病变，其声像图表现为肌腱肿胀、纹理紊乱、中断，内可见不规则低回声区，部分可见强回声钙化灶。结论高频超声检查可发现类风湿性肩关节炎早期病变，对疾病的早期诊断有重要价值。 关键词高频超声；类风湿性肩关节炎；彩色多普勒血流显像；诊断价值 肩关节是类风湿性关节炎患者经常受累的部位，关节的肿胀、疼痛，以及肩关节囊、周围滑囊、肌腱等组织炎症反应均可引起肩关节粘连及活动受限，严重影响患者的生活质量[1，2]。因此，从超声影像学角度，分析和总结类风湿性肩关节炎表现，对提高诊断正确率和及时治疗有一定的临床意义。 1 资料与方法 1. 1 一般资料按照顺序纳入2013年2月～2014年11月在本院门诊就诊，且符合中华医学会风湿病学分会风湿性肩关节炎诊治指南诊断标准的患者[3]。排除标准：年龄<18岁；其他结缔组织疾病者；既往有肩关节手术史。共纳入类风湿性肩关节炎患者27例，其中男13例，女14例，年龄25～73岁，平均年龄（5 2.3士2.5）岁。患者均知情同意。 1. 2 方法采用PHILIP IU22超声诊断仪，高频线阵探头，检查频率5～12 MHz。患者取坐位，充分暴露上半身，嘱受检者变换上臂姿势，观察肩关节腔腋囊侧及后隐窝侧、肩峰下滑囊、肱二头肌长头肌腱鞘4个区域内滑膜厚度、积液深度；利用彩色多普勒观察滑膜血流显示情况[4]。 2 结果 27例患者的超声表现：5例患者出现肱二头肌长头腱肌腱炎表现，其声像图表现为肌腱肿胀，纹理紊乱，可见片状低回声，肌腱滑膜增生，腱鞘积液，CDFI于部分病例可见较多短线状及树枝状血流信号。9例患者出现滑膜炎表现，其声像图表现为肩关节可见滑膜增，CDFI部分增生的滑膜内可见较多点状及短
肩关节体格检查概述 与传统骨科的体格检查程序类似，对于肩关节疾患也是从“视、触、动、量（包括特殊试验）”等方面进行检查。 衣着准备：充分显露双侧肩关节，女性吊带衫为宜。 一、“视”：患者双肩应充分暴露，观察肩关节的轮廓，有无外伤、手术改变，有无肌肉萎缩，畸形、肿块等。 二、“触”：分别于肩锁关节、喙突、喙肱韧带、肱骨大结节、肱二头肌长头腱、Bankart点（盂唇前缘中点）等部位检查有无压痛。为了与颈椎病鉴别，还需了解颈椎有无压痛。 三、“动”：主要观察肩关节的主动和被动活动度（range of motion，ROM）。主要检查肩关节的前屈、后伸、外展、外旋、内旋活动度。 四、“量”：为了与颈椎病等疾病鉴别，需要检查患侧手部的感觉、肌力等另外需要重点检查肩袖的肌力、撞击试验、盂肱关节稳定性等。 五、特殊检查 （一）肩关节活动度检查 肩关节活动度受盂肱关节、肩锁关节、胸锁关节、肩胛骨胸壁活动度的共同影响。其中盂肱关节属于球窝关节，有很大的关节活动度。为了简化临床检查程序，通常检查肩前屈（forward flexion）、外展（abduction）、外旋（external rotation）、内旋（internal rotation）四个方向的活动度。
屈肘90°，肩外展90°：旋前：0-90°；旋后：0-90° 1、前屈活动度 2、后伸 3、外展活动度 4、肩外旋活动度：1)内收位外旋、2)外展90度位外旋 5、肩内旋活动度 6、Apley 摸背试验（Apley Scratch test） 1、前屈活动度：上肢保持内收位，肘关节伸直，上肢自前方向上举直至超过头顶，前屈至最上方时掌心向前。 2、后伸：上臂从侧方向后摆：正常运动范围：0～60°。 3、外展活动度：上肢保持肘关节伸直，自身体侧方向上举直至超过头顶，外展至最上方时掌心向外。 2.肩外旋活动度：1)内收位外旋：患者肩内收位，肘部贴紧身体，屈肘90度，前臂旋转中立位。肩关节外旋使手向侧方移动。
超声引导下神经阻滞复合全麻在肩关节镜手术中的应用 发表时间：2016-01-22T09:54:47.120Z 来源：《健康世界》2015年11期供稿作者：曾献坤 [导读] 湖南省湘潭市韶山市人民医院探究超声引导下神经阻滞符合全麻在肩关节镜手术中的应用 湖南省湘潭市韶山市人民医院 411300 摘要：目的：探究超声引导下神经阻滞符合全麻在肩关节镜手术中的应用。方法：抽取2013年12月--2014年12月在我院就诊的70例接受肩关节镜手术的患者进行临床研究，随机分为治疗组与对照组，治疗组患者接受神经阻滞复合麻醉，对照组患者接受单纯全麻，观察比对两组患者麻醉诱导钱、手术开始后20min、手术结束、拔管后10min几个事件的平均动脉压（MPA）和心率（RP），并进行视觉模拟评分。结果：术前两组患者的MAP、PR均无明显差别（P>0.05）；术中技术后2h治疗组患者的血流动力学明显比对照组平稳，并且在血压及心率等方面优于对照组（P<0.05）；进行市局模拟评分，治疗组患者显著低于对照组（P<0.05）。结论：肩关节镜手术中应用超声引导下的神经阻滞符合全麻，可有效维持术中血流动力学稳定，减少麻醉药物的使用量，有效提高患者舒适度使得镇痛时间延长，对患者的康复具有促进作用，有效减少患者痛苦，可在临床中推广。 