Shoulder: Anatomy
and Techniques
CHAPTER OUTLINE
OVERVIEW
Patient Position
Standard Position 1: Biceps Tendon
Standard Position 2: Rotator Interval
Standard Position 3: Subscapularis Tendon
Standard Position 4: Supraspinatus Tendon
Standard Position 5: Infraspinatus and Teres
Minor Tendon
OVERVIEW
The important bony landmarks in the evaluation of the
supraspinatus tendon are the humeral head, the coracoid,
the clavicle and acromium, joined at the acromioclavicular
joint. The glenohumeral joint is an inherently unstable joint
and depends on the surrounding soft tissues for stabilization.
Soft tissue stabilizers are divided into intrinsic and extrinsic.
The most important extrinsic soft tissues are the supraspina­
tus tendon superiorly, infraspinatus posteriorly and subscap­
ularis anteriorly (Fig. 1.1). The important intrinsic soft tissue
stabilizers are the glenohumeral joint and capsule.
The supraspinatus and infraspinatus are difficult to sepa­
rate close to their insertions and share what is almost a
conjoined tendon. Some of the fibres crisscross each other,
making the two tendons difficult to separate. Anteriorly the
subscapularis tendon is separated from the supraspinatus
tendon by a gap, the rotator interval, which allows passage
of the long head of biceps out of the joint and into its groove
in the upper arm. The long head of biceps originates from
the superior glenoid margin. The coracohumeral ligament
helps keep the long head of biceps in position within the
upper groove, by forming a sling mechanism in conjunction
with the superior glenohumeral ligament. These ligaments
pass from the coracoid and glenoid respectively, and insert
into the humeral head on either side of the biceps tendon,
securing it in place. Another important ligament, the cora­
coacromial ligament (CAL). Links the coracoid to the acro­
mium and forms the coracoacromial arch along with the
bony acromium.
Shoulder pain is a common complaint in the general
population and impingement is a common underlying
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1
Eugene McNally
Standard Position 6: Supraspinatus Muscle
and Acromioclavicular Joint
DYNAMIC SHOULDER ASSESSMENT
Dynamic Assessment for Cuff Tears
DYNAMIC ASSESSMENT OF BURSAL
IMPINGEMENT
JOINT SUBLUXATION
cause. Impingement is a clinical diagnosis, whereby pain
occurs during arm abduction, as the supraspinatus tendon
and subacromial subdeltoid bursa are compressed between
the humeral head and the coracoacromial arch. This clini­
cal scenario is also called painful arc syndrome, as pain is
maximal in an arc of abduction between 30° and 60°. Inter­
estingly, patients frequently complain of pain on the lateral
deltoid rather than in the region of the acromion.
A complete ultrasound examination involves evaluating
the four major tendons of the rotator cuff (biceps, subscapu­
laris, supraspinatus and infraspinatus), the subacromial sub­
deltoid bursa and the acromioclavicular joint.
PATIENT POSITION
The easiest position in which to examine the shoulder is
with the patient seated. A stool with either no back or a low
back and arms is ideal. This will allow for full access and
permit the shoulder to be moved into a range of positions.
It is a matter of personal preference whether the examiner
carries out the examination standing or sitting, behind or
in front of the patient. There are minor advantages and
disadvantages to each of these, but none is particularly
important and the choice is a matter of personal preference.
Some variations in position are required for patients in
wheelchairs and for patients who must remain recumbent
whether because of illness, surgery or fear of fainting. Many
wheelchairs allow the sidearm to be removed, facilitating
arm movement. If the patient is also able to sit a little
forward in the chair then generally all of the important
positions can be achieved without too much difficulty.
It is important to take a history directly from the patient
before the examination begins as this can often provide
3
4 PART 1 — SHOULDER
Supraspinatus
Biceps tendon
Infraspinatus
and Teres
Subscapularis
Figure 1.1  The glenohumeral joint is stabilized by a combination of
the joint capsule with its condensations, the glenohumeral ligaments
and the rotator cuff tendons. The coracoacromial arch overlies the
supraspinatus comprising the coracoid, acromial and CAL.
useful diagnostic information. The examination itself begins
