MSK Ultrasound in young athletes -with a focus on shoulder technique

Johnathan Chen, MD Assistant Clinical Professor UCLA David Geffen School of Medicine Department of Radiological Sciences Disclosures I receive compensation as a consultant for Bayer pharmaceuticals and Siemens Medical Imaging.

3 ACGME Core competencies Patient Care: Covering direct patient care and interaction for scanning techniques of the shoulder Medical Knowledge: Literature review will be presented as needed Interpersonal skills and Communication Skills: UIM standard reporting guidelines will be covered for Shoulder US exams Professionalism: US exam technique will address adherence to ethical principals Practice based Learning and Improvement: We will cover the economics and billing procedures of MSK US Systems based Practice: Discussion of efficient delivery of US care will be discussed.

4 Goals and Objectives • Overview of available MSK US in children and adolescents • Knowledge of the advantages and disadvantages of MSK US compared to other modalities • Billing for Shoulder US and US guided procedures • Learn how to perform basic exam of the shoulder rotator cuff • Appearance of common pathology in MSK US • Advantages of using MSK US in interventional radiology procedures Outline • Advantages and disadvantages • Brief literature review • Shoulder technique MSK US Advantages • Growth plate : eg Throwers shoulder

• Imaging comparison to contralateral side with ease

• Subtle fractures noted with higher sensitivity than x ray

• Injuries

• Can do dynamic scanning and avoid an arthrogram

• Tendon Injuries

• Less common in children but faster acquisition than MRI

• Greater resolution with ultrasound vs MRI

• Dynamic imaging (compression)

• Apophyseal imaging and cartilage imaging of superficial joints US VS MRI for Cuff tears

Surgery Gold standard MRI Accuracy = 91.1% US Accuracy = 90.1% No statistical difference US advantages continued • Improved Diagnosis

• Location of pain can be immediately interrogated

• On field assessment • Immediate Diagnosis with radiologist onsite • Lower cost when compared to MRI • No Ionizing radiation when compared to X ray or CT • No worries about claustrophobia • Real time visualization Downside • Not all Sonographers and Sonologists are proficient in MSK US exams • Cannot image marrow lesions (eg stress reaction or ) • OCD may be occult • The time benefit my be exaggerated. MRI protocols at UCLA for non contrast are 5 pulse sequences or less. 11 12 13 14 12% of shoulder MRI at one institution. Of these, 78% were articular sided partial tears

15 Normal Tendon US Appearance Normal Ligament US Appearance Normal appearance of Bone Normal Appearance of Hyaline Cartialge Normal Appearance of Nerves Normal Appearance of Vessels Pitfall: Anisotropy

Shoulder technique Sonography of Shoulder

Physician Practice Guideline is established

by AIUM & ACR for the Shoulder U/S

Adapted from Jacobson 2011 Structured report

• Exam: Complete Left Shoulder Ultrasound

• Technique: Sonographic interrogation of the Left shoulder biceps tendon, rotator cuff, AC joint,

Posterior labrum, and subacromial/subdeltoid bursa. Dynamic imaging performed for subacromial impingement and shoulder laxity.

• Findings:

• Long Head Biceps Tendon:

• Rotator Cuff:

• Posterior Labrum:

• AC joint and SA/SD Bursa:

• Impingement test:

28 29 30 31 Shoulder technique

Modified Crass Maneuver

SS Tendon tear GT Fracture US For Guided Injection • Controversial • Many clinicians believe that they can get in the joint blindly • Very easy and quick do to in radiology outpt imaging center with usually no sedation needed. Posterior approach X Anterior Approach Subacromial Injection • 30% of injections miss subacromial bursa • Eustace (1997) • Yamakado (2002) • Henkus (2006) • Sethi (2006) Elbow Elbow Elbow UCL

Hip—Transient Transient Synovitis • Mean age: 4-5 • Usually between 3-8 years • Kocher criteria: , non-weight bearing, High WBC, High ESR • aspiration shows neg cultures and neg WBC—pts often have improvement with aspiration

Hip joint aspiration and injection References • Mistry A et al: Microinstability and internal impingement of the shoulder. Semin Musculoskelet Radiol. 19(3):277-83, 2015

• Chambers L et al: Microinstability and internal impingement in overhead athletes. Clin Sports Med. 32(4):697-707, 2013

• Reinold MM et al: Microinstability of the shoulder in the overhead athlete. Int J Sports Phys Ther. 8(5):601-16, 2013

• Chang EY et al: Superior labrum anterior and posterior lesions and microinstability. Magn Reson Imaging Clin N Am. 20(2):277-94, x-xi, 2012

• Drakos MC et al: Internal impingement of the shoulder in the overhead athlete. J Bone Joint Surg Am. 91(11):2719-28, 2009

• Steinbach LS: MRI of shoulder instability. Eur J Radiol. 68(1):57-71, 2008

• Woertler K et al: MR imaging in sports-related glenohumeral instability. Eur Radiol. 16(12):2622-36, 2006

• Tirman PF et al: Shoulder imaging in athletes. Semin Musculoskelet Radiol. 8(1):29-40, 2004

• Burkhart SS et al: The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 19(4):404-20, 2003

• Ruotolo C et al: Controversial topics in shoulder arthroscopy. Arthroscopy. 18(2 Suppl 1):65-75, 2002

• Savoie FH 3rd et al: Anterior superior instability with rotator cuff tearing: SLAC lesion. Orthop Clin North Am. 32(3):457-61, ix, 2001

• Pagnani MJ et al: Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am. 77(7):1003-10,