development of statutory definitions of
6.4.1 Defining a Gypsy Report
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FIGURE 6B- SONOGRAPHIC IMAGE OF THE LONG HEAD OF THE BICEPS BRACHII TENDON WITHIN THE BICIPITAL GROOVE; SHORT-AXIS VIEW (SAX) AT THE LEVEL OF THE INTERTUBERCULAR SULCUS
FIGURE 6A–
PATIENT AND PROBE POSITIONING FOR EXAMINING THE LHBT IN SHORT-AXIS VIEW
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FIGURE 7B - SONOGRAPHIC IMAGE OF THE LONG HEAD OF THE BICEPS BRACHII TENDON (LHBT); LONG AXIS VIEW ( LAX ) AT THE LEVEL OF THE GREATER TUBEROSITY
FIGURE 7 A–
PATIENT AND PROBE
POSITIONING FOR EXAMINING THE LHBT IN LONG AXIS VIEW
LHBT
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The subscapularis (SCT) tendon was imaged next. The patient’s arm was further rotated externally to optimally visualize the tendon. The transducer was placed in a transverse orientation at the level of the lesser tuberosity and moved medially along the long axis of the tendon (Figure 8). Internal and external rotation of the arm helped confirm that the tendon was intact. The transducer was then turned 90° to view the tendon fibres perpendicular to their long axis (Figure 9). This view was useful to diagnose superior partial- or full-thickness tears.
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FIGURE 8B - SONOGRAPHIC IMAGE OF THE SUBSCAPULARIS TENDON; LONG AXIS VIEW AT THE LEVEL OF THE LESSER TUBEROSITY
FIGURE 8A-
PATIENT AND PROBE POSITIONING FOR EXAMINING THE
SUBSCAPULARIS TENDON IN LONG AXIS VIEW
SUBSCAPULARIS TENDON
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FIGURE 9B - SONOGRAPHIC IMAGE OF THE SUBSCAPULARIS TENDON; SHORT AXIS VIEW AT THE LEVEL OF THE LESSER TUBEROSITY
FIGURE 9A-PATIENT AND PROBE POSITIONING FOR EXAMINING THE SUBSCAPULARIS TENDON IN SHORT AXIS VIEW
SUBSCAPULARIS TENDON
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The supraspinatus (SST) tendon was scanned on an anterior view of the shoulder (Figure 10) with the patient seated, facing the operator. The patient’s arm was extended posteriorly, with the dorsal hand on the opposite iliac wing (Crass Position) or the palmar hand on the ipsilateral iliac wing (Modified Crass or Middleton Position). The cuff was evaluated from the most lateral aspect of the greater tuberosity where it inserts to as far medially as possible to ensure that more medial mid-substance tears were not missed. The transducer was also compressed against the deltoid muscle to detect any non-retracted tears. The transducer was then turned 90° to visualize the cuff in short-axis orientation (Figure 11). This view was used to measure the width and determine the location of a cuff tear.
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FIGURE 10B – SONOGRAPHIC IMAGE SHOWING THE BIRD BEAK APPEARANCE OF THE SUPRASPINATUS TENDON IN LONG AXIS VIEW AT THE LEVEL OF THE GREATER TUBEROSITY FIGURE 10A- PATIENT AND PROBE POSITIONING FOR EXAMINING THE SUPRASPINATUS TENDON IN THE CRASS (LEFT) AND MODIFIED CRASS OR MIDDLETON (RIGHT) POSITIONS;
LONG AXIS VIEW
SUPRASPINATUS TENDON
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FIGURE 11B – SONOGRAPHIC IMAGE OF THE SUPRASPINATUS TENDON; SHORT AXIS VIEW AT THE LEVEL OF THE GREATER TUBEROSITY
FIGURE 11A- PATIENT AND PROBE POSITIONING FOR EXAMINING THE SUPRASPINATUS TENDON IN THE CRASS (LEFT) AND MODIFIED CRASS OR MIDDLETON (RIGHT) POSITIONS; SHORT AXIS VIEW
SUPRASPINATUS TENDON
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Next, the posterior glenohumeral joint and the posterior aspect of the infraspinatus tendon (IST) were evaluated with the patient’s arm in front of the body, flexed and adducted to rest on the contralateral shoulder (Figure 12).