with a brief inspection of the shoulder, useful to detect
muscle wasting. As with most ultrasound examinations the
probe should be held lightly with sufficient, but not exces­
sive, contact with the skin. Holding the probe between the
thumb and adjacent fingers while resting the little finger
on the patient’s skin is an ideal way of obtaining excellent
contact with minimal pressure.
The cuff is examined from biceps anteriorly to teres
minor posteriorly and from the acromioclavicular joint
superiorly to deltoid insertion inferiorly. The examination
is concentrated on the four major tendons, but it is impor­
tant to have a routine to ensure that none of the other
important structures is overlooked. My preference is to
begin with the biceps tendon and rotator interval anteriorly,
then move sequentially through subscapularis, supraspina­
tus and infraspinatus and teres in that order (Fig. 1.2). The
examination concludes with an assessment of the posterior
glenohumeral joint, infraglenoid notch, supraspinatus
muscle and the acromioclavicular joint, before sweeping
down to the deltoid insertion.
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The cuff tendons, particularly supraspinatus, should be
examined both statically and dynamically. The static exami­
nation is divided into six standard positions with specific
imaging goals in each position. The dynamic examination
has many components, but primarily seeks to evaluate the
behaviour of the subacromial subdeltoid bursa as it abuts
the coracoacromial arch on arm abduction.
STANDARD POSITION 1: BICEPS TENDON
IMAGING GOALS
1. Confirm that biceps tendon lies within groove.
2. Identify abnormal fluid in the sheath and bursa.
3. Identify normal internal tendon structure.
TECHNIQUE
The patient sits and places their hand on their knee palm
upwards. This induces a little external rotation sufficient to
bring the bicipital groove to an anterior position (Fig. 1.3).
The groove is easily located by placing the probe in an axial
plane on the anterior aspect of the humeral head. The
probe is then moved superiorly and inferiorly, tracing the
biceps tendon from the upper part of the groove to below
its upper musculotendinous junction. The normal tendon
has a bright speckled appearance in the axial plane, made
up of the poorly reflective tendon fibre bundles and the
hyperechoic connective tissue matrix. Care must be taken
to ensure that the probe is always held at 90° to the tendon
to remove the effects of anisotropy. Anisotropy is an artefact
whereby areas of reduced reflectivity simulating tendinopa­
thy occur as a result of incident echoes arriving at angles
other than perpendicular and being reflected away from the
tendon, rather than bouncing back to the probe to help
form an image.
At its upper part, the biceps tendon sheath surrounds the
tendon. As is well known, this is an extension of the gleno­
humeral joint and a small quantity of fluid is often identified
within it. Also in its upper part, the anterior portion of the
subacromial subdeltoid bursa can be seen deep to the
deltoid muscle and anterior to the biceps sheath. The ante­
rior limb of the circumflex humeral artery is frequently
visible around the tendon. Distally, the relationship of the
musculotendinous junction with the traversing pectoralis
tendon should be noted. A number of tendon variations
may be identified. There are often a number of slips that
pass from the upper humerus to the tendon. Occasionally
a duplex tendon is encountered.
The probe is then rotated 90° so that the tendon can
be examined in its long axis (Fig. 1.4). Maintaining the
tendon in view during this manoeuvre takes a little practice;
however, if the probe falls off the tendon it is very easy to
move a little medial or lateral to find it again, noting where
the reflective humeral shaft drops away as the probe crosses
the groove. In most individuals, the tendon travels deeper
as it passes distally. This introduces an element of anisot­
ropy, which can be easily corrected by some gentle pressure
at the distal end of the probe. This manoeuvre is called
‘heel toeing’ and is used in several locations in musculo­
skeletal ultrasound. The long-axis image of the tendon is
very useful for confirming integrity; however, as with most
tendons, the internal structure is best evaluated in the axial
plane.
 CHAPTER 1 — Shoulder: Anatomy and Techniques 5

