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DOI: 10.1148/rg.262045719
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Right arrow Musculoskeletal Radiology
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US of the Rotator Cuff: Pitfalls, Limitations, and Artifacts1

Matthieu J. C. M. Rutten, MD, Gerrit J. Jager, MD, PhD and Johan G. Blickman, MD, PhD

1 From the Department of Radiology, Jeroen Bosch Hospital, Nieuwstraat 34, 5211 NL ‘s-Hertogenbosch, the Netherlands (M.J.C.M.R., G.J.J.); and the Department of Radiology, University Medical Center, Nijmegen, the Netherlands (J.G.B.). Presented as a refresher course at several RSNA Annual Meetings. Received July 28, 2004; revision requested September 22; final revision received August 26, 2005; accepted August 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Anisotropy. (a) Tendon fibers have a parallel arrangement. Emitted sound waves are optimally reflected when they are perpendicular (at 90°) to the long axis of the fibers. (b) Deviation of the insonating beam from this angle causes a decrease in the echogenicity of the fibers because not all of the reflected sound waves will return to the transducer.

 

Figure 1
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  		Figure 1b.  Anisotropy. (a) Tendon fibers have a parallel arrangement. Emitted sound waves are optimally reflected when they are perpendicular (at 90°) to the long axis of the fibers. (b) Deviation of the insonating beam from this angle causes a decrease in the echogenicity of the fibers because not all of the reflected sound waves will return to the transducer.

 

Figure 2
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  		Figure 2a.  Anisotropy at the insertion of the supraspinatus tendon. GT = greater tuberosity. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows that the fibers parallel to the transducer have a normal hyperechoic linear appearance (arrowheads). However, the fibers at the insertion (arrows) are poorly demonstrated due to anisotropy. (b) Corresponding image obtained with the transducer moved a bit laterally. The fibers at the supraspinatus tendon (SSP) insertion (arrows) are now parallel to the transducer and therefore have a normal hyperechoic appearance.

 

Figure 2
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  		Figure 2b.  Anisotropy at the insertion of the supraspinatus tendon. GT = greater tuberosity. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows that the fibers parallel to the transducer have a normal hyperechoic linear appearance (arrowheads). However, the fibers at the insertion (arrows) are poorly demonstrated due to anisotropy. (b) Corresponding image obtained with the transducer moved a bit laterally. The fibers at the supraspinatus tendon (SSP) insertion (arrows) are now parallel to the transducer and therefore have a normal hyperechoic appearance.

 

Figure 3
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  		Figure 3a.  Anisotropy. (a, b) Short-axis US scans of the long head of the biceps tendon (BT). (a) When the insonating beam is perpendicular to the tendon fibers, the tendon appears hyperechoic. It is round or oval and lies in the bicipital groove (BG). GT = greater tuberosity, LT = lesser tuberosity. (b) The tendon appears hypoechoic because the transducer is angled relative to the long axis of the tendon. (c, d) Long-axis US scans of the long head of the biceps tendon. (c) When the transducer is parallel to the tendon fibers, the tendon has a normal hyperechoic, linear, fibrillar appearance (arrows). (d) The tendon is not seen (arrows) due to anisotropy. Arrowheads = fibers parallel to the transducer.

 

Figure 3
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  		Figure 3b.  Anisotropy. (a, b) Short-axis US scans of the long head of the biceps tendon (BT). (a) When the insonating beam is perpendicular to the tendon fibers, the tendon appears hyperechoic. It is round or oval and lies in the bicipital groove (BG). GT = greater tuberosity, LT = lesser tuberosity. (b) The tendon appears hypoechoic because the transducer is angled relative to the long axis of the tendon. (c, d) Long-axis US scans of the long head of the biceps tendon. (c) When the transducer is parallel to the tendon fibers, the tendon has a normal hyperechoic, linear, fibrillar appearance (arrows). (d) The tendon is not seen (arrows) due to anisotropy. Arrowheads = fibers parallel to the transducer.

