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(Radiology. 2001;219:29-34.)
© RSNA, 2001

Musculoskeletal Imaging

Role of US in the Preoperative Evaluation of Patients with Anterior Shoulder Instability1

Mariann V. Hammar, MD, Göran B. Wintzell, MD, PhD, K. Gunnar O. Åström, MD, PhD, Sune Larsson, MD, PhD and Anders Elvin, MD, PhD

1 From the Departments of Radiology (M.V.H., K.G.O.A., A.E.) and Orthopedic Surgery (G.B.W., S.L.), University Hospital (Akademiska sjukhuset), 751 85 Uppsala, Sweden. From the 1999 RSNA scientific assembly. Received October 14, 1999; revision requested November 23; final revision received July 17, 2000; accepted August 2. Address correspondence to M.V.H. (e-mail: s.hammar@telia.com.)


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To assess the value of ultrasonography (US) in the preoperative evaluation of patients with anterior shoulder instability.

MATERIALS AND METHODS: Twenty-two patients with one-sided anterior shoulder instability were examined with US by using three dynamic scanning approaches: two frontal and one axillary. The anterior labrum, the anterior ligamental-capsular complex, and the presence of humeral head and glenoid rim fractures were evaluated. Arthroscopy or arthrotomy was subsequently performed in all patients and was considered the standard.

RESULTS: US correctly depicted the presence (n = 20) or absence (n = 1) of humeral head fractures and the presence (n = 10) or absence (n = 9) of glenoid rim fractures. All 22 patients had anterior labral tears; 21 tears were correctly depicted with US. The labral tear was seen as a hypoechoic zone larger than 2 mm (n = 15), labral movement (n = 10), a degenerated labrum (n = 6), or a vacuum phenomenon (n = 3). The anterior ligamental-capsular complex was correctly evaluated in 14 patients. The use of multiple approaches helped to prevent misinterpretation, but there were no substantial differences among the approaches in the depiction of the anterior shoulder structures.

CONCLUSION: The high accuracy in the depiction of labral tears and associated fractures indicates that US can provide useful preoperative information in patients with anterior shoulder instability.

Index terms: Shoulder, abnormalities, 41.42, 41.43, 41.48 • Shoulder, injuries, 41.41, 41.42, 41.43, 41.48 • Shoulder, US, 41.1298 • Ultrasound (US), comparative studies


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Anterior shoulder dislocation with persistent instability is a debilitating condition that primarily affects young active people. In most patients with recurrent dislocation, the initial injury is caused by some kind of trauma.

Reliable diagnostic imaging is mandatory not only for establishing a correct diagnosis but also for evaluation when different treatment options are considered. Imaging is especially important when clinical findings are contradictory or sparse.

Magnetic resonance (MR) arthrography is considered to be the most sensitive technique in the depiction of labral tears and capsular damage, including damage to the superior, middle, and inferior glenohumeral ligaments (1–3). Although MR arthrography can provide valuable images, there are several drawbacks with this technique. MR arthrography is an invasive, time-consuming, and expensive technique. Furthermore, in patients with severe shoulder instability, there might also be a problem with pain if they try to adopt shoulder positions that are known to be beneficial for diagnostic imaging of unstable shoulders (4–6).

Ultrasonography (US) is an inexpensive, dynamic, fast, and easily accessible method. US has been shown (7–9) to be useful in the evaluation of shoulder abnormalities, such as complete rotator cuff tears. The usefulness of US in patients with partial-thickness tears (10), shoulder instability (11), humeral head fractures (11,12), and anterior labral tears (13) has recently been reported. However, the ability of US to depict and allow characterization of glenoid rim fractures, labral tears, and, especially, ligamental-capsular injuries is not thoroughly documented.

The aim of this study was to determine the value of US by using three US scanning approaches in the preoperative evaluation of patients with persistent anterior shoulder instability after recurrent shoulder dislocations and to compare these findings with those of arthroscopy and/or arthrotomy.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Preoperative US was performed in 22 patients (16 men, six women; age range, 20–40 years; mean age, 27 years) with a clinical history of persistent one-sided anterior instability following repeated dislocations due to trauma or sports-related injuries. All patients were consecutively included by an orthopedic shoulder surgeon (G.B.W.) and had clinical findings indicating anterior instability, with positive apprehension and relocation test findings (14).