a b c

d e f

g h

i j

Figure 1.2  Standard ultrasound examination positions. (A, B) Dorsum of hand on patient’s knee with some shoulder extension: used to
visualise biceps tendon in short and long axis. (C, D) Shoulder extended, hand by side position for subscapularis (external rotation can also
be used). (E, F) Hand on back pocket: used for supraspinatus short and long axis. (G, H, I, J) Arm across anterior chest for teres minor long
and short axis, supraspinatus muscle belly and acromioclavicular joint.

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6 PART 1 — SHOULDER

Deltoid

CHL

Humeral head A
Short head Subscapularis
ML
b P c

Figure 1.3  Position 1: the biceps lies centrally within its groove.

A
S I
b P c

Figure 1.4  Position 2: long axis of biceps with the subacromial subdeltoid bursa just visible anterior to the superior part of the tendon.

When assessment of the long head of biceps is complete, be covered in a later section. The probe is then returned to
the probe is moved medially to locate the short head of the upper biceps to review the rotator interval.
biceps. The bony margin of the coracoid process provides a
very useful landmark. The short head arises from its inferior STANDARD POSITION 2: ROTATOR INTERVAL
margin superficial to the insertion of the pectoralis minor
and coracobrachialis tendons. The tendon of pectoralis IMAGING GOALS
major can be identified as a long, thin slip passing over the 1. Identify ligamentous sling around biceps.
biceps tendon around the level of the proximal musculoten­ 2. Confirm ligaments are intact.
dinous junction. The more detailed anatomy of the arm will 3. Evaluate Doppler signal.

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a
Deltoid
Supraspinatus
Biceps
CHL
Humeral head
SCT
b P
Figure 1.5  Rotator interval image. The coracohumeral ligament re-
inforced by the superior glenohumeral ligament separates supraspi-
natus from infraspinatus.
TECHNIQUE
As has already been mentioned, the rotator interval is the
name given to the space between the subscapularis and the
supraspinatus tendons through which the long head of
biceps passes as it exits the glenohumeral joint. Because the
tendon undergoes a 90° turn as it enters the bicipital groove,
it must be supported to ensure that it does not displace
medially. Two ligaments in particular combine to create
this support, which is also referred to as the rotator pulley
(Fig. 1.5). The two ligaments are the coracohumeral and
the superior glenohumeral ligaments. The pulley is also
reinforced by fibres of the subscapularis tendon passing
superficially to the coracohumeral ligament and inserting
on the lateral aspect of the groove. These fibres are some­
times erroneously referred to as the transverse ligament.
The patient position is the same as for the biceps tendon.
The rotator interval is best evaluated with the probe in the
axial plane, positioned just above the upper part of the
biceps groove. In this position, a rim of tissue is seen around
the biceps tendon, between the subscapularis medially and
the supraspinatus laterally. This ‘rim’ represents the con­
joined coracohumeral and superior glenohumeral liga­
ments and the bridging subscapularis fibres. The margins
of the coracohumeral ligament can usually be identified
with good-quality equipment. It measures approximately
1.5 mm in thickness and should have the striated, predomi­
nantly reflective appearance typical of ligaments elsewhere.
It should have little or no Doppler activity within it.
On the medial aspect of the interval, particularly at its
uppermost extent, the contribution from the superior gle­
nohumeral ligament can be identified. This is seen as a
nodule of tissue often inserting itself just underneath the
biceps tendon and blending with the coracohumeral liga­
ment, from which it is often difficult to separate. Note
should be made of thickening or abnormal Doppler activity
in and around the coracohumeral ligament, before moving
the probe medially to assess subscapularis.
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CHAPTER 1 — Shoulder: Anatomy and Techniques 7
STANDARD POSITION 3: SUBSCAPULARIS
TENDON
IMAGING GOALS
1. Identify tendon in long axis.
2. Identify tendon in short axis.
3. Note relationship of tendon with rotator interval.
TECHNIQUE
Subscapularis arises, as the name suggests, from the under­
surface of the scapula and is an internal rotator of the
shoulder. It is a multipennate muscle forming several
tendons that insert as a conjoined unit on the medial border
of the bicipital groove. The tendon measures approximately
8 cm from superior to inferior. Its upper margin is adjacent
to the anterior interval. The tendon must be examined in
A both its long and short axis, as, because of the width of the
tendon, significant tears may be present in one location, yet
ML
other areas of the tendon will appear completely normal.
Following a successful examination of the biceps tendon
and rotator interval, the patient is asked to move their elbow
posteriorly, then, keeping the elbow firmly by their side, the
shoulder is externally rotated by asking the patient to move
their hand as far as possible laterally. This draws the sub­
scapularis out from beneath the coracoid, making it easier
to examine in its full extent (Fig. 1.6). Patients with adhesive
capsulitis will find it difficult to externally rotate the shoul­
der, an important initial clue to this diagnosis. Take care to
ensure the patient doesn’t lift their arm to try and simulate
external rotation.
In the axial plane, the normal bright reflective tendon
should be followed from musculotendinous junction to
insertion. In some normal patients, and patients with
chronic tendinopathy, the tendon may be very thin and dif­
ficult to separate from the surrounding bursa. If there is any
doubt as to its integrity, moving the tendon by internal/
external rotation easily separates it from surrounding struc­
tures and isolates what is tendon and what is surrounding
bursa.
Once the axial view is completed, the probe is rotated 90°
to assess the tendon in its short or sagittal axis. The examiner
should be careful not to displace the probe too far laterally
beyond the subscapularis insertion and into the supraspina­
tus tendon. In the short axis, the subscapularis tendon is
recognized by its multifascicular pattern (Fig. 1.7). It should
be examined from upper to lower border. If the upper
border cannot be clearly defined, it is brought more inferi­
orly by further posterior movement of the elbow. Sharp
definition of the upper border is important, as many injuries
begin at the upper border of the tendon. The normal upper
border should have a nice rounded margin and the biceps
tendon should lie just above and lateral to it. The relation­
ship of the upper border of the tendon and the rotator
interval is also easier to appreciate in this position.
In addition to examining the tendon, the underlying
humeral head should be scrutinized; that said, it is not
uncommon to identify asymptomatic surface defects. The
anterior compartment of the glenohumeral joint lies deep
to the subscapularis, although visualization of the anterior
labrum is insufficient for reliable diagnosis. Capsular con­
densations representing the middle glenohumeral ligament
may be seen. Anteriorly, the subacromial subdeltoid bursa
8 PART 1 — SHOULDER

