Patients presenting with shoulder problems can generally be categorised clinically into a number of specific syndromes. The commonest amongst these is impingement where pain is induced on lateral abduction of the arm. The majority of these patients have subacromial subdeltoid bursitis with a small proportion having impingement below the acromioclavicular joint, termed high arc impingement. The management of patients with subacromial subdeltoid bursitis is generally conservative however a proportion will have rotator cuff tears which may be better managed with surgery. The principle role of imaging is differentiate patients who have impingement between those with subacromial subdeltoid bursitis only and those with rotator cuff tears.

The high spatial resolution of ultrasound renders it an ideal imaging technique for the detection of rotator cuff tears. A comprehensive examination includes an assessment of the biceps, subscapularis, supraspinatus and infraspinatus tendons, an assessment of the anterior interval for adhesive capsulitis and supraglenoid notch for ganglia are also useful applications. Other structures that can be identified but often incompletely examined include the posterior labrum. Ultrasound of the shoulder should not be regarded as a static examination and sonopalpation, probe and arm movement are all helpful to elucidate the precise nature of injury.

The procedural approach and key findings are elucidated in the ultrasound section of the ESSR website www.essr.org. This presentation will emphasise the importance of the key anatomic relationship between the biceps tendon, the leading edge of supraspinatus and the superior portion of subscapularis.

Rotator cuff tears follow familiar patterns. A tear of the anterior leading edge is common in the younger patient. In older patients the tear may be located in the mid substance of the tendon with sparing of the anterior and posterior fibres. Larger tears, termed massive tears, may be associated with extension into infraspinatus and tendon retraction. When a tear is detected, the ultrasonologist should record the size and the location, associated injury to other structures and if possible the presence or absence of muscle atrophy. All of these factors assist in determining the surgical approach.

A useful approach is the detection of supraspinatus tears is to 1) identify the leading edge, 2) determine whether there is gap between biceps and the leading edge indicative of free edge tear, 3) determine whether there is a tear of the mid substance of the tendon. The three questions can all be answered with the probe in the axial position. The coronal images help to detect more subtle tears particularly close to the tendon insertion.

Ultrasound is an ideal means of guiding intervention procedures of the shoulder which will be discussed in a separate talk.