The diameters of the supraspinatus and infraspinatus tendons were determined as a mean of three measured values, at intervals of 1 cm, on the transverse scans of the tendons. The diameter of the long head of biceps tendon was obtained by measuring the width of the LHBT in the bicipital groove on short-axis scan.105 Its diameter in long-axis view was taken as a mean of three values measured 1, 3 and 5 cm proximal to its musculo-tendinous junction.106 The depth of the bicipital groove (Intertubercular Sulcus) was measured from anterior to posterior on short-axis view of the groove and LHBT.
The subscapularis tendon diameter was obtained on anterior long axis view with the shoulder in maximum external rotation, at a point 2 cm medial to biceps tendon. Caliper placement for measurement of the tendons excluded the articular cartilage. Subdeltoid bursa thickness was measured on longitudinal view at its point of maximum diameter.107
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FIGURE 12B – SONOGRAPHIC IMAGE OF THE INFRASPINATUS TENDON, LONG AXIS VIEW AT A LEVEL JUST INFERIOR AND PARALLEL TO THE SPINE OF SCAPULA
FIGURE 12A– PATIENT AND PROBE POSITIONING FOR EXAMINING THE
INFRASPINATUS TENDON IN LONG AXIS VIEW
INFRASPINATUS TENDON DELTOID MUSCLE
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The shoulder subluxation distance was measured by determining the Acromion-Greater Tuberosity Distance (AGTD). The patient was seated with their hips and knees flexed to 90° and feet resting flat on the ground. The shoulder was in neutral rotation, with the elbow at 90° of flexion and forearm in pronation. The forearms were rested on a pillow (placed on the patient’s lap), but the elbow itself remained unsupported to ensure that the shoulder girdle was not elevated. Once in this position, the lateral border of the acromion was palpated, and the ultrasonographic transducer head placed over the acromion along the vertical/longitudinal axis of the humerus to scan the shoulder. These two bony reference points were then identified on the frozen image, and the AGTD measured from the lateral edge of the acromion process of scapula to the nearest margin of the superior part of greater tuberosity of the humerus (Figure 13). A dark linear acoustic shadow beneath the acromion helped to identify its lateral edge. The supraspinatus tendon which is normally clearly visible as a thick band (acoustic hyperechoic appearance) at its point of insertion facilitated identification of the greater tuberosity. To allow for normal anatomic variation, the shoulder subluxation ratio was also determined as the ratio of the ultrasonographic AGT distance measurement in the affected shoulder divided by that in the unaffected shoulder of the stroke patients.49-51 In the controls, the corresponding ratio was obtained by dividing the larger AGTD measurement by the smaller.
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FIGURE 13B– SONOGRAPHIC IMAGE SHOWING THE ACROMION – GREATER TUBEROSITY DISTANCE (AGTD) MEASUREMENT
EDGE OF ACROMION
APEX OF GREATER TUBEROSITY
FIGURE13A – PATIENT AND PROBE POSITIONING FOR MEASURING THE ACROMION – GREATER TUBEROSITY DISTANCE (AGTD)
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Sonographic evaluation for the presence of adhesive capsulitis was done by measuring the thickness of the coracohumeral ligament (CHL). Studies have shown that the coracohumeral ligament (CHL) is thickened in adhesive capsulitis.44, 46 The CHL appears as a thick, homogeneously echogenic band of tissue that covers the LHBT; and can be differentiated from the LHBT because it is less anisotropic.108 The coracohumeral ligament was assessed in the rotator interval, which was optimally visualized in the oblique plane with the patient’s fist held by the side45 (Figure 14). The maximal thickness of the CHL was obtained.
All examinations were performed by me to eliminate interobserver errors. Each dimension was measured three times and the average recorded for analysis.
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FIGURE 14B – SONOGRAPHIC IMAGE OF THE CORACOHUMERAL LIGAMENT (CHL) IN THE ROTATOR CUFF INTERVAL
FIGURE 14A-– PATIENT AND PROBE POSITIONING FOR EXAMINING THE CORACOHUMERAL LIGAMENT IN THE ROTATOR CUFF INTERVAL
CHL
LHBT
61 Sonographic Criteria
The sonographic criteria were as described by other authors: 28, 33, 57, 60, 70
1. Sonographic findings for a full-thickness rotator cuff tear were non-visualization or absence of cuff tissue, a full-thickness hypoechoic defect (discontinuity in the normal homogeneous echogenicity of the cuff), visualization of the underlying hyaline cartilage (or naked tuberosity), heterogeneously hypoechoic cuff with bursal fluid, replacement of normal homogeneous echogenicity by a central echogenic band and herniation of the deltoid muscle or SASD bursa into the cuff.