Deltoid

ursa
SASD B

Short head
ris
ula
c ap A
bs Humeral
Su head M L
P
b c

Figure 1.6  External rotation draws the subscapularis tendon laterally out from under the coracoid. This image is obtained just below the tip
of the coracoid, demonstrating the proximal portions of short head of biceps and coracobrachialis muscle.

Bursa
SASD Subscapularis Deltoid

BT
A Humeral head
S I
b P c

Figure 1.7  In short axis, subscapularis muscle is multipennate, forming an elongated tendon that inserts in a slight depression on to the neck
of the humerus.

lies between subscapularis and deltoid, and fluid frequently

gravitates in this position. TECHNIQUE
As with tendons elsewhere, supraspinatus is examined in
STANDARD POSITION 4: SUPRASPINATUS both planes. In order to best visualize the tendon, the
TENDON patient is asked to abduct and internally rotate their shoul­
der. This is best achieved by placing the palm of their hand
IMAGING GOALS on their ‘back pocket’. Alternatively, the patient can be
1. Identify the tendon in short axis. asked to put their arm in an ‘armlock’ position. These posi­
2. Note the relationship with biceps tendon. tions bring supraspinatus forward and out from under the
3. Identify the tendon and long axis. cover of the coracoacromial arch (Fig. 1.8). Although

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 CHAPTER 1 — Shoulder: Anatomy and Techniques 9

b c

Figure 1.8  Extending and internally rotating the shoulder draws the supraspinatus forward and laterally from under the coracoacromial arch.
The biceps tendon provides a key landmark identifying the rotator interval with subscapularis medially and supraspinatus laterally.

similar, the two positions do not result in an identical con­

figuration of the tendon and bursa. As such, moving between
them can be very useful to create changes in tension, which
can be useful diagnostically.
Just as patients with adhesive capsulitis (frozen shoulder)
may find it difficult to adopt the best position for visualiz­
ing subscapularis, patients with impingement may struggle
to achieve the positions described above. In these instances,
asking the patient to let their arm hang by their side a
and internally rotate as much as they are able may be
sufficient.
Once a comfortable position is achieved, begin with the White
short axis examination. This is usually referred to as the
axial view, but in practice, the image is achieved with Supraspinatus
the probe held in a slightly tilted axial position (see Fig.
In
1.5). The biceps tendon is the key landmark. In some fr
as
patients who internally rotate particularly well, the biceps A
pi
na
Humeral head
may be very medial and out of the field of examination. ML tu
s
Gentle manipulation of the patient’s position can usually b P
bring it into better view.
Figure 1.9  The orientation of the fibres of infraspinatus is slightly
Once the biceps tendon is located, it is easy to identify different from supraspinatus. The resulting anisotropy renders the
the leading edge of supraspinatus which lies adjacent to infraspinatus fibre slightly darker than supraspinatus.
biceps on the lateral side. The supraspinatus tendon is an
oval-shape structure with a smooth round anterior border.
Occasionally this can appear particularly reflective and
mimic the appearance of the biceps tendon itself: the false tendon should be predominantly a bright, reflective, stri­
biceps sign. The area of supraspinatus adjacent to the biceps ated structure until the junctional area between the supra­
is also referred to as the leading edge or the free edge. It spinatus and the infraspinatus is reached. At this point,
usually lies very close to the biceps, occasionally overlapping low-reflective striations become visible. This is the anterior
them. Any significant increase in the distance between the part of infraspinatus. The fibres run in a different plane to
biceps tendon and the free edge of the supraspinatus should supraspinatus and therefore appear anisotropic and dark in
be regarded as suspicious for a free edge tear. comparison to supraspinatus.
The probe is then moved laterally, keeping it in the tilted The probe is then rotated 90° to view supraspinatus in its
axial plane, to view the midportion of the supraspinatus long axis. This is the classic image of supraspinatus, and is
(Fig. 1.9). The internal structure of the supraspinatus usually referred to as the coronal plane because the

