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American Journal of Physical Medicine & Rehabilitation:
doi: 10.1097/PHM.0b013e318224d42a
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Ultrasound-Guided Examination and Injection of the Shoulder

Chiang, Yi-Pin MD; Feng, Chien-Fei MD; Lew, Henry L. MD, PhD

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From the Department of Rehabilitation Medicine, Mackay Memorial Hospital, Taipei, Taiwan (Y-PC, C-FF); Defense and Veterans Brain Injury Center, Richmond, Virginia (HLL); and Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia (HLL).

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

With this issue of the American Journal of Physical Medicine & Rehabilitation, we introduce a new and exciting feature. This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal's Website. We hope that this new feature will change and enhance the learning experience.

Walter R. Frontera, MD, PhD, Editor-in-Chief

Video Gallery: To view the online video of these procedures, use your smartphone camera QR Reader App to scan and capture this QR Code or visit www.AJPMR.com to locate this digital video content.

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URL: http://journals.lww.com/ajpmr/Pages/videogallery.aspx?videoId=1

All correspondence and requests for reprints should be addressed to Yi-Pin Chiang, MD, Mailing address: 92 Sec. 2, Chung-Shan North Rd, Taipei, Taiwan.

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ULTRASOUND-GUIDED EXAMINATION OF THE ROTATOR CUFF

Diagnostic ultrasound has been gaining popularity in physiatry because of its convenience, its lack of radiation, and its ability to make dynamic examinations.1,2 Determining the integrity of the rotator cuff is one of the most common uses of diagnostic ultrasound in musculoskeletal medicine. In this article, the authors will use not only words but also pictures and videos to demonstrate the procedure involved in obtaining standard ultrasound images of the rotator cuff. The rotator cuff consists of four tendons around the shoulder joint, which are as follows: (1) subscapularis, (2) supraspinatus, (3) infraspinatus, and (4) teres minor (Fig. 1). In scanning the shoulder joint using an ultrasound probe or transducer, the examination typically begins with the patient sitting in an upright position on a revolving chair, with the patient's hands resting on the laps. The first identifiable anatomic landmark on the screen is the long head of the biceps tendon. When the examiner places the transducer in a horizontal position, the biceps tendon can be visualized on the screen, as a round, echogenic structure located between the greater and lesser tuberosities. The readers are encouraged to review the 2007 article by Lew et al.1 for a review of the basic anatomy and procedures involved in examining the shoulder (Fig. 2).

Figure 1
Figure 1
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Figure 2
Figure 2
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1. The long-axis view of the subscapularis tendon is best demonstrated with the patient's arm in external rotation. The tendon is then pulled laterally and anteriorly for dynamic imaging. As the examiner rotates the ultrasound transducer 90 degrees, the transverse view of the subscapularis tendon is revealed.

2. To visualize the supraspinatus tendon, the examiner needs to move the patient's arm to an internally rotated position and place the dorsal side of the patient's ipsilateral hand on his/her posterior-inferior iliac spine. With the transducer vertically placed on the anterior side of the shoulder, the long-axis view of the supraspinatus tendon can be seen on the screen. In this view, the supraspinatus tendon is identified as a characteristic beak-shaped, echogenic structure. If we turn the transducer into a horizontal position, the short-axis view of the tendon is readily demonstrated. During the process, the examiner should pay special attention to the overall morphology and echogenicity of the tendon to determine its associated pathologies. While viewing the supraspinatus tendon, one can also visualize the deltoid muscle, the subacromial-subdeltoid bursa, and the hyaline cartilage. Placing the patient in a modified Crass position may also enhance visualization of the suprapsinatus tendon. The examiner can instruct the patient to put the palm of his/her ipsilateral hand on the back pocket while pointing the elbow posteriorly. In doing so, the shoulder is externally rotated and hyperextended. The transducer is placed parallel to the humeral shaft so that the long-axis view of supraspinatus tendon can be shown. This position is especially useful for patients who cannot tolerate the pain associated with internal rotation and for patients with a limited range of motion.

3. and 4. The infraspinatus tendon, the teres minor tendon, and the posterior glenohumeral joint are examined conjointly. By putting the patient's arm across the chest, with the hand on the opposite shoulder, the posterior cuff is examined by placing the transducer on the posterior-lateral part of the shoulder. The infraspinatus tendon can be visualized inferior to the spine of the scapula. Dynamic examination can be easily performed with either an active or passive external rotation of the shoulder. If the examiner slightly moves the transducer caudally, the teres minor tendon can be visualized on the monitor.

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ULTRASOUND-GUIDED INJECTION OF THE SUBACROMIAL-SUBDELTOID BURSA

Palpation-guided injection to the shoulder joint has been done by experienced practitioners as a procedure for pain relief. It has been suggested that the injection may be more accurate and efficacious when performed under the guidance of ultrasound.3 To conclude this article, the authors demonstrate the images and procedure involved in an ultrasound-guided injection of the subacromial-subdeltoid bursa. After sterilization of patient's skin and of the transducer, a 25-gauge needle was inserted through the skin. The echogenic metallic needle can be visualized under ultrasound. The needle was carefully advanced toward the bursa until the needle tip reached its target. As the needle tip went into the bursa, a small amount of fluid was injected into it, and slight volume expansion was noted. After confirming needle placement, the medication was injected safely into the bursa, without leakage to the surrounding muscle and tendons.

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ACKNOWLEDGMENTS

We thank Drs. David Cifu, Chiu-Shiang Chen, Tyng-Guey Wang, Carl Chen, Simon Tang, and Walter Frontera for their assistance and support.

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REFERENCES

1. Lew HL, Chen CP, Wang TG, et al: Diagnostic ultrasound in musculoskeletal medicine, Part 1: Introduction and examination of the upper limb. Am J Phys Med Rehabil 2007;86:310-21

2. Chew K, Stevens K, Wang TG, et al: Introduction to diagnostic musculoskeletal ultrasound: Part 2: Examination of the lower limb. Am J Phys Med Rehabil 2008;87:238-48

3. Chen PC, Lew HL, Chen MJ, et al: Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-5

© 2011 Lippincott Williams & Wilkins, Inc.

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