Ultrasound signs of injuries and diseases of the shoulder joint

Damage to the rotator cuff.

As noted above, ultrasound is a highly sensitive method for assessing the condition of the rotator cuff. Speech, first of all, is about the detection of traumatic injuries, which are characterized by pronounced differences both in morphology and in the severity of the process. The rupture of the rotator cuff can be complete and partial, longitudinal and transverse. The sharp discontinuities have a transverse configuration, whereas for chronic ruptures the longitudinal direction is more typical and they take an oval or triangular shape. Chronic tears of the rotator cuff are usually present in the elderly, in whom there are pronounced degenerative-degenerative processes in the joint (see below impingement syndrome). Such gaps may even be asymptomatic.

The tendons of the supraspinous and subacute muscles are most often damaged, more rarely the subscapular muscle. With ruptures of the subscapular muscle, a dislocation of the tendon of the long biceps head is usually observed.

There are many classifications of rotator cuff ruptures. The main classification breaks provides for their division, depending on the amount of damage to partial and complete. Full gaps, in turn, are also divided into several groups. The first classification is based on the largest distance between the ripped ends of the tendons. At small ruptures, the diastase is less than 1 cm, with an average length of 1 to 3 cm, at large - more than 3 cm, with a massive length of more than 5 cm. Classification, based on the degree of involvement of the tendons of the muscles that make up the rotator cuff, . The first group of ruptures includes all partial (intra-articular, intraarticular, extraarticular) or complete discontinuities less than 1 cm. To the second group - complete ruptures of the supraspinatus. To the third - full tendon ruptures more than 1 muscle. By the fourth - massive ruptures with osteoarthritis.

The classification also provides information on the duration of the damage. There are acute - less than 6 weeks, subacute - from 6 weeks to six months, chronic - from 6 months to a year, chronic - more than a year.

Classification of rotator cuff ruptures

Depending on the duration of the damage		The length of the rupture (the maximum diastase)		Anatomical localization
The nature of the gap	Time since the break	Type of gap	Gap width	Groups	Length
Sharp	Less than 6 weeks	Small	Less than 1 cm	1	Partial or total less than 1 cm
Subacute	From 6 weeks to 6 months	Average	1-3 cm	2	Complete breaks of the supraspinatus
Chronic	From 6 months to 1 year	Big	3-5 centimeters	3	Complete tendon ruptures of more than 1 muscle group
Older	More than 1 year	Massive	More than 5 cm	4	Massive ruptures with osteoarthritis

Full rupture of the rotator cuff.

With a complete rupture of the supraspinous muscle, both longitudinal and transverse scans reveal a violation of the integrity of its contours. In the place of rupture of the supraspinous muscle, a hypo- or anechogenous cleft with irregular, diffuse contours is visible. Due to injury, the humerus through the resulting tendon gap directly communicates with the subacromial-sublatta bag. Reporting the cortical layer of the humerus through a tendon slit with a subacromial-sublatellite bag is the main sign of a complete rupture.

When scanning, an increase in the volume of the subacromial-sub-dentoid bag is visualized, the humerus of the humerus is exposed in the place where the deltoid muscle is attached. Gradually develops atrophy of the deltoid muscle in the form of a decrease in its thickness, heterogeneity of the structure, uneven contours. A hernia of the deltoid muscle can form, which looks like a tumor-like formation of an elastic consistency that decreases in volume during muscle tension.

Partial rupture of the rotator cuff.

With these ruptures, only part of the tendon fibers of the rotator cuff is damaged. There are several types of partial ruptures of the rotator cuff: intraarticular, extraarticular and intramuscular. Their schematic representation is shown in the figures. With a partial rupture of the supraspinous muscle in the cuff area, a small hypo- or anechogenous region with uneven, distinct contours is defined. The most common are intra-barrel partial discontinuities.

It is easiest to visualize them in the orthogonal projection. The rarest extraarticular ruptures - in which the rupture area faces the deltoid muscle and communicates with the sublantoid-subacromial sac.

At intraarticular ruptures the cavity of rupture is turned into a joint cavity and effusion, as a rule, is not observed. There is another type of rupture, the so-called detachment, in which there is a separation of the cartilaginous or cortical layer of the humerus.