关键词：超声引导；神经阻滞全麻；肩关节镜手术；临床应用 1958年肩关节镜手术在世界范围内开展，由于人们对于手术微创化的追求，使得关节镜手术的发展得到了极大的优势，肩关节镜手术凭借其损伤小、恢复快【1】、疗效好的特点得到医生和患者广泛认可，并在临床中得到广泛应用。现代麻醉技术的不断提高，麻醉理念也得到了生化，麻醉方式不断多样化，因此人们对麻醉的要求也越来越高，不仅是能够完成手术【2】，更要求能够有足够的舒适度和安全性，尤其是术后恢复的要求。区域神经阻滞具有可良好控制应激反应、生理干扰小、术后镇痛确切及术后恢复的有点，因此引起了人们的关注。传统的麻醉方式就收到了挑战。本文为探究超声引导下神经阻滞符合全麻在肩关节镜手术中的应用，抽取2013年12月--2014年12月在我院就诊的70例接受肩关节镜手术的患者进行临床研究，取得满意效果。现详细报告如下： 1.资料与方法 1.1一般资料 抽取2013年12月--2014年12月在我院就诊的70例接受肩关节镜手术的患者进行临床研究，其中男性患者38例，女性患者32例，平均年龄（43.2±10.2）岁，ASA评级均在I~II级范围，随机将患者分为治疗组与对照组，两组患者在年龄、性别及病情等方面均无明显差异（P>0.05）。 1.2排除标准 有显著心血管系统、呼吸系统、神经功能障碍及肝肾疾病者；肌肉疾病病史者；妊娠期及哺乳期妇女；局麻药过敏、卤化麻醉剂过敏者；穿刺点感染着；确定或可以恶性高热病史或家族史者。 1.3麻醉方法 所有患者进入手术室后，均进行常规生命体征监护【3】，上肢静脉通路开放。治疗组患者选择臂丛神经及劲浅丛神经阻滞，取患者仰卧位，在肩胛间垫一个小枕头（去掉枕头后），将头转向对侧，手贴蹄髈。于胸锁乳突肌上环状软骨水平方向防止与慢耦合剂的超声探头，保证超声科探测到颈动脉、静脉。将探头内外侧稍微一动则可分辨前、中斜角肌。这是，视野内将出现神经根和神经干，均为均匀的低密度影。取探头外2cm作为穿刺点，与皮肤呈45°刺入【4】，穿刺针则以长轴平面内穿刺进针，在屏幕上可以看到针尖透过中斜角肌，回吸无血或脑脊液后于两斜角肌注入15~20ml0.5%罗哌卡因。对照组患者则接受全身麻醉。 0.01mg/kg盐酸戊乙奎醚、0.05mg/kg咪达挫仑注射液、0.5mg/kg枸橼酸舒芬太尼注射液、1.5mg/kg丙泊酚、0.6mg/kg罗库溴铵注射液作为全麻诱导剂【5】，随后将呼吸回路连接好，观察呼气末CO2波形，在有效通气后进行机械通气，潮气量为9ml/kg，呼吸频率保持12次/min，呼吸比为1： 2。维持PetCO235~40mmHg，术中用2~3%七氟醚维持麻醉，有必要时可追加静脉药物。手术结束后，若患者自主呼吸良好，呼之可拔管。所有患者送至麻醉恢复至，待完全清醒后回病房， 1.4统计学方法 本文数据均采用SPSS16.0软件处理，用例数、百分数（n，%）进行数据表示，组间数据用χ2检验计数资料，P＜0.05具有统计学意义。 2.结果 治疗组患者芬太尼使用量、术后按压至疼泵的次数均显著少于对照组，具有统计学差异（P<0.05）；比对满意度，治疗组患者的满意度显著高于对照组，具有统计学差异（P<0.05）；术前两组患者的MAP、PR均无明显差别（P>0.05）；术中技术后2h治疗组患者的血流动力学明显比对照组平稳，并且在血压及心率等方面优于对照组（P<0.05）；进行市局模拟评分，治疗组患者显著低于对照组（P<0.05）。治疗组患者的临床各项指标均明显优于对照组，具有统计学差异（P<0.05）。详见表1、2、3。
[重点]肩关节体格检查 肩关节体格检查 站立位 被动内旋活动 用手摸后背，到达肩胛区，拇指尖指示脊柱节段代表肩关节内旋程度。该患者左肩关节内旋L3水平，右肩关节内旋T7水平。 主动全肩关节上举活动 背靠墙站立，可以防止背部后伸，病人向天花板举起上臂，检查者侧面观察肘关节跨过的弧度。 后方不稳定实验(Jerk试验) 在后方不稳定患者中，将上臂前屈90?、内旋90?和轻微内收，接着施加向后作用力，患者肱骨头可以出现向后的半脱位。 Lift-off试验 检查者将患者手置于离开背部的位置时，有肩胛下肌功能但肌力差的患者还能将手保持在离开背部的位置;肩胛下肌功能丧失的患者不能将手退离后背，也不能将手维持在离开后背的位置。 压腹试验 压腹试验(-):患者完成压腹动作的同时能够保持腕关节伸直并保持肘关节位于身体前方;压腹试验(+):患者需要屈腕关节才能完成压腹动作。 Napoleon试验—改良的压腹试验 让患者将手置于腹部，肘关节置于体侧，接着病人保持手的位置而将肘关节置于病人身体前方，如果需要将整个肩胛带前移才能将肘关节置于身体前方，则Napoleon试验(+)。
