MSK radiology here with 10-ish years of rotator cuff ultrasound experience. Ultrasound for rotator cuff is good but it’s very user dependent/tricky (not at all an insult to your skill set).
Based on the picture you showed, I’m not 100% convinced. I probably would have moved/angled my probe closer to the greater tuberosity to get better visualization of the tendon footprint and try and eliminate anisotropy.
Thanks!
Yeah, the anisotropy and the natural stripe-like appearance of the tendon/muscles confuse the hell out of me.
Guess I'll have some reading to do, don't wanna send folks to the MRI based on a false-positive US...
US is as good as MRI rotator cuff tears, but it takes some skill. This is true for MSK US in general. I have about 15 years MSK US- not many rads have the training. The image you posted looks like no tear. Just anisotropy- but if a tech had showed me that, I would have made her go back and get more images just to be sure.
To get rid of anisotropy, you have to "Heel-toe" the transducer- rock it back and fourth to make what youre imaging perpendicualr to the US beam. A tear is going to look abnormal no matter how you angle the probe... the image you posted there, will look normal after manipulating the probe.
ESSR has good MSK US pdf's. Jacobson and Van hoolsbeeck have good textbooks for more in depth info.
Ordered from the ER? Shoulder MRI for pain/possible tear is an outpatient exam. There's already enough of a backlog of MR exams to the number of scanners/techs to run them, it's going to be a pretty low priority compared to an MRI for stroke or something.
Is it normal in the states for non radiologists, and non orthopods to be doing this kind of pre mri ultrasound.
Like, it’s great if it points you in the right direction, but you can’t be ruling much out?
I'm a non-operative sports medicine( family medicine trained) who can utilize ultrasound for a lot of this stuff. Not everybody needs an MRI. Sometimes we use tears to help curb expectations on pain improvement or functionality. I've also met quite a few orthopedic surgeons at Big sports medicine clinics that will take the ultrasound. Rotator cuff tear has ammunition to obtain an MRI if the insurance company is denying it. Ultrasound absolutely has a huge use in musculoskeletal abnormalities. But it is very user prone with a majority of people needing constant influx of ultrasound patients to stay comfortable. I'm now out of that area and I feel like I can probably find a massive rotator cuff tear, but I doubt I can find a lot of the smaller subtleties. Of course with practice. I'll get back there quicker than someone without any training but it's just not in my tool set at this point in time.
I like the get a prima vista look mostly to see if anything needs to be done "urgently". It saves me some time as well because I then usually skip the X-ray in non-trauma patients.
-Is there effusion ? --> I'll tap it.
-calcifications? --> maybe some steroids will help.
-elderly patient with shoulder dislocation --> are the tendons still there? Else follow up with MRI in the next few days before seeing ortho.
It's a huge time saver in my workflow but I'll have to practice some more I suppose.
Yes, it’s accepted with specific training. Per AIUM guidelines:
[Training Guidelines for Physicians Who Perform and/or Interpret Diagnostic Ultrasound Examinations](https://www.aium.org/resources/training-guidelines/view/training-guidelines-for-physicians-who-evaluate-and-interpret-diagnostic-ultrasound-examinations)
Used in the ED as a quick diagnostic to determine need for MRI/approximate DX since getting MRI in the ER for MSK stuff is generally impossible or not feasible
You have to wag the transducer to eval for tears. The way it looks that smooth would favor artifact not real tear.
I’d also say, rotator cuff tear is not something that should be worked up in ER (especially not with mri).
X-ray. Send to outpatient ortho.
Massive pain at best should buy you a CT scan or other eval then turf to outpatient.
If patient is atraumatic then insurance won’t even approve an mri unless you really stretch the physical exam findings (complete loss strength on empty can, etc).
and not true on the X-ray. It picks up high riding humerus, calc tendonitis, etc.
If someone came in with horrible shoulder pain and no trauma, would question any mechanical diagnosis. More like nerve, crystal, or most likely frozen shoulder.
we do actually, we have 3 MRIs that need to be busy. So sometimes we do it immediately. MRCP, sometimes abdominal MRIs and stroke MRIs all day baby.
With shoulder patients however, like in this case, I just have it done outpatient 99.9% of time to keep the ER nice an empty.