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10 PART 1 — SHOULDER
Deltoid
Ten Supraspinatus
don
foo
tpri Art
nt icu
lar
S Car
Humeral head
LM
b I
Figure 1.10  A slight ridge is noted between the articular surface of the humeral head and the supraspinatus footprint. Note the low-reflective
articular cartilage ending just proximal to the medial point of the insertion of supraspinatus.
ultrasound image mimics the coronal image seen on MRI
(Fig. 1.10). It will be noted that the probe is actually held
in a tilted rather than true coronal plane, and even quite
sagittal in some patients, depending on the degree of shoul­
der internal rotation. If there is uncertainty, the biceps
tendon can be located anteriorly and the probe gently
rotated until the best longitudinal view of biceps is achieved.
The same angle is then used to examine supraspinatus in
the coronal plane.
In the coronal position, supraspinatus has a very charac­
teristic appearance. Its upper border is convex with a bright
margin representing the subacromial subdeltoid bursa. The
tendon fibres can be seen arching towards its insertion onto
the greater tuberosity and should have a predominantly
bright, reflective, striated appearance. Two distinct layers of
the tendon are frequently observed in this position. The
more medial fibres have to turn more acutely than the
lateral fibres to insert and so reflectivity at the insertion is
variable, usually ranging from dark medially to brighter and
more normal laterally, depending on the orientation of the
probe. This is a form of anisotropy, which can be problem­
atic at many tendon insertions. Dynamic probe manipula­
tion with heel toeing, beam steering and lateral movement
are combined with slight movement of the patient’s shoul­
der and can help to overcome this problem.
The insertion of supraspinatus in this position is called
the footprint. It measures approximately 2 cm medial to
lateral. It should be examined carefully, anterior to poste­
rior, to ensure that the entire footprint has been visualized.
Particular attention should be paid to the medial margin of
the joint surface where tears may begin. These tears are
sometimes referred to as ‘rim-rent’ tears. The coronal image
is best for examining the lateral margin of supraspinatus
insertion but poor at demonstrating the leading edge. The
axial image works in the opposite way.
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tila
ge
c
The articular cartilage of the humeral head will be seen
deep and medial. The cartilage is hyporeflective, though
with high-resolution equipment will be noted to have a thin
bright reflective surface. Deeper again, the highly reflective
surface of the humeral head is noted. The subacromial
subdeltoid bursa lies superficially, and overlying this is the
deltoid muscle.
There is a modification of Position 4 whereby the forearm
under examination is held further across the back in the
so-called armlock position. In some patients the ‘hand on
pocket’ is better than the armlock for visualizing pathology
and vice versa in others. In all patients, both arm positions
should be used and the tendon should be observed under
movement as the hand passes between the two. Patients
quickly become familiar with the names of the two positions
and easily understand when movement between the two
positions is needed. The examiner can then concentrate on
observing the tendon during this movement. More exten­
sive dynamic movements are also helpful to depict pathol­
ogy (these will be described in a later section).
Although the majority of supraspinatus fibres are orien­
tated in the coronal plane, there are some that have
more transverse orientation. These are referred to as the
rotator cable and are said to have an important role in
determining both the location and rate of propagation of
rotator cuff tears.
The subacromial subdeltoid bursa overlies the supraspi­
natus tendon in the coronal plane. It is a low-reflective
structure itself but it is surrounded by reflective fat and con­
nective tissue. The bursa should be traced laterally by
moving the probe around the greater tuberosity and into
the upper arm. In the seated patient, small quantities of
fluid gravitate in these dependent areas. Care must be taken
not to apply too much pressure with the transducer and
underestimate the size or presence of bursal fluid. The
 CHAPTER 1 — Shoulder: Anatomy and Techniques 11