 

Figure 3
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  		Figure 3c.  Anisotropy. (a, b) Short-axis US scans of the long head of the biceps tendon (BT). (a) When the insonating beam is perpendicular to the tendon fibers, the tendon appears hyperechoic. It is round or oval and lies in the bicipital groove (BG). GT = greater tuberosity, LT = lesser tuberosity. (b) The tendon appears hypoechoic because the transducer is angled relative to the long axis of the tendon. (c, d) Long-axis US scans of the long head of the biceps tendon. (c) When the transducer is parallel to the tendon fibers, the tendon has a normal hyperechoic, linear, fibrillar appearance (arrows). (d) The tendon is not seen (arrows) due to anisotropy. Arrowheads = fibers parallel to the transducer.

 

Figure 3
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  		Figure 3d.  Anisotropy. (a, b) Short-axis US scans of the long head of the biceps tendon (BT). (a) When the insonating beam is perpendicular to the tendon fibers, the tendon appears hyperechoic. It is round or oval and lies in the bicipital groove (BG). GT = greater tuberosity, LT = lesser tuberosity. (b) The tendon appears hypoechoic because the transducer is angled relative to the long axis of the tendon. (c, d) Long-axis US scans of the long head of the biceps tendon. (c) When the transducer is parallel to the tendon fibers, the tendon has a normal hyperechoic, linear, fibrillar appearance (arrows). (d) The tendon is not seen (arrows) due to anisotropy. Arrowheads = fibers parallel to the transducer.

 

Figure 4
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  		Figure 4a.  Transducer position. D = deltoid muscle, H = humeral head. (a) Normal long-axis US scan of the supraspinatus tendon (SSP). GT = greater tuberosity. (b) Short-axis US scan of the supraspinatus tendon obtained too far laterally (at line 4b in a). At this position, the rotator cuff cannot be visualized between the humeral head and deltoid muscle, an appearance suggestive of a full-thickness tear of the supraspinatus tendon. (c) Normal short-axis US scan of the supraspinatus tendon (SSP), obtained at line 4c in a, shows the normal soft-tissue layers around the humeral head. c = hyaline cartilage.

 

Figure 4
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  		Figure 4b.  Transducer position. D = deltoid muscle, H = humeral head. (a) Normal long-axis US scan of the supraspinatus tendon (SSP). GT = greater tuberosity. (b) Short-axis US scan of the supraspinatus tendon obtained too far laterally (at line 4b in a). At this position, the rotator cuff cannot be visualized between the humeral head and deltoid muscle, an appearance suggestive of a full-thickness tear of the supraspinatus tendon. (c) Normal short-axis US scan of the supraspinatus tendon (SSP), obtained at line 4c in a, shows the normal soft-tissue layers around the humeral head. c = hyaline cartilage.

 

Figure 4
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  		Figure 4c.  Transducer position. D = deltoid muscle, H = humeral head. (a) Normal long-axis US scan of the supraspinatus tendon (SSP). GT = greater tuberosity. (b) Short-axis US scan of the supraspinatus tendon obtained too far laterally (at line 4b in a). At this position, the rotator cuff cannot be visualized between the humeral head and deltoid muscle, an appearance suggestive of a full-thickness tear of the supraspinatus tendon. (c) Normal short-axis US scan of the supraspinatus tendon (SSP), obtained at line 4c in a, shows the normal soft-tissue layers around the humeral head. c = hyaline cartilage.

 

Figure 5
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  		Figure 5.  Deltoid septum. Short-axis US scan of the supraspinatus tendon (SSP) in a normal volunteer shows hyperechoic lines (arrowheads) in the deltoid muscle (D), which represent septa of connective tissue. A posterior acoustic shadow (arrow) may appear when the insonating beam is perpendicular to the septa; such a shadow could be mistaken for a tear in the underlying tendon.

 

Figure 6
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  		Figure 6a.  Rotator cuff interval. (a) On a short-axis US scan of the supraspinatus tendon (SSP), the rotator cuff interval (RI) anterior to this tendon can easily be mistaken for a rotator cuff tear. BT = biceps tendon (long head), D = deltoid muscle, H = humeral head. (b) Oblique sagittal T1-weighted magnetic resonance (MR) arthrogram shows the position of the long head of the biceps tendon (BCP) in the rotator cuff interval. A = acromion, C = coracoid process, ISP = infraspinatus tendon, SSC = subscapular tendon, SSP = supraspinatus tendon.