The examination was performed with a 9-MHz linear transducer and a 5-MHz curved-array transducer (Elegra; Siemens, Seattle, Wash). Our university ethics committee indicated that its approval was not required. Oral informed consent was obtained (G.B.W.) from all patients.

All patients were examined by two investigators together (A.E., M.V.H.) by using three scanning approaches.

The first approach was the anterior transverse approach performed with the patient’s arm in an adducted position and with the patient sitting with the hands on the thighs. This static evaluation was followed by a dynamic examination of the shoulder during internal and external rotation with the arm still adducted. The internal rotation was achieved by placing the lower arm behind the lower back (7,11,15).

The second approach was the anterior transverse approach with the patient supine and the arm abducted 90°, with 90° flexion in the elbow and the forearm directed at the ceiling with 0° external rotation. Dynamic assessments were performed (a) during increasing external rotation from 0° to maximal tolerable external rotation—the dynamic apprehension test position (3,4,6) (Fig 1)—and (b) during back and forth rotation between approximately 25° internal rotation and 75° external rotation.



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  		Figure 1. Dynamic anterior apprehension test scanning approach with the patient in supine position and the arm in maximal external rotation.

 
The third approach was the axillary transverse approach (probe in a transverse position to the anterior inferior part of the glenoid) with the patient and the arm in the same position as in the second approach. This approach included the dynamic assessments described previously in the second approach (Fig 2).



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  		Figure 2. Dynamic axillary apprehension test scanning approach with the patient in supine position and the arm in maximal external rotation.

 
The anterior and posterior labrum and anterior capsular complex (including the capsule and anterior ligaments), as well as the presence of fractures in the bony structures (humeral head fractures and glenoid rim fractures) were evaluated. US findings were evaluated by consensus (A.E., M.V.H.) according to a specific protocol, without the radiologist knowing the results of previous radiologic or clinical examinations other than those stated in the inclusion criteria.

The criterion for a humeral head fracture was flattening of the convexity of the posterosuperior profile of the humeral head or a notched defect (11,12) in the humeral head located above the level of the coracoid process.

The criterion for glenoid rim fracture was a defect or irregularity in the cortical structure and/or bony structure of the anterior inferior part of the glenoid. By irregularity, we meant asymmetry or jaggedness compared with the other side. By involvement of the bony structure, we meant that the defect also involved subcortical bone (Fig 3).



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  		Figure 3. Transverse US image obtained with the second scanning approach shows a V-shaped bony defect (solid arrow) at the anterior inferior part of the glenoid, which was verified arthroscopically as a glenoid rim fracture. Adjacent to the bony defect is a hematoma (open arrow). Arrowheads indicate the humeral head.

 
A labral tear was defined as the presence of a hypoechoic zone larger than 2 mm at the base of the labrum (Fig 4). Other criteria were the vacuum phenomenon (gas) between the glenoid and the labrum, the absence of a labrum, a degenerated labrum (Fig 5), or movement of the labrum when dynamic examination was performed. The criterion for a degenerated labrum was a small anterior labrum, with an altered configuration, that was smaller than the ipsilateral posterior labrum and smaller than the anterior labrum on the normal side (16,17). Subjectively, the visibility of labral tears was graded for each of the three scanning approaches as follows: 0 was not visible, 1 was visible, and 2 was easily visible (Table 1).



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  		Figure 4a. Transverse US images show examples of a labral tear with hypoechoic zones larger than 2 mm at the labral base (straight solid arrow). The tears were verified with arthroscopy. (a) Image obtained with the first scanning approach in a 27-year-old woman with a 2.2-mm hypoechoic zone at the labral base. The labrum (curved arrow) is small. Arrowheads indicate the humeral head, the open arrow indicates the glenoid. (b) Image obtained with the second scanning approach in a 25-year-old man with a 2.5-mm hypoechoic zone at the labral base (between the crosshairs). The size of the labrum (arrowhead) is normal. (c) Image obtained with the second scanning approach in a 26-year-old man with a 3.9-mm hypoechoic zone at the labral base.