2. The signs suggestive of a partial-thickness cuff tear were a heterogeneous tendon with hypoechoic areas (> 3 mm) that did not reach both sides of the tendon or a large linear echogenic focus within the cuff substance (i.e., a purely intrasubstance tear) and a hypoechoic defect that involves the articular or bursal surface, i.e. either a hypoechoic or an anechoic cleft within the tendon with bursa or articular extension in both the longitudinal and transverse planes.
3. Biceps tendinosis was considered as decreased echogenicity and enlargement of the biceps tendon more than 8mm. Tendinosis of the rotator cuff was defined as hypoechoic and swelling changes, with a difference in tendon thickness > 2 mm in comparison with the healthy side. The term “tendinosis” (or “tendinopathy”) has superseded the term “tendinitis” as studies have shown the absence of active inflammation in these conditions. Tendinosis appeared as a focal or diffuse, poorly demarcated hypoechoic regions accompanied by tendon swelling or enlargement, and an increase of the interfibrillar distance in the absence of border
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defect. The presence of an internal fibrillar pattern and the lack of tendon atrophy differentiated tendinosis from partial tears.
4. An anechoic area (> 2 mm) surrounding the long head of the biceps tendon (LHBT) in transverse view or a anechoic/hypoechoic crescent deep to the LHBT in longitudinal views was interpreted as effusion in the biceps tendon sheath.
5. If fluid accumulation was observed in the SASD bursa, with an increased thickness of greater than 2 mm, bursitis was confirmed.
6. Calcification was diagnosed as small or large echogenic foci within the tendon that are point-shaped or arc-shaped, with or without an acoustic shadow.
7. AGTD for shoulder subluxation was interpreted relative to the contralateral shoulder. The normal AGTD is 1.91 – 2.84cm; with the average normal difference between shoulders of 0.21cm (range = 0 – 0.36cm). 109 AGTD difference > 0.5 cm indicated presence of subluxation.
8. Coracohumeral ligament thickness > 3 mm indicated presence of adhesive capsulitis. The documented normal thickness in literature is 1 – 3 mm.44, 46,108
The numbers of abnormal sonographic findings in each shoulder were counted. Each abnormal ultrasound (USS) finding was assigned a score of one (1) if present or zero (0) if absent. Thus, LHBT effusion, SASD effusion, subluxation, and adhesive capsulitis scored one each when present. Tendon tear, tendinosis, and tendon degeneration were similarly scored for each of the four tendons examined per shoulder. The sum of these scores yielded the raw ultrasound (USS) score92,93 such that the minimum score was zero (normal examination) while the maximum score was 16. A score of 1, 2, 3, etc. meant that 1, 2, 3, etc. abnormal sonographic findings were present in that particular shoulder.
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The raw USS scores were then classified/grouped into graded USS scores92 such that 0, 1-2, 3-4, 5-6, and more than 6 abnormal sonographic findings represented normal shoulder, mild damage, moderate damage, severe damage, and intense damage respectively. Furthermore, the hemiplegic shoulders were grouped into two based on MRC scale scores: poor motor status (score = 0 – 2) and good motor status (score = 3 – 5).60,94
Data Analysis
The data were reported as mean and standard deviation (mean ± SD) for continuous variables, while categorical and dichotomous variables were reported as frequencies and percentages. The mean tendon thicknesses and other metric sonographic measurements were compared using the independent samples t test for normally distributed variables and the Mann-Whitney U test for skewed variables. Chi square analysis was performed to detect differences in the prevalence of abnormal sonographic findings such as effusion, tendon tear, degeneration, etc. between hemiplegics and controls. One-way analysis of variance (ANOVA) was used to compare means of variables across age groups. The related paired samples t test was used to compare means of measurements in the hemiplegic and unaffected shoulders of hemiplegics, while the McNemar chi square test was applied to compare the prevalence of abnormal findings in the hemiplegic and unaffected shoulders of hemiplegics. Pearson’s correlation was also carried out to evaluate any linear relationship between age, tendon thicknesses and other metric sonographic measurements. Statistical significance was defined as P < 0.05. Analysis was done using the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) software, version 20.0 for windows.
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