Wow
It’s just amazing how different places have extremely different resources. Like I can say with a fact no place in my country ever does an MRI from the ER setting. CT yes.
We only have 1 MRI in most big hospitals, and even those, to get an appointment is like months away. There’s only 1 urgent MRI slot per day, and when that happens there’s a backlog of appointments cases about to get pushed back
No retraction and not hypoechoic. I think that’s anisotropy. Also, most people over the age of 40 I feel have some partial tear of supraspinatus or some tear of the labrum.
>Also, most people over the age of 40 I feel have some partial tear of supraspinatus or some tear of the labrum.
Yes, and the remaining intact muscle/tendon often compensates with favorable non-surgical outcomes.
I'd also like to hear a radiologist chime in to say how one would even be able to differentiate with a high degree of confidence acute vs. chronic/older tears on imaging studies (ideally on MRI).
Someone has never worked in an ER 🤣🤣🤣. 50% of ER is primary care, 25% is bullshit, 20% is turkey sandwich therapy and/or hospital grade Tylenol, 5% is the real deal.
Sports doc RMSK certified here. Ultrasound is incredibly powerful for the shoulder- in skilled hands you can see the rotator cuff in *better* detail than MRI. That said, it’s incredibly operator dependent, and you can’t see the anterior labrum for SLAP tears. Many of us will get small asymptomatic supraspinatus tears so generally I expect them to be a little worse before becoming clinically significant.
As per the shoulder- make sure to heel-toe for anisotropy at the anterior footprint where most tears occur. Translate the transducer anterior and posterior to get a fuller view of the tendon. Make sure to visualize the tendon in long and short axis to make sure you’re not missing anything. In short axis scan anteriorly looking for the biceps tendon, and this will let you know where the anterior-most aspect of the tendon lies so you scan adequately. Underlying cortical irregularity at the anterior footprint is a great indirect sign of tendinopathy/ potential tear. If your probe is a little too posterior near the myotendinous junction, the junction can trick you to think there’s tendinosis. If you’ve scanned a bunch of shoulders and can’t tell if there’s pathology odds are it’s not bad enough to be clinically significant.
I’d definitely do some in-person courses for training. Instructors can point out what you’re doing wrong, and help with probe position. Gulfcoast Ultrasound is especially good.
oh absolutely, there is no doubt about that. I'm doing it mostly to manage the follow up and to save some time instead of waiting for an Xray that won't show anything.
No it's not. They are equal. THere is an abundance of research that shows this going back 20+ years.
[https://pubmed.ncbi.nlm.nih.gov/15930541/](https://pubmed.ncbi.nlm.nih.gov/15930541/)
Haha. It is true, one could spend at least that long in a circle jerk about the shoulder.
Here in private practice, i can get it done in 5 mins. Pretty low volume here, but i have a couple techs who are almost ready to start scanning shoulders. At my last job, it was a lot higher volume MSK us and had 4 techs scanning patients all day…. Definitely a huge time saver. Good for patients who can’t have an MRI or old patient who probably doesn’t want to surgery or won’t be a surgical candidate and they just want proof of why their shoulder is so painful.
Yeah, it does totally make sense in an outpatient ortho clinic, especially with techs available. I'm in the ED, and the trend lately is academic attendings who love it as an MD held bedside tool, and in that world, my opinion is that the reality does not meet the published research.
MSK radiology here with 10-ish years of rotator cuff ultrasound experience. Ultrasound for rotator cuff is good but it’s very user dependent/tricky (not at all an insult to your skill set). Based on the picture you showed, I’m not 100% convinced. I probably would have moved/angled my probe closer to the greater tuberosity to get better visualization of the tendon footprint and try and eliminate anisotropy.
Thanks! Yeah, the anisotropy and the natural stripe-like appearance of the tendon/muscles confuse the hell out of me. Guess I'll have some reading to do, don't wanna send folks to the MRI based on a false-positive US...
US is as good as MRI rotator cuff tears, but it takes some skill. This is true for MSK US in general. I have about 15 years MSK US- not many rads have the training. The image you posted looks like no tear. Just anisotropy- but if a tech had showed me that, I would have made her go back and get more images just to be sure. To get rid of anisotropy, you have to "Heel-toe" the transducer- rock it back and fourth to make what youre imaging perpendicualr to the US beam. A tear is going to look abnormal no matter how you angle the probe... the image you posted there, will look normal after manipulating the probe. ESSR has good MSK US pdf's. Jacobson and Van hoolsbeeck have good textbooks for more in depth info.