 


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  		Figure 4b. Transverse US images show examples of a labral tear with hypoechoic zones larger than 2 mm at the labral base (straight solid arrow). The tears were verified with arthroscopy. (a) Image obtained with the first scanning approach in a 27-year-old woman with a 2.2-mm hypoechoic zone at the labral base. The labrum (curved arrow) is small. Arrowheads indicate the humeral head, the open arrow indicates the glenoid. (b) Image obtained with the second scanning approach in a 25-year-old man with a 2.5-mm hypoechoic zone at the labral base (between the crosshairs). The size of the labrum (arrowhead) is normal. (c) Image obtained with the second scanning approach in a 26-year-old man with a 3.9-mm hypoechoic zone at the labral base.

 


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  		Figure 4c. Transverse US images show examples of a labral tear with hypoechoic zones larger than 2 mm at the labral base (straight solid arrow). The tears were verified with arthroscopy. (a) Image obtained with the first scanning approach in a 27-year-old woman with a 2.2-mm hypoechoic zone at the labral base. The labrum (curved arrow) is small. Arrowheads indicate the humeral head, the open arrow indicates the glenoid. (b) Image obtained with the second scanning approach in a 25-year-old man with a 2.5-mm hypoechoic zone at the labral base (between the crosshairs). The size of the labrum (arrowhead) is normal. (c) Image obtained with the second scanning approach in a 26-year-old man with a 3.9-mm hypoechoic zone at the labral base.

 


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  		Figure 5. Transverse US image obtained with the third scanning approach shows a small degenerated labrum (straight solid arrow) with a large zone (open arrow) at the base, which indicates a labral tear (verified with arthroscopy). The arrowhead indicates the glenoid, and the curved arrow indicates the humeral head.

 

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  		TABLE 1. Signs of Anterior Labral Tears during Subjective Evaluation of Three Dynamic Scanning Approaches
 
The criterion for anterior ligamental-capsular rupture was a discontinuity or irregular texture of the anterior capsular complex. Furthermore, an irregular movement of the complex was considered a sign of rupture.

The corresponding anterior structures in the contralateral normal shoulder were scanned by using all three approaches described previously for comparison in all patients.

The posterior labrum on the ipsilateral side was also scanned for comparison. With the patient still sitting after the evaluation of the humeral head for fractures (first scanning approach), the transducer was moved posteriorly, and the posterior labrum was evaluated. The posterior labrum was not evaluated with dynamic movement of the arm.

Twelve patients underwent arthroscopy; three, arthrotomy; and seven, arthroscopy directly followed by arthrotomy. Arthroscopy and/or arthrotomy was performed (G.B.W.) within 2 weeks to 8 months after US (mean, 3.4 months; SD, 1.8) and was considered the standard. None of the patients had a history of new symptoms or dislocations between US and arthroscopic examinations.

Statistical analyses included determination of the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy. The positive predictive value was calculated as the number of true-positive results divided by the number of true-positive and false-positive results. The negative predictive value was calculated as the number of true-negative results divided by the number of true-negative and false-negative results. Sensitivity was calculated as the number of true-positive results divided by the number of true-positive and false-negative results. Specificity was calculated as the number of true-negative results divided by the number of true-negative and false-positive results. Accuracy was calculated as the number of true-negative and true-positive results divided by the total number of results.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
US correctly depicted the presence of a full anterior labral tear in 21 of 22 patients. Sensitivity was 0.95, and accuracy was 0.95. One finding was false-negative; a humeral head fracture and an undetected full labral tear occurred in the same patient.