At the same time, a hyperechoic linear fragment, surrounded by a hypoechoic region, is visualized. With repeated damage to the supraspinatus in the sub-dentoid and subacromial bags, an effusion appears in the acromioclavicular joint. It must be taken into account that a powerful muscle layer can obscure the presence of effusion in the joint. Fluctuation of the fluid is best determined by the posterior edge of the deltoid muscle or from the side of the axilla.

Echographic criteria for the rupture of the rotator cuff.

1. Lack of visualization of the cuff of the shoulder joint. It is observed at large ruptures, when the cuff is detached from the large tuber and its retraction to the acromial process occurs. In such cases, the deltoid muscle adjoins the head of the humerus and there is no echo from the rotator cuff between the deltoid muscle and the head.
2. Intermittence of its circuits. Occurs when the defect in the place of rupture of the rotator cuff is filled with liquid. There is a marked asymmetry when compared with a healthy shoulder.
3. The appearance of hyperechoic zones in the projection of the rotator cuff. This feature is not as reliable as the previous ones. Hyperechoic zones usually occur when the granulation tissue of the rupture zones is replaced by granulation tissue. Symptom should be considered as a sign of rupture of the rotator cuff only in case of pronounced asymmetry in comparison with the opposite arm.
4. The presence of a small gipoehogennoy strip in the area of the rotator cuff makes you think about tearing the supraspinous muscle. These changes are often accompanied by subacromial and subfertinal bursitis.

Impingement syndrome and damage to the rotator cuff.

It is important to remember that the rupture of the rotator cuff in the elderly is not a consequence of injuries, but often comes as a result of degenerative changes in the joint and in its constituent elements. As a result of degenerative changes, protrusive tendonitis occurs, up to the complete degenerative rupture of the rotator cuff of the shoulder. This can be accompanied by bursitis not only in the subacromial, but also in the sub-dentate bag. The preferred localizations of these changes are the base of the tendon of the supraspinatus, the subacute muscle and the large tubercle of the humerus. All these changes can lead to the development of the so-called impingement syndrome. This disease is characterized by persistent degenerative changes in the paracapsular tissues of the shoulder joint and is accompanied by a variety of clinical manifestations. It often occurs with a marked pain syndrome and is accompanied by varying degrees of restriction of the volume of motion in the joint.

The causes of the development of impingement syndrome are: microtractic injuries of the capsule, shoulder injury, complicated by rupture of the rotator cuff, as well as diseases such as rheumatoid arthritis and diabetic arthropathy.

There are 3 stages of the disease, which usually follow one another.

The first stage (edema and hemorrhage). Pain manifests after physical exertion, characterized by night pain. Most often occurs at a young age. At this stage, a symptom of the "arc" or "arches of painful leads" is determined, when a pain occurs within the range of 60-120 degrees of active abduction when the patient's arm is withdrawn. This indicates that there is a collision of a large tubercle of the humerus, the anterior-external edge of the acromion and the coraco-acromial ligament. Between these structures, at the place where the rotational cuff is attached, its infringement occurs.

In ultrasound examination, the articular bag shows an uneven thickening of the tendon of the supraspinatus with the presence of hyperechoic fibrosis. In the projection of the apex of the acromial process of the scapula, at the point of attachment of the tendon of the supraspinatus to the large tuberosus of the humerus, its thickening and subacromial bursitis are noted.

The second stage (fibrosis and tendonitis). There are painful phenomena in the shoulder joint with complete absence of active movements. They occur between the ages of 25 and 40. Degenerative changes occur in the tendon-muscle and ligamentous complex of the shoulder joint. As a result, the stabilizing function of the tendon apparatus decreases.

In UZ-study there is a heterogeneity of the tendon structure of the supraspinatus, the appearance of multiple small hyperechoic inclusions. In the intercampis fossa, thickened, uneven contours of the long head of the biceps arm muscle with single point calcifications and effusions are visualized.

The third stage (tears of the rotator cuff). Patients have sustained pain contracture with passive movements and almost complete loss of movements in the shoulder joint. Observed in persons over 40 years. As a result, the cavity of the shoulder joint significantly decreases in volume, the joint capsule becomes rigid and painful. In the periarticular tissues and in the synovial membrane, an adhesive capsulitis develops.

Ruptures of the biceps tendon of the shoulder.