 

Figure 6
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  		Figure 6b.  Rotator cuff interval. (a) On a short-axis US scan of the supraspinatus tendon (SSP), the rotator cuff interval (RI) anterior to this tendon can easily be mistaken for a rotator cuff tear. BT = biceps tendon (long head), D = deltoid muscle, H = humeral head. (b) Oblique sagittal T1-weighted magnetic resonance (MR) arthrogram shows the position of the long head of the biceps tendon (BCP) in the rotator cuff interval. A = acromion, C = coracoid process, ISP = infraspinatus tendon, SSC = subscapular tendon, SSP = supraspinatus tendon.

 

Figure 7
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  		Figure 7.  Supraspinatus-infraspinatus interface. Short-axis US scan of the supraspinatus tendon (SSP) shows normal thinning of the rotator cuff at the supraspinatus-infraspinatus (ISP) interface (arrows). There is a significant difference between the diameter at the interface and the normal rotator cuff diameter (arrowheads).

 

Figure 8
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  		Figure 8.  Musculotendinous junction of the subscapular tendon. Long-axis US scan of the subscapular tendon (SSC) shows varying echogenicity of the interdigitating hyperechoic tendinous fibers and hypoechoic muscle fibers (*), an appearance that mimics tendinosis or a rotator cuff tear.

 

Figure 9
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  		Figure 9a.  Fibrocartilaginous insertion. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows the hypoechoic appearance of the fibrocartilaginous attachment zone (arrowheads) near the greater tuberosity (GT). C = articular hyaline cartilage, H = humeral head. (b) Macroscopic section from the cadaver of a 78-year-old man shows the fibrocartilaginous insertion (arrowheads) of the supraspinatus tendon.

 

Figure 9
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  		Figure 9b.  Fibrocartilaginous insertion. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows the hypoechoic appearance of the fibrocartilaginous attachment zone (arrowheads) near the greater tuberosity (GT). C = articular hyaline cartilage, H = humeral head. (b) Macroscopic section from the cadaver of a 78-year-old man shows the fibrocartilaginous insertion (arrowheads) of the supraspinatus tendon.

 

Figure 10
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  		Figure 10a.  Tendon inhomogeneity. D = deltoid muscle, H = humeral head. (a) Short-axis US scan of the supraspinatus tendon (SSP) shows a hypoechoic appearance of the anterior part of the tendon (arrows) due to tendinosis. (b) Short-axis US scan of the supraspinatus tendon (SSP), obtained with a minor change in the angle of the insonating beam, shows near invisibility of the tendon due to a combination of tendinosis and anisotropy.

 

Figure 10
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  		Figure 10b.  Tendon inhomogeneity. D = deltoid muscle, H = humeral head. (a) Short-axis US scan of the supraspinatus tendon (SSP) shows a hypoechoic appearance of the anterior part of the tendon (arrows) due to tendinosis. (b) Short-axis US scan of the supraspinatus tendon (SSP), obtained with a minor change in the angle of the insonating beam, shows near invisibility of the tendon due to a combination of tendinosis and anisotropy.

 

Figure 11
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  		Figure 11.  Acoustic shadowing. Long-axis US scan of the subscapular tendon (SSC) shows scar tissue (arrows) in the deltoid muscle (D). The scar tissue produces an acoustic shadow (arrowheads) at the insertion of the tendon, an appearance that mimics tendinosis or a tear. LT = lesser tuberosity.

 

Figure 12
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  		Figure 12a.  Acoustic shadowing. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows calcification (arrows) in the subacromial-subdeltoid bursa. The calcification produces an acoustic shadow, which obscures visualization of the tendon insertion. D = deltoid muscle, H = humeral head. (b) Radiograph shows the calcification (arrows).

 

Figure 12
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  		Figure 12b.  Acoustic shadowing. (a) Long-axis US scan of the supraspinatus tendon (SSP) shows calcification (arrows) in the subacromial-subdeltoid bursa. The calcification produces an acoustic shadow, which obscures visualization of the tendon insertion. D = deltoid muscle, H = humeral head. (b) Radiograph shows the calcification (arrows).

 

Figure 13
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  		Figure 13.  Nondiastasis of ruptured tendon fibers. Long-axis US scan of the supraspinatus tendon (SSP) shows a full-thickness tear (arrows) in the anterior part of the tendon insertion. Note that the torn ends of the long-standing tear lie close together. There is hardly any fluid in the tendon defect to facilitate depiction.