In the 22 patients, 34 findings consistent with full labral tear were observed. Fifteen patients had a hypoechoic zone larger than 2 mm at the base (range, 2.1–3.9 mm), 10 had movement of the labrum during dynamic examination, six had a small degenerated anterior labrum, and three had a vacuum phenomenon at the labral base. In six patients, the most common combination of pathologic findings was a zone larger than 2 mm at the base and labral movement (Table 1). In none of the patients was the anterior labrum absent.

The anterior ligamental-capsular complex was correctly evaluated with US in 14 of 22 patients. In two of eight patients in whom the ligamental-capsular complex was erroneously assessed, the labrum was detached from the glenoid. Because fluid was present outside the capsular structures, the presence of the fluid was misinterpreted as a ligamentous rupture (Fig 5). Four other findings were false-positive and one was false-negative for ligamentous rupture. In one patient, a vacuum phenomenon prevented depiction of the ligamentous structures (Table 2).


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  		TABLE 2. Depiction of Findings: US Compared with Arthroscopy and/or Arthrotomy
 
US correctly depicted the presence of a humeral head fracture in 20 of 21 patients, and a fracture was correctly excluded in one patient. One finding was false-negative. The positive predictive value was 1.0, the negative predictive value was 0.5, sensitivity was 0.95, specificity was 1.0, and accuracy was 0.95.

A glenoid rim fracture was correctly depicted as being present in 10 patients and absent in nine. The findings in three patients were false-positive. The positive predictive value was 0.77, the negative predictive value was 1.0, sensitivity was 1.0, specificity was 0.75, and accuracy was 0.86.

No findings for full labral tear described herein were identified in the ipsilateral posterior labrum or in the anterior labrum of the contralateral side. In none of the normal shoulders did we find signs of anterior ligamental-capsular rupture, humeral head fracture, or glenoid rim fracture.

The results of subjective evaluation of the labrum in the three scanning approaches is shown in Table 1. The use of multiple scanning approaches provided complementary information that helped to prevent false-negative results. There were no major differences between the three scanning approaches. The position in the first approach (anterior approach with the arm adducted) was the best position for depicting humeral head fractures, while the positions in the second and third approaches (anterior and axillary approaches with the arm in the dynamic apprehension test position) provided the best views for depiction of glenoid rim fractures.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Persistent shoulder instability is usually treated surgically. The success of the procedure is to a large extent dependent on a precise understanding of the direction of instability and the degree of soft-tissue injury. In a large proportion of patients with anterior shoulder instability, a correct diagnosis can be achieved with a combination of medical history taking, clinical evaluation, and plain radiography. However, in some patients, symptoms are subtle, or there is a discrepancy between the clinical findings and symptoms. In these patients, it is important to improve the diagnostic accuracy before the method of treatment is selected.

The patients included in the present study consisted of a highly selected group of younger patients with a fairly clear-cut histories and clinical findings that indicated unilateral anterior shoulder instability. This study design was deliberately chosen because our main aim was to determine whether US could be used to identify abnormal findings associated with recurrent shoulder dislocations and persistent instability. This study design meant that the probability for positive findings of a labral tear was high and that the focus was obviously on determining the sensitivity of the method. Thus, we did not calculate any positive predictive value for that diagnosis. However, the presence of humeral head fractures and glenoid rim fractures could not be deduced from the clinical history. The present study revealed high diagnostic accuracy for the diagnosis of those injuries, which indicated the valuable diagnostic capabilities of US in the evaluation of anterior shoulder instability.

At present, when detailed pathologic information is needed, diagnostic arthroscopy, computed tomographic (CT) arthrography, and MR arthrography are the most commonly used techniques for the evaluation of unstable shoulders. MR arthrography has proved to be superior to other imaging techniques in the evaluation of the glenohumeral ligaments, labrum, and biceps-labral complex (2,17). The use of intraarticular contrast medium and placement of the arm in the abduction and external rotation position (the arm is abducted with the palm behind the head, which provide a moderate external rotation) (4) or the apprehension test position (6) provide improved access to the anterior labrum and the inferior glenohumeral ligament. The major drawbacks with the arthrographic techniques are that they are invasive, time-consuming, and expensive. Some patients cannot be examined with MR imaging due to various causes, such as claustrophobia or the presence of a pacemaker or ferromagnetic aneurysm clips.