Tears of the tendon of the biceps arm muscle arise when lifting heavy weights or sharp extension of the arm bent at the elbow joint. Most often, gaps occur between the ages of 40 and older. Predisposing factors are degenerative changes in the tendon. The main symptoms: severe pain, crunching at the time of injury, reducing the strength of the hand to flex. In the upper part of the shoulder there is an area of depressions. The torn part shrinks in the distal direction and swells under the skin. It should be remembered that evaluation of the condition of the tendon of the long biceps head is extremely important, since such information helps in the search for a possible rupture of the rotator cuff.

Partial ruptures. With partial ruptures of the biceps tendon in the synovial membrane, effusion is noted, tendon fibers are traced, but there is discontinuity and defibration at the point of rupture. In transverse scanning, the hyperechoic tendon will be surrounded by a hypoechoic rim.

Full gaps. With a complete rupture, the tendon of the biceps arm muscle is not visualized. On echograms in the place of rupture, a hypoechoic region of a heterogeneous structure with fuzzy uneven contours is determined. A small depression (groove) is formed due to the abnormality of the muscle tissue. With longitudinal scanning, you can see a torn part of the tendon and a shortened muscle. In the energy mapping mode, there is an increase in blood flow in this zone.

As a rule, in practice with traumatic injuries we are dealing with a combined pathology. Often, with combined tendon ruptures of the supraspinatus and subscapular muscles, dislocation and subluxation of the tendon of the biceps muscle are observed. In such cases, it is necessary to look for the location of its displacement, since the intertubercular groove will be empty. Most often the tendon of the biceps is shifted towards the subscapular muscle.

Fractures of humerus.

Clinically, it is difficult to differentiate acute damage to the rotator cuff of the shoulder joint and damage to the rotator cuff in fractures of the head of the humerus. With ultrasound in the area of fracture, the bone surface is uneven, fragmented. Often fractures of the head of the humerus are combined with damage to the rotator cuff. When ultrasound angiography at an early stage in the fracture fusion zone, as a rule, pronounced hypervascularization is noted. Sometimes, with the help of ultrasound, it is possible to visualize the fistula as well as the cavity after the osteosynthesis of the humerus by a metal plate.

Tendonitis and tenosynovitis of the biceps.

Tenosynovitis of the biceps muscle is a common pathology in the impingement syndrome. However, it can also be combined with tendinitis of the rotator cuff. In the synovial membrane of the bicep tendon there is an effusion, the fibers of the tendon can be traced completely. In transverse scanning, the hyperechoic tendon will be surrounded by a hypoechoic rim. With chronic tenosynovitis, the synovial membrane will be thickened. With ultrasound angiography, as a rule, there is an increase in the degree of vascularization.

Tendonitis and tendonopathy of the rotator cuff.

As a result of frequent injuries of the shoulder joint, infection, metabolic disorders in the tendons of the rotator cuff of the shoulder, pathological changes can occur, manifested by tendonitis, dystrophic calcification, mucoid degeneration.

Tendonitis. The presence of tendinitis is typical for patients of young age, usually younger than 30 years. With ultrasound, the appearance of hypoechoic patches of irregular shape, with uneven contours. The tendon is thickened, enlarged in volume and, as a rule, locally. The increase in the thickness of the tendon on the side of the lesion is already 2 mm, compared with the contralateral side, may be indicative of tendonitis. With ultrasound angiography, there may be increased vascularization, which reflects hyperemia of soft tissues.

The calcifying tendonitis. Calcific tendonitis shows itself a pronounced soreness. In ultrasound examination, many small calcifications are determined in the tendons.

Mucoid degeneration. Mucoid degeneration, apparently, is the basis of hypoechoic manifestations in ruptures of the rotator cuff that occur with the progression of degenerative processes in the tendon.

Initially, mucoid degeneration manifests itself in the ultrasound study in the form of small hypoechoic point areas, which then acquire a diffuse character.

It seems difficult to differentiate the presence of degenerative processes in the tendons caused by the progression of inflammatory changes, age changes or systemic diseases such as rheumatoid arthritis.

Subacromial-subglottic bursitis.

Subacromial bag is the largest shoulder bag. Uncertain in normal, with pathological changes in the shoulder joint, it increases in size and is located along the contour of the rotator cuff under the deltoid muscle.