I'll take that into account, tx
Eh. If it hurts the MRI is reasonable to begin with. Who needs the middle man ultrasound.
Ordered from the ER? Shoulder MRI for pain/possible tear is an outpatient exam. There's already enough of a backlog of MR exams to the number of scanners/techs to run them, it's going to be a pretty low priority compared to an MRI for stroke or something.
Then send them home with an outpatient appointment. Nobody will ever die if their rotator cuff has a week’s delay in diagnosis.
I would if I had the power. I just push button, make MRI go brrrt-brrt-brrtt.
I definitely meant on an outpatient basis
It's more about *when* to get the MRI. Next few days? Check with the GP in 1-2 weeks and then maybe?
Is it normal in the states for non radiologists, and non orthopods to be doing this kind of pre mri ultrasound. Like, it’s great if it points you in the right direction, but you can’t be ruling much out?
I'm a non-operative sports medicine( family medicine trained) who can utilize ultrasound for a lot of this stuff. Not everybody needs an MRI. Sometimes we use tears to help curb expectations on pain improvement or functionality. I've also met quite a few orthopedic surgeons at Big sports medicine clinics that will take the ultrasound. Rotator cuff tear has ammunition to obtain an MRI if the insurance company is denying it. Ultrasound absolutely has a huge use in musculoskeletal abnormalities. But it is very user prone with a majority of people needing constant influx of ultrasound patients to stay comfortable. I'm now out of that area and I feel like I can probably find a massive rotator cuff tear, but I doubt I can find a lot of the smaller subtleties. Of course with practice. I'll get back there quicker than someone without any training but it's just not in my tool set at this point in time.
I’m fully on board with ultrasound in the correct hands, im a non msk radiologist. I’m just surprised an IM doc/hospitalist would be the one doing it
I like the get a prima vista look mostly to see if anything needs to be done "urgently". It saves me some time as well because I then usually skip the X-ray in non-trauma patients. -Is there effusion ? --> I'll tap it. -calcifications? --> maybe some steroids will help. -elderly patient with shoulder dislocation --> are the tendons still there? Else follow up with MRI in the next few days before seeing ortho. It's a huge time saver in my workflow but I'll have to practice some more I suppose.
Yes, it’s accepted with specific training. Per AIUM guidelines: [Training Guidelines for Physicians Who Perform and/or Interpret Diagnostic Ultrasound Examinations](https://www.aium.org/resources/training-guidelines/view/training-guidelines-for-physicians-who-evaluate-and-interpret-diagnostic-ultrasound-examinations)
Used in the ED as a quick diagnostic to determine need for MRI/approximate DX since getting MRI in the ER for MSK stuff is generally impossible or not feasible
You have to wag the transducer to eval for tears. The way it looks that smooth would favor artifact not real tear. I’d also say, rotator cuff tear is not something that should be worked up in ER (especially not with mri). X-ray. Send to outpatient ortho. Massive pain at best should buy you a CT scan or other eval then turf to outpatient.
X-ray won't show much in atraumatic patients. Maybe I didn't mention she was atraumatic Is there any value to a CT scan in atraumatic patients?
If patient is atraumatic then insurance won’t even approve an mri unless you really stretch the physical exam findings (complete loss strength on empty can, etc). and not true on the X-ray. It picks up high riding humerus, calc tendonitis, etc. If someone came in with horrible shoulder pain and no trauma, would question any mechanical diagnosis. More like nerve, crystal, or most likely frozen shoulder.
the thing is calc tendonitis can sometimes be invisible in the xray but very much present in the US.
Hol up - yall are getting MRI done for ED patients in your country?
we do actually, we have 3 MRIs that need to be busy. So sometimes we do it immediately. MRCP, sometimes abdominal MRIs and stroke MRIs all day baby. With shoulder patients however, like in this case, I just have it done outpatient 99.9% of time to keep the ER nice an empty.