Bear hug试验 病人将手置于健侧肩关节上，检查者握住其肘关节以防屈肘，检查者试图将患者的手从对侧肩关节上抬起，而患者能抵抗这一动作，不出现疼痛，说明患者肩胛下肌功能良好;检查者能够将患者的手从对侧肩关节上抬起，说明肩胛下肌无力或没有功能。 冈上肌肌力测试(冈上肌不易从三角肌活动中分离) 患者肩关节在肩胛骨平面上上举90?，并将上臂完全内旋。检查者将上臂下压，病人抵抗下压动作。(如果三角肌没有受伤，任何肌力上差异都与冈上肌有关) 冈下肌和小圆肌测试(冈下肌和小圆肌容易从三角肌活动中分离) 检查者将病人上臂最大限度被动外旋，当检查者放开上臂时，患者不能维持刚才位置，说明Lag征阳性(肘关节屈曲90?时病人在体侧能维持住上臂的位置)，冈下肌和小圆肌无力或者功能缺失。(三角肌对于外旋肱骨能量有限，任何外旋力量下降都与这些肌肉功能异常相关。) Hawkins-Kennedy撞击征 检查者站在病人体侧，病人肩关节置于90?前屈位，肘关节屈曲90?，检查者内旋患侧上臂，重现肩峰下撞击导致疼痛。 Jobe-Yocum试验 患者将上臂置于肩胛骨平面的90?上举和完全内旋位，在患者腕部施加向下的作用力，患者阻抗并维持上述体位;B:患者将手置于旋后位时，再进行该项检查，内旋位抗阻产生的疼痛在手部旋后位得到改善，则说明冈上肌腱炎。 内旋抗阻应力试验 病人站立位，上臂在冠状面上置于外展90?外旋80?，检查者站在病人身后，一手稳定患者患侧肘关节，另一手握住腕关节，测试等长外旋肌力，再测试等长内旋肌力。抗阻外旋无力表示典型的肩峰下撞击。抗阻内旋无力表示关节内撞击肩锁关节试验
European Society of MusculoSkeletal Radiology
Musculoskeletal Ultrasound Technical Guidelines I. Shoulder
Ian Beggs, UK Stefano Bianchi, Switzerland Angel Bueno, Spain Michel Cohen, France Michel Court-Payen, Denmark Andrew Grainger, UK Franz Kainberger, Austria Andrea Klauser, Austria Carlo Martinoli, Italy Eugene McNally, UK Philip J. O’Connor, UK Philippe Peetrons, Belgium Monique Reijnierse, The Netherlands Philipp Remplik, Germany Enzo Silvestri, Italy
Shoulder
1
Although patient’s positioning for shoulder US varies widely across different Countries and Institutions reflecting multifaceted opinions and experiences of different examiners, we strongly recommend to examine the patient while seated on a revolving stool. This position allows the examiner to reach the anterior, lateral and posterior aspects of the shoulder with the probe by simply asking the patient to rotate on the chair.
2
Place the arm in slight internal rotation (directed towards the contralateral knee) with the elbow flexed 90°, palm up. Start by finding the long biceps tendon in between the greater and lesser tuberosities – Use short and long (more limited utility) axis planes to examine the biceps.
SubS
GT LT
Shift the probe up to examine the biceps in its intraarticular course and down to reach the myotendinous junction (level of the pectoralis major tendon).
SubS
SupraS
SH
LH
H
Legend: SubS, subscapularis tendon; SupraS, supraspinatus tendon; Arrow, long head of the biceps tendon; LT, lesser tuberosity; GT, greater tuberosity; SH, short head of the biceps; LH, long head of the biceps; H, humeral shaft; Arrowheads, pectoralis major tendon
1