One major advantage of US is the possibility to examine the shoulder structures during movement and to almost contemporaneously compare the findings of the symptomatic side with those of the asymptomatic side. Furthermore, the cost of US is a fraction of that of MR imaging or CT arthrography.

In our study, we combined the experience from former US studies (7–11,15) and MR studies (3–6) in shoulder positioning. Our aim was to evaluate alternative approaches that could facilitate the assessment of the shoulder structures in patients with recurrent anterior shoulder instability. If US could be shown to be reliable in depicting abnormality in unstable shoulders, it might perhaps replace MR imaging as a primary diagnostic tool.

When the humeral head was examined for a fracture, the anterior approach with the arm in adducted position was most useful. This result is supported in other articles (11,12) describing high sensitivity (95%) and specificity (93%) with US. In one patient, a full labral tear and a humeral head fracture were missed. This patient was examined early in the series of patients, and the missed abnormal findings were attributed to the learning curve. When the anterior rim of the glenoid was examined for a fracture, all three approaches were needed to decide whether there was a fracture. Still, the best position of the arm was the dynamic apprehension test position. There was no obvious difference between the anterior and axillary positions of the transducer.

The anterior ligamental-capsular complex was assessed as a unit because of the difficulties in separating the superior, middle, and inferior ligaments from each other and, in most cases, from the capsule (Fig 6). In particular, the existence of extracapsular fluid (Fig 7) increased these difficulties. In difficult cases, the homogeneity of the movements of the ligamental-capsular complex helped us in the assessment of rupture.



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  		Figure 6a. Transverse US images show examples of the anterior ligamental-capsular complex. (a) Image obtained with the third scanning approach in a 20-year-old woman. The anterior ligamental-capsular complex (solid arrows) was assessed as a unit. The arrowhead points to a small degenerated labrum with a 1.8-mm hypoechoic zone (open arrow) at the base. A labral tear was diagnosed at arthroscopy. (b) Image obtained with the second scanning approach shows a rupture of the anterior ligamental-capsular complex with a discontinuity (solid arrows) of the anterior complex. The labrum (open arrow) and the glenoid (arrowhead) are marked.

 


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  		Figure 6b. Transverse US images show examples of the anterior ligamental-capsular complex. (a) Image obtained with the third scanning approach in a 20-year-old woman. The anterior ligamental-capsular complex (solid arrows) was assessed as a unit. The arrowhead points to a small degenerated labrum with a 1.8-mm hypoechoic zone (open arrow) at the base. A labral tear was diagnosed at arthroscopy. (b) Image obtained with the second scanning approach shows a rupture of the anterior ligamental-capsular complex with a discontinuity (solid arrows) of the anterior complex. The labrum (open arrow) and the glenoid (arrowhead) are marked.

 


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  		Figure 7. Transverse US image obtained with the second scanning approach shows fluid in the extracapsular location (open arrows), which was misinterpreted as resulting from a rupture in the anterior ligamental-capsular complex. The arrowhead indicates the glenoid, the solid arrow indicates the labrum.

 
It seems that a hypoechoic zone larger than 2 mm at the base of the labrum is highly diagnostic of a labral tear. To our knowledge, this US finding has not previously been described. Using MR and CT arthrography, Chandnani and co-workers (17), considered a labral fragment to be detached when it was separated from either the remaining labral tissue or hyaline cartilage or glenoid by more than 2 mm. At the preparatory pilot stage, we found the hypoechoic zone in a patient with a previous anterior shoulder dislocation. We assumed that the hypoechoic zone was identical to the criteria of Chandnani et al listed earlier for labral tear, and we translated the pathologic standard of a zone larger than 2 mm to our study. However, although our results indicated that this hypoechoic zone larger than 2 mm represented labral detachment, further comparative MR imaging and US studies need to be performed to define the morphologic study of the zone and its normal values. In neither the posterior labra nor the contralateral anterior labra did this zone exceed 2 mm.