Exudation in articular bags of the shoulder joint may occur: with rupture of the rotator, inflammatory diseases of the shoulder joint, synovitis, metastatic lesion. With traumatic or hemorrhagic bursitis, the contents have a heterogeneous ehostruktura.

With hypertrophy of the synovial membrane lining the bag, various growths, unevenness of the thickness of the bag walls

In the acute phase, ultrasound angiography shows increased vascularization. Subsequently, calcifications can form inside the bag.

Tears of acromioclavicular joint.

Damages in the acromioclavicular joint can mimic the ruptures of the rotator cuff, as the tendon of the supraspinatus passes right under this joint. Patients experience severe pain when raising their hands through the side up. There are complete and incomplete gaps in the clavicle-acromial joint. When a single clavicular-acromial ligament ruptures, an incomplete dislocation of the acromial end of the clavicle occurs, and with a ruptured and coracoid-clavicular ligament a complete dislocation occurs. With a full rupture, the clavicle protrudes upward, its outer end distinctly probed under the skin. When you move your shoulder, your collarbone remains motionless. With incomplete dislocation, the clavicle retains its connection with the acromion, and the outer end of the clavicle can not be touched. When pressing on the clavicle, the dislocation is quite easily eliminated, but it is necessary to stop the pressure - it reappears. This is the so-called "key" symptom, which serves as a reliable sign of the rupture of the acromioclavicular ligament.

Echographically, gaps in the clavicle-acromial joint are manifested by an increase in the distance between the clavicle and the acromion of the scapula, in comparison with the contralateral side. If the clavicle and acromion are normally at the same level, then at breaks the clavicle is shifted to the top, the boundaries of the levels change. In the place of the rupture, a hypoechoic region is visualized - a hematoma, the torn ends of the thickened ligament are seen. The rupture of the fibers of the subacromial bag to be carried is accompanied by the appearance of a "geyser" symptom.

Another most common pathology of this joint is osteoarthritis. With this pathology, the capsule of the joint is stretched due to synovitis, there are separate fragments and "articular mice" appearing in it. In the distal end of the clavicle, osteolysis can occur. These changes are most common among players of contact sports and weightlifters. Very often, pathological changes in this joint are missed by specialists performing ultrasound examinations, since all attention is focused on the shoulder joint.

Damage of anterior joint lip.

With traumatic injuries in the shoulder joint, accompanied by rupture of the joint capsule in the shoulder-scapular articulation, the so-called Bankart syndrome is observed, which is characterized by rupture of the anterior joint lip. The presence of effusion in the shoulder-and-shoulder joint and the extension of the capsule make it possible to identify the rupture of the cartilaginous tissue by means of a convection sensor during ultrasound examination. Bankart's rupture with ultrasound examination is accompanied by a violation of the integrity of the contours of the anterior joint lip and the appearance of fluid in the joint cavity causing thickening and bulging of the capsule

Damage of the posterior articular lip.

If the lesion affects the posterior articular lip of the shoulder-scapular articulation, the presence of rupture of the cartilaginous tissue and the presence of detached bone fragments of the head of the humerus will be called Hill-Sachs syndrome. By analogy with ruptures of the anterior joint lip, ultrasound examination also shows a violation of the integrity of the contours of the posterior articular lip, the appearance of fluid, bulging and thickening of the capsule.

Rheumatoid arthritis.

Degenerative changes and tendon ruptures in inflammatory rheumatic diseases are not echographically different from changes of other origin.

With rheumatoid arthritis, the joint cavity and the bag, as well as the articular surface of the bone, are most often affected, in the form of erosions. Erosions are visualized as small defects of bone tissue, irregular shape with sharp edges. A counterfeit bag is usually filled with liquid contents. Very often, this disease reveals muscle atrophy. Intermuscular septa become isoechoic and it is difficult to differentiate groups of muscles.

In the acute phase of the disease, hypervascularization in soft tissues is clearly detected, which is usually not observed in the remission phase.

Using the technique of ultrasound angiography, it is possible to conduct dynamic control of treatment for rheumatoid arthritis.

Thus, we can conclude that ultrasound is an important method of visualizing changes in the shoulder joint.

Modern ultrasound capabilities allow us to use it both for the primary diagnosis of pathological changes in the joint, and for monitoring the treatment. Simplicity and reliability of ultrasonic techniques provide him with undoubted priority over other instrumental methods.