 

Figure 14
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  		Figure 14a.  Proliferation of synovial tissue. (a) Arthroscopic image of the subacromial-subdeltoid bursa shows extensive proliferation of synovial tissue (arrows). (b) Short-axis US scan of the supraspinatus tendon (SSP) shows proliferating synovial tissue in the subacromial-subdeltoid bursa (*). The synovial tissue fills in several tendon defects (arrowheads), including a full-thickness rotator cuff tear (arrows).

 

Figure 14
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  		Figure 14b.  Proliferation of synovial tissue. (a) Arthroscopic image of the subacromial-subdeltoid bursa shows extensive proliferation of synovial tissue (arrows). (b) Short-axis US scan of the supraspinatus tendon (SSP) shows proliferating synovial tissue in the subacromial-subdeltoid bursa (*). The synovial tissue fills in several tendon defects (arrowheads), including a full-thickness rotator cuff tear (arrows).

 

Figure 15
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  		Figure 15.  Extensive chronic bursitis. Short-axis US scan of the supraspinatus tendon (SSP) shows thickened synovial bursal layers (B), which mimic a thickened rotator cuff tendon (ie, tendinosis).

 

Figure 16
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  		Figure 16.  Massive rotator cuff tear. Short-axis US scan shows a full-thickness tear of the supraspinatus tendon. The deltoid muscle (D) lies directly on the humeral head (H), thus mimicking the rotator cuff. * = long head of the biceps tendon in cross section.

 

Figure 17
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  		Figure 17.  Massive rotator cuff tear. Short-axis US scan shows a massive full-thickness tear of the supraspinatus tendon. The hypoechoic layer between the deltoid muscle (D) and humeral head (H) is intraarticular fluid (F). The deltoid muscle should not be mistaken for the rotator cuff. ST = subcutaneous tissue, * = long head of the biceps tendon in cross section.

 

Figure 18
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  		Figure 18a.  Soft-tissue layers around the humeral head. (a) Short-axis US scan of the normal supraspinatus tendon (SSP) shows three soft-tissue layers: the subcutaneous tissue (ST), deltoid muscle (D), and rotator cuff tendon. In each sonographic section of the shoulder, these layers can be visualized around the humeral head. (b) Diagram of a short-axis view of the normal supraspinatus tendon (SSP) shows the subcutaneous tissue (ST), deltoid muscle (D), and rotator cuff tendon around the humeral head (H). B = subacromial-subdeltoid bursa, BT = biceps tendon (long head), C = cutis, HC = hyaline cartilage.

 

Figure 18
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  		Figure 18b.  Soft-tissue layers around the humeral head. (a) Short-axis US scan of the normal supraspinatus tendon (SSP) shows three soft-tissue layers: the subcutaneous tissue (ST), deltoid muscle (D), and rotator cuff tendon. In each sonographic section of the shoulder, these layers can be visualized around the humeral head. (b) Diagram of a short-axis view of the normal supraspinatus tendon (SSP) shows the subcutaneous tissue (ST), deltoid muscle (D), and rotator cuff tendon around the humeral head (H). B = subacromial-subdeltoid bursa, BT = biceps tendon (long head), C = cutis, HC = hyaline cartilage.

 

Figure 19
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  		Figure 19a.  Massive full-thickness rotator cuff tears in two patients with rheumatoid arthritis. H = humeral head. (a) Short-axis US scan shows a tear of the supraspinatus tendon. Three layers are seen; the hypoechoic inner layer consists of fluid and pannus (large *). The deltoid muscle (D) could be mistaken for the rotator cuff. The hypoechoic zone in the deltoid muscle represents pannus (small *). (b) Long-axis US scan of the infraspinatus tendon (ISP). The intraarticular (*) and bursal (B) pannus could be mistaken for a rotator cuff. D = deltoid muscle, G = glenoid.

 

Figure 19
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  		Figure 19b.  Massive full-thickness rotator cuff tears in two patients with rheumatoid arthritis. H = humeral head. (a) Short-axis US scan shows a tear of the supraspinatus tendon. Three layers are seen; the hypoechoic inner layer consists of fluid and pannus (large *). The deltoid muscle (D) could be mistaken for the rotator cuff. The hypoechoic zone in the deltoid muscle represents pannus (small *). (b) Long-axis US scan of the infraspinatus tendon (ISP). The intraarticular (*) and bursal (B) pannus could be mistaken for a rotator cuff. D = deltoid muscle, G = glenoid.

 




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