Lennard Funk is a consultant shoulder and upper limb surgeon and honorary clinical lecturer at Salford Royal Hospitals and the University of Manchester. He is also an upper limb surgeon and co-director of the Manchester Sports Medicine Clinic, a private practice that he runs together with a sports physician and two other orthopaedic surgeons. He specialises in arthroscopic (keyhole) and minimally invasive surgery of the shoulder and elbow, as well as general upper limb surgery and trauma. His particular interests include shoulder dislocations, frozen shoulder, arthritis, stiff elbows and sports injuries of the shoulder.
Nearly six million people a year in the UK visit a doctor because of shoulder sprain, strain, dislocation or other shoulder problem. The shoulder joint's mobility makes it prone to injury and frequent overhead movements or sudden trauma can damage tissues within the shoulder, causing pain, tenderness, weakness, instability and limitation of movement in the joint.
The most common shoulder injuries seen at the Manchester Sports Medicine Clinic (MSMC) are impact and contact injuries, usually in rugby players. Chronic shoulder injuries are also very common, specifically in swimmers, overhead athletes such as tennis and badminton players, and wheelchair athletes. Many of these injuries involve damage to the rotator cuff, a sleeve of muscle that surrounds the shoulder joint and is primarily responsible for most shoulder movements. With age, the rotator cuff tendons degenerate and become more prone to acute injury after an impact. It is currently believed that it is better to repair rotator cuff tears as soon as possible in order to maximise restoration of function.
Ultrasound is a particularly useful imaging tool when examining muscle and tendon injuries, particularly of the shoulder. By performing 'office' shoulder ultrasound during clinical examinations, patients can be instantly scanned at the first clinic appointment, providing an immediate, one-stop diagnosis and assessment that allows quicker treatment and recovery. It also helps surgeons to plan their patient management, and reduces costs, such as those incurred by a radiology report, by the patient taking additional days off work and the cost of clinicians' time. Traditionally, ultrasound of the shoulder has been carried out by radiologists in the UK and USA, although in mainland Europe it has been done by surgeons and clinicians. However, recent advances in ultrasound technology, particularly the development of small, portable ultrasound instruments with rapidly improving resolutions, and the increasing awareness and availability of training courses, have made the approach more accessible for clinicians.
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| Figure 1: Ultrasound scans of full thickness rotator cuff tear (supraspinatus) |
Ultrasound helps to diagnose a number of rotator cuff pathologies in the shoulder, especially complete rotator cuff tears, which can be well visualised (Fig 1). Rapid assessment and diagnosis of these injuries is critical, since rotator cuff tears generally get bigger with time, so the longer a patient waits for repair, the more difficult the surgery might be and the longer the projected recovery time. Direct signs of complete tears include flattening of the superficial border of the tendon (the normal tendon is convex); a hypoechoic zone separating the tendon edges; absence of the normal tendon, replaced by a thin hypoechoic line representing the hypertrophic bursa surrounding the greater tuberosity; and flattening of the tendon in response to a compression test (the intact cuff cannot be compressed). A number of indirect signs of rotator cuff tears can also be seen, such as effusion around the long head of the biceps tendon; double effusion where joint effusion is seen around the biceps tendon and subacromial subdeltoid bursitis; deltoid herniation, where the deltoid muscle bulges deeply into the gap of the rotator cuff; and muscle atrophy. Partial rotator cuff tears can also be depicted with ultrasound, but the accuracy is lower than that for complete tears. An audit of the MSMC's ultrasound use in 2006 demonstrated 92 per cent sensitivity for complete rotator cuff tears and 86 per cent sensitivity for partial tears, in 64 patients.
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