Deltoid
Figure 1.11  The low-signal subacromial subdeltoid bursa is
assessed adjacent to the coracoacromial ligament. The thickness is
noted at rest and in arm abduction. Bursal bunching may be demon-
atus
strated in patients with impingement, although this is not always Infraspin
associated with symptoms. The schematic diagram demonstrates the
location and appearance of bursal bunching with thickening of the
bursa lateral and thinning inferior and medial to the coracoacromial Humeral head P
ligament. ML
A
b

bursa should also be traced medially to the lateral margin

of the acromium (posteriorly) or to the CAL (anteriorly).
In the coronal image, the ligament will be visualized in cross
section as a 1–2 mm bright, oval shaped reflective structure.
If there is difficulty in identifying it, what sometimes helps
is to locate it in long axis first and then rotate the probe to
see it in its short axis. To locate it longitudinally, place the
medial end of the probe over the reflective surface of the
coracoid and hold the probe in the axial plane. Then rotate
the lateral end of the probe upwards, keeping the medial
end still. As the lateral end reaches the acromium, a thin
linear, highly reflective, striated structure representing the
CAL comes into view. Keeping the ligament in the centre of
the image and rotating the probe brings up the ligament in c
cross section. Once the appearance in this plane has been
recognized a few times it will be more easily picked up on Figure 1.12  With the arm abducted and internally rotated, the
the conventional coronal image without having to go tendon of the infraspinatus extends quite far laterally. It has a similar
through this localization process. This is the point where appearance to the supraspinatus tendon, though is generally thinner.
bursal bunching will be sought as the patient abducts their
arm. This is discussed in more detail in the section on
dynamic shoulder examination (Fig. 1.11). of the greater tuberosity posterior to the insertion for supra­
spinatus. To examine it in long axis, the patient is asked to
STANDARD POSITION 5: INFRASPINATUS AND place their arm across the front of their chest, internally
TERES MINOR TENDON rotating the humeral head and elongating infraspinatus.
The probe is placed in the axial plane with its medial border
IMAGING GOALS a little lower than lateral to align itself along the tendon.
1. Identify tendon in long access from musculotendinous The appearance of the tendon is very similar to supraspina­
junction. tus, although generally smaller (anterior to posterior) (Fig.
2. Note underlying posterior labrum and glenohumeral 1.12). Its relationships are similar with the humeral head
joint. deep and deltoid muscle superficial. The tendon should
3. Find the spinoglenoid notch and neurovascular bundle. be traced medially where it becomes the central tendon
of infraspinatus muscle. The musculotendinous junction
TECHNIQUE should be carefully scrutinized as injuries may occur at this
Infraspinatus, as the name suggests, rises from the dorsal location rather than at the insertion. The tendon also passes
aspect of the scapula below its spine, and inserts on a facet over the dorsal aspect of the glenohumeral joint, where the

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12 PART 1 — SHOULDER

a a

Deltoid
Deltoid

IST

IST
TM
Triceps

P
P
ML
A S I
b b A
Figure 1.13  The spinoglenoid notch is located on the posterosupe-
rior aspect of the scapula. It is located by moving the probe a little
medially and superiorly from the position used to locate the infraspi-
natus tendon. The glenohumeral joint and glenoid labrum (postero-
superior part) are identified.

posterior labrum can be readily identified in thin patients.

The posterior recess of the joint is also visible and this is a
good location to detect joint effusion (Fig. 1.13). Cartilage
damage and marginal osteophytes should be sought here.
The spinoglenoid notch lies medial to the posterior labrum
and glenoid margin. This is a bony depression with a well
rounded margin that contains reflective fat and the supra­
scapular neurovascular bundle. The commonest pathology
identified in this location is a ganglion cyst arising from the
posterior labrum which may expand within the fossa, com­
press the nerve and also cause infraspinatus muscle atrophy.
Increased echotexture of the muscle belly is a sign of infra­
spinatus muscle atrophy, which is more often a complication
of throwing sports.
Keeping it in the axial plane, the probe is moved inferi­
orly to overlie the teres minor tendon. This tendon has a
similar appearance to infraspinatus and in some patients
can be difficult to separate from it. One feature that can
assist is that the deep relation of teres minor is bone whereas
the structure deep to infraspinatus is articular cartilage. The
c
Figure 1.14  In short axis, the teres minor muscle is identified on the
inferior aspect of the infraspinatus tendon, although sometimes can
be difficult to differentiate from it. It has a slightly rounder contour
than the infraspinatus.
musculotendinous junction occurs at a similar location or
perhaps slightly more laterally than infraspinatus.
The quadrilateral space can be identified just below the
teres minor tendon. The circumflex humeral artery is prom­
inent in this location and can be used as a marker for the
axillary nerve. The probe is then rotated 90° to demonstrate
infraspinatus and teres minor in short axis (Fig. 1.14).