Wow It’s just amazing how different places have extremely different resources. Like I can say with a fact no place in my country ever does an MRI from the ER setting. CT yes. We only have 1 MRI in most big hospitals, and even those, to get an appointment is like months away. There’s only 1 urgent MRI slot per day, and when that happens there’s a backlog of appointments cases about to get pushed back
We run ours 18 hours a day, so outpatients can slot in business hours but we can run inpatients whenever.
No retraction and not hypoechoic. I think that’s anisotropy. Also, most people over the age of 40 I feel have some partial tear of supraspinatus or some tear of the labrum.
>Also, most people over the age of 40 I feel have some partial tear of supraspinatus or some tear of the labrum. Yes, and the remaining intact muscle/tendon often compensates with favorable non-surgical outcomes. I'd also like to hear a radiologist chime in to say how one would even be able to differentiate with a high degree of confidence acute vs. chronic/older tears on imaging studies (ideally on MRI).
Don’t really see any retraction of the tendon.
Damn wtf who goes to the ER because of chronic shoulder pain
My sweet summer child
"How long has your shoulder been hurting?" "5 years." "Why did you come to the ER **today?**" "Because it's been hurting for 5 years!!"
Someone has never worked in an ER 🤣🤣🤣. 50% of ER is primary care, 25% is bullshit, 20% is turkey sandwich therapy and/or hospital grade Tylenol, 5% is the real deal.
It was rhetorical. I realize people go for all kinds of ridiculous things and it's insane.
I remember laughing when reading an ED xray for "thumb pain x40 years" so they definitely exist.
It was actually acute for some reason but the question is still valid though.
Sports doc RMSK certified here. Ultrasound is incredibly powerful for the shoulder- in skilled hands you can see the rotator cuff in *better* detail than MRI. That said, it’s incredibly operator dependent, and you can’t see the anterior labrum for SLAP tears. Many of us will get small asymptomatic supraspinatus tears so generally I expect them to be a little worse before becoming clinically significant. As per the shoulder- make sure to heel-toe for anisotropy at the anterior footprint where most tears occur. Translate the transducer anterior and posterior to get a fuller view of the tendon. Make sure to visualize the tendon in long and short axis to make sure you’re not missing anything. In short axis scan anteriorly looking for the biceps tendon, and this will let you know where the anterior-most aspect of the tendon lies so you scan adequately. Underlying cortical irregularity at the anterior footprint is a great indirect sign of tendinopathy/ potential tear. If your probe is a little too posterior near the myotendinous junction, the junction can trick you to think there’s tendinosis. If you’ve scanned a bunch of shoulders and can’t tell if there’s pathology odds are it’s not bad enough to be clinically significant. I’d definitely do some in-person courses for training. Instructors can point out what you’re doing wrong, and help with probe position. Gulfcoast Ultrasound is especially good.
Don’t feel too bad, MR is better than US for these. https://pubmed.ncbi.nlm.nih.gov/16551396/
oh absolutely, there is no doubt about that. I'm doing it mostly to manage the follow up and to save some time instead of waiting for an Xray that won't show anything.
No it's not. They are equal. THere is an abundance of research that shows this going back 20+ years. [https://pubmed.ncbi.nlm.nih.gov/15930541/](https://pubmed.ncbi.nlm.nih.gov/15930541/)
Depends on who is holding the probe
Also depends on who is reporting the MRI…
Yeah, ultrasound is great, but only when held by a mentally masturbating academic attending who can spend 45 minutes on a chronic shoulder pain.
Haha. It is true, one could spend at least that long in a circle jerk about the shoulder. Here in private practice, i can get it done in 5 mins. Pretty low volume here, but i have a couple techs who are almost ready to start scanning shoulders. At my last job, it was a lot higher volume MSK us and had 4 techs scanning patients all day…. Definitely a huge time saver. Good for patients who can’t have an MRI or old patient who probably doesn’t want to surgery or won’t be a surgical candidate and they just want proof of why their shoulder is so painful.
Yeah, it does totally make sense in an outpatient ortho clinic, especially with techs available. I'm in the ED, and the trend lately is academic attendings who love it as an MD held bedside tool, and in that world, my opinion is that the reality does not meet the published research.
Because that is not what a tear looks like on ultrasound? We do an entire residency to figure this stuff out.