The glenoid labrum is difficult to evaluate with MR imaging due to its small size and variable appearance (18,19). Altered intralabral and perilabral signal intensity is common with MR images; this signal intensity has been attributed to degeneration, tears, and normal variations (19–21). Histologic analysis of the labrum has demonstrated it to be composed of poorly vascularized bundles of fibrous connective tissue (19). Often, there is a sublabral transitional band of intermediate signal intensity, depending on a zone of fibrocartilage that may represent the normal hypoechoic zone of less than 2 mm seen at US in the present study of normal labra in nondislocated shoulders. In our US study, we did not find any intralabral changes; therefore, US seems to be less sensitive than MR imaging in the depiction of intralabral findings. This finding, however, has not yet been proved to be of clinical importance.

The differentiation between a labral tear and anatomic variants, such as a sublabral foramen and a sublabral recess, can be difficult. In none of our patients was the labral tear situated in only the anterior superior or superior posterior part, which are the locations for such variants (2,21,22). Therefore, we believe all our findings to be labral tears and not anatomic variants.

Another important pathologic finding that indicated a labral tear was movement of the labrum when the patient rotated the humerus. Labral movements have been shown (6) by using open magnets and the apprehension test position. However, with dynamic US, the extreme external rotation was not needed for this or any of the other pathologic findings mentioned herein, which made US examination more convenient for the patient.

With this study, we have become convinced that the most important benefit of US in the examination of shoulders with recurrent anterior instability is the possibility to perform real-time scanning with dynamic movements of the transducer and the object. A combination of all three scanning approaches improved our diagnostic capability and accuracy in the detection of labral tears and associated fractures. We believe that, in many patients, US is the only imaging method besides conventional radiography that can be used in the preoperative assessment of anterior shoulder instability.


   ACKNOWLEDGMENTS
 
We express our sincere gratitude to Mason Lee, MD, for the qualified linguistic revision of our manuscript.