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 CHAPTER 1 — Shoulder: Anatomy and Techniques 13

STANDARD POSITION 6: SUPRASPINATUS

MUSCLE AND ACROMIOCLAVICULAR JOINT
IMAGING GOALS
1. Identify supraspinatus muscle belly.
2. Compare echotexture with trapezius.
3. Examine acromioclavicular joint for structure and
tenderness.

TECHNIQUE
The final examination position is also posterior. Having
completed the examination of teres minor in the sagittal
plane, the probe is once again rotated into the axial plane
and moved superiorly, passing above the spine of the scapula
into the area of the supraspinatus muscle belly. This is par­
ticularly important in patients with rotator cuff tears, as
associated muscle atrophy can be detected here (Fig. 1.15).
a
The bulk and reflectivity of the muscle are compared with
the overlying trapezius muscle. The ease and clarity with
which the central tendon is visualized is also useful; increas­
ing fatty atrophy absorbs the ultrasound beam and blurs the
margins of the central tendon, making it appear larger than Trapezius
normal. The margins of the muscle also be come less clear.
Having assessed the muscle in both long and short axes
(Fig. 1.16), the probe is moved laterally to overlie the acro­
mioclavicular joint. It is easy to locate the joint by passing
the probe along the clavicle until the joint is encountered SSM
(Fig. 1.17). The normal joint margins are smooth, although
the capsule will frequently bulge a little upwards. The
margins of the joint are assessed for osteophytes and ero­
sions and the joint cavity itself should be reviewed to detect
effusion and synovitis. More important than abnormal joint
morphology, gentle compression with the ultrasound probe S
over the joint may reproduce symptoms, if they arise, from ML
the joint. The acromioclavicular joint is also examined I
b
dynamically. The patient is asked to move their arm from its
position across the chest to the ipsilateral knee, then back
to the contralateral shoulder. This cycle is repeated and
note is made of the relative movement of the lateral aspect
of the clavicle with respect to the acromium. Under normal
circumstances the two bones will approximate slightly,
though some superior/inferior movement may be observed.
When subluxation is present, the lateral end of the clavicle
deviates upwards and there will be abnormal movement of
the capsule and synovial contents.

DYNAMIC SHOULDER ASSESSMENT

Dynamic assessment of the shoulder is most often used

to detect subacromial subdeltoid bursal impingement;
however, there are a number of other useful dynamic tech­
niques that can be applied to detect cuff tears, including
patient movement, probe movement, fluid movement and
the use of bursography as well as dynamic manoeuvres to
assess glenohumeral instability.
c
Figure 1.15  The conspicuity of the central tendon of supraspinatus
within the supraspinatus muscle belly is used to assess for supraspi-
natus atrophy. Loss of definition or increased reflectivity around the
tendon representing a fatty replacement is an indication of atrophy.

can be observed during this movement. Changes in tissue

DYNAMIC ASSESSMENT FOR CUFF TEARS
During the routine examination, supraspinatus should be
examined in a number of different positions, as has previ­
ously been outlined. With prompting, the patient can move
efficiently between the optimal positions and the tendon
tension with separation of fibres can all help with the diag­
nosis of cuff tears, and particularly the movement of tissue
interfaces. If an abnormality in the region of this interface
is detected, its behaviour under movement can help with
differential diagnosis. Changes in bursal dimension may be

