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Abstract
Purpose
To evaluate the objective difference of the shoulder position during ultrasound examination regarding diagnostic value for shoulder lesion, view range and visibility.
Materials and Methods
A prospective study was performed enrolling 312 patients who underwent diagnostic ultrasonography due to shoulder pain between January 2016 and June 2016. Examination was performed by a single orthopaedic surgeon with 5 years of musculoskeletal ultrasonography experience. Images of the longitudinal and transverse plane of the supraspinatus tendon and the nearby soft tissues (subscapularis and biceps long head tendon, subdeltoid bursa, etc.) were obtained in the three different positions, shoulder extension, modified Crass, and Crass position. The correlation between the demographic data (age, sex and body mass index) and the visual analogue scale (VAS) of the affected shoulder & the capable shoulder position was analyzed. Another orthopaedic independently measured the size of the tear and using classified the image visibility of the supraspinatus, subscapularis, and biceps long head tendon on the short-axis view from the rotator interval into I to III and X.
Results
Of the 312 patients, 126 were excluded and total of 186 cases were included in this study. None of the demographic data were related to the possible arm position. However, VAS for pain was the only factor related with the number of possible arm positions during sonography. Kappa agreements for the diagnosis were mostly high of over 0.90. Grades of the short-axis view from the rotator interval in each position were mostly grade II or grade III, which refers to that the anterior portion of supraspinatus tendon, which is the most fragile portion to the tear and it was well-defined regardless of the arm position. The average longitudinal tear sizes were 1.48, 1.52, and 1.61 cm in the shoulder extension, modified Crass (Middleton), and Crass position, respectively.
Conclusion
Shoulder extension position during ultrasonography examination of shoulder shows similar diagnosis rate of supraspinatus tendon tear or calcific tendinitis compared to modified Crass (Middleton) or Crass position, the two well-known standard positions. It is also a useful position for patients who suffer with severe shoulder pain.
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Figure 1
This figure shows positioning of the arm during sonography. (A) Shoulder extension position. (B) Modified Crass position. (C) Crass position.
Figure 2
These sonographic images show the grading of the short-axis view of the rotator interval. (A) Grade I, when the border between the BLHT and the SST tendon is not observed prominently. (B) Grade II, when the border between the BLHT and the SST tendon is observed prominently, while the border between the BLHT and the SSC tendon is not observed prominently. (C) Grade III, when the border between the SSC tendon, the BLHT, and the SST tendon is prominently observed in one field of view. (D) Grade X, when the border is ambiguous due to a complete rupture of the SST tendon or BLHT or an extensive rupture of the rotator cuff. DE, deltoid muscle; SST, supraspinatus; GT, greater tubercle; BLHT, biceps long head tendon; SSC, subscapularis.
Table 1
Comparisons of Demographic Data
Values are presented as number only, mean±standard deviation, or median (range). Group E, shoulder extension position; Group EM, shoulder extension and modified Crass position; Group EMC, shoulder extension, modified Crass position, and Crass position; BMI, body mass index; VAS, visual analogue scale.
Table 2
Frequency of Findings in Each Position and Kappa Agreements among 3 Positions
Table 3
Grading of the Short-Axis View of the Rotator Interval in Each Position by Two Examiners
Values are presented as number only. Grade I, when the border between the biceps long head tendon and the supraspinatus tendon is not observed prominently; Grade II, when the border between the biceps long head tendon and the supraspinatus tendon is observed prominently, while the border between the biceps long head tendon and the subscapularis tendon is not observed prominently; Grade III, when tthe border between the subscapularis tendon, the biceps long head tendon, and the supraspinatus tendon is prominently observed in one field of view; Grade X, when the border is ambiguous due to a complete rupture of the supraspinatus tendon or biceps long head tendon or an extensive rupture of the rotator cuff.
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