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14 PART 1 — SHOULDER
a
Trapezius
SSM
S
P A
I c
b
Figure 1.16  The bulk in reflectivity of supraspinatus muscle can also
be assessed in short axis. The muscle generally should fill the arch
between the spine and upper border of the body of the scapula.
observed and movement between the planes of supraspina­
tus and the subacromial subdeltoid bursa is particularly
useful at differentiating bursal surface partial tears from
areas of bursal thickening. If the abnormal tissue moves
synchronously with the supraspinatus tendon, it is a partial
tear. If the tendon moves independently of the tissue then
the abnormality is likely to represent an area of bursal
thickening.
In addition to using patient movement, the compress­
ibility of the underlying tissue can be assessed using sono­
palpation. Sonopalpation refers to the cyclical compression
and release of probe pressure, while observing the behaviour
of the underlying tissue. Normal and minimally diseased
tissue is poorly compressible. The fibres will respond syn­
chronously and continuity is preserved. With more advanced
stages of tendinopathy, the tendon becomes increasingly
compressible and the behaviour of the underlying fibre is
more abnormal. Structural integrity is poorly preserved
during compression.
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Clavicle Acromium
S
ML
b I
Figure 1.17  The acromioclavicular joint is located in long axis on
the superior aspect of the shoulder. The superior coracoclavicular
ligament overlies, demarcating the upper aspect of the joint space.
The deltoid ligament attaches to the lateral aspect of the acromion.
If fluid is present in the bursa it can be used dynamically
to assist in the differentiation of cuff tears. Bursal fluid
located in the dependent position can be massaged into a
more useful location on the superior aspect of the tendon
with lateral compression on the outer aspect of the patient’s
shoulder. The patient can even be positioned in a prone
recumbent position, although this is rarely necessary. Fluid
movement, combined with sonopalpation and patient move­
ment, may either fill a previously unrecognized tear or dem­
onstrate that an apparent partial tear is in fact complete, by
showing a fluid connection between the bursa and joint.
In addition to fluid that is already present within the
bursa, if the patient undergoes diagnostic or therapeutic
bursal injection, the fluid introduced can be used to identify
more subtle pathology, especially of the bursal surface. It is
helpful to re-examine the biceps tendon sheath when par­
ticulate corticosteroids are injected into the bursa. If the
reflective steroid is identified in the glenohumeral joint or
the biceps tendon sheath, a full-thickness tear is confirmed.

DYNAMIC ASSESSMENT OF BURSAL
IMPINGEMENT
As has been described above, the thickness of the subacro­
mial subdeltoid bursa can be assessed as it overlies the supra­
spinatus and other tendons. The method for locating the
CAL has also already been described. Once these principal
structures have been located, the patient’s arm can be gently
abducted, with the elbow flexed and level with the wrist, and
any changes in the configuration of the bursa as it abuts the
CAL noted. Typical findings include increased thickness of
the bursa as it tries to pass beneath the CAL. Occasionally,
thickening is sufficient to prevent further abduction, or,
after initial resistance, the bursa may pass under the liga­
ment with an audible and palpable click. The most impor­
tant finding during these manoeuvres is the patient’s
response. Bursal bunching without pain is of doubtful sig­
nificance but pain without bunching is an important clinical
finding. Despite this nonspecificity, the manoeuvre can be
a useful adjunct to the routine examination, especially when
equivocal symptoms are present. The same findings may
also occur with the bursa impinging against the bony acro­
mium; however, impingement against the CAL is more
usually assessed.
JOINT SUBLUXATION
Glenohumeral joint subluxation is difficult to assess with
ultrasound, but a number of techniques have been described.
The examination is generally carried out from a posterior
approach. The probe is initially placed in the transverse
plane with the arm across the anterior aspect of the chest
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CHAPTER 1 — Shoulder: Anatomy and Techniques 15
in the same position as is used to assess infraspinatus. The
posterior recess of the joint is identified deep to this and
the relationship of the round humeral head and posterior
margin of the glenoid noted. The patient is asked to draw
back the arm into the late cocking position. As the humeral
head externally rotates, its effect on the posterosuperior
labrum is reviewed as posterosuperior impingement may
be identified. The manoeuvre is completed by asking the
patient to simulate a forward throwing action. Any loss of
congruity between the humeral head and the glenoid
should be noted. As with any other dynamic manoeuvre, it
is useful to undergo several practice cycles with the patient,
as some movement of the probe is required to keep the
relevant structures in view. It is difficult, under physiological
conditions, to maintain visualization of the glenohumeral
joint, and the power and range of movement of the simu­
lated throwing manoeuvre is only a fraction of a normal
dynamic throw. Consequently, it is likely that this technique
carries a significant false negative.
Acromioclavicular joint subluxation is more easily
assessed. The patient begins with their hand on the ipsilat­
eral knee, then moves it to the contralateral shoulder and
back. Under normal conditions, there is some approxima­
tion of the acromium at the lateral end of the clavicle. Sig­
nificant inferior–superior movement is not detected unless
there is ligamentous laxity. As the joint moves, synovial tissue
and fluid may be extruded. In some patients with a large
quantity of fluid in the subacromial subdeltoid bursa, often
in association with a massive rotator cuff tear, a communica­
tion can exist between the bursa and the joint. Under these
circumstances, significant quantities of fluid may pass
through the joint to emerge on its superior aspect, filling
a large synovial cyst. This is referred to as the geyser
phenomenon.