   FOOTNOTES
 
Author contributions: Guarantors of integrity of entire study, M.V.H., A.E.; study concepts, K.G.O.A., S.L., G.B.W.; study design, K.G.O.A., M.V.H., A.E.; definition of intellectual content, K.G.O.A., S.L., A.E., M.V.H.; literature research, M.V.H., A.E., K.G.O.A.; clinical studies, G.B.W., A.E., M.V.H.; data acquisition, M.V.H., A.E., G.B.W.; data analysis, M.V.H., A.E., K.G.O.A.; statistical analysis, M.V.H., A.E.; manuscript preparation, M.V.H.; manuscript editing, K.G.O.A., S.L., A.E.; manuscript review and final version approval, all authors.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Palmer WE, Caslowitz PL, Chew FS. MR arthrography of the shoulder: normal intraarticular structures and common abnormalities. AJR Am J Roentgenol 1995; 164:141-146.[Abstract/Free Full Text]
  2. Beltran J, Rosenberg ZS, Chandnani VP, Cuomo F, Beltran S, Rokito A. Glenohumeral instability: evaluation with MR arthrography. RadioGraphics 1997; 17:657-673.[Abstract]
  3. Kwak SM, Brown RR, Trudell D, Resnick D. Glenohumeral joint: comparison of shoulder position at MR arthrography. Radiology 1998; 208:375-380.[Abstract/Free Full Text]
  4. Tirman PFJ, Bost FW, Steinbach LS, et al. MR arthrographic depiction of tears of the rotator cuff: benefit of abduction and external rotation of the arm. Radiology 1994; 192:851-856.[Abstract/Free Full Text]
  5. Cvitanic O, Tirman PFJ, Feller JF, Bost FW, Minter J, Carroll KW. Using abduction and external rotation of the shoulder to increase the sensitivity of MR arthrography in revealing tears of the anterior glenoid labrum. AJR Am J Roentgenol 1997; 169:837-844.[Abstract/Free Full Text]
  6. Wintzell G, Larsson H, Larsson S. Indirect MR arthrography of anterior shoulder instability in the ABER and the apprehension test positions: a prospective comparative study of two different shoulder positions during MRI using intravenous gadodiamide contrast for enhancement of the joint fluid. Skeletal Radiol 1998; 27:488-494.[Medline]
  7. Mack LA, Matsen FA, III, Kilcoyne RF, Davies PK, Sickler ME. US evaluation of the rotator cuff. Radiology 1985; 157:205-209.[Abstract/Free Full Text]
  8. Hodler J, Fretz CJ, Terrier F, Gerber C. Rotator cuff tears: correlation of sonographic and surgical findings. Radiology 1988; 169:791-794.[Abstract/Free Full Text]
  9. Farin PU, Jaroma H. Acute traumatic tears of the rotator cuff: value of sonography. Radiology 1995; 197:269-273.[Abstract/Free Full Text]
  10. van Holsbeeck MT, Kolowich PA, Eyler WR, et al. US depiction of partial-thickness tear of the rotator cuff. Radiology 1995; 197:443-446.[Abstract/Free Full Text]
  11. Pancioni L, Gatti G, Mecozzi B. Diagnosis of Hill-Sachs lesions of the shoulder: comparison between ultrasonography and arthro-CT. Acta Radiol 1997; 38:523-526.[Medline]
  12. Farin PU, Kaukanen E, Jaroma H, Harju A, Vaatainen U. Hill-Sachs lesion: sonographic detection. Skeletal Radiol 1996; 25:559-562.[Medline]
  13. Schydlowsky P, Strandberg C, Galbo H, Krogsgaard M, Jorgensen U. The value of ultrasonography in the diagnosis of labral lesions in patients with anterior shoulder dislocation. Eur J Ultrasound 1998; 8:107-113.[Medline]
  14. Hawkins RJ, Bokor DJ. Clinical evaluation of shoulder problems. In: Rockwood CA, Matsen FA, III, eds. The shoulder. Edinburgh, England: Churchill Livingstone, 1990; 1:169-171.
  15. Mack LA, Matsen FA, III. Rotator cuff. In: Fornage BD, eds. Musculoskeletal ultrasound. New York, NY: Churchill Livingstone, 1995; 113-133.
  16. Seeger LL, Gold RH, Basset LW. Shoulder instability: evaluation with MR imaging. Radiology 1988; 168:695-697.[Abstract/Free Full Text]
  17. Chandnani VP, Yeager TD, DeBerardino T, et al. Glenoid labral tears: prospective evaluation with MR imaging, MR arthrography, and CT arthrography. AJR Am J Roentgenol 1993; 161:1229-1235.[Abstract/Free Full Text]
  18. Longo C, Loredo R, Yu J, et al. MRI of the glenoid labrum with gross anatomic correlation. J Comput Assist Tomogr 1996; 20:487-495.[Medline]
  19. Loredo R, Longo C, Salonen D, et al. Glenoid labrum: MR imaging with histologic correlation. Radiology 1995; 196:33-41.[Abstract/Free Full Text]
  20. McCauley TR, Pope CF, Jokl P. Normal and abnormal glenoid labrum: assessment with multiplanar gradient-echo MR imaging. Radiology 1992; 183:35-37.[Abstract/Free Full Text]
  21. Shankman S, Bencardino J, Beltran J. Glenohumeral instability: evaluation using MR arthrography of the shoulder. Skeletal Radiol 1999; 28:365-382.[Medline]
  22. Yeh L, Kwak S, Kim YS, et al. Anterior labroligamentous structures of the glenohumeral joint: correlation of MR arthrography and anatomic dissection in cadavers. AJR Am J Roentgenol 1998; 171:1229-1236.[Abstract/Free Full Text]



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A. Papatheodorou, P. Ellinas, F. Takis, A. Tsanis, I. Maris, and N. Batakis
US of the Shoulder: Rotator Cuff and Non-Rotator Cuff Disorders
RadioGraphics, January 1, 2006; 26(1): e23 - e23.
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AIUM Practice Guideline for the Performance of a Shoulder Ultrasound Examination
J. Ultrasound Med., October 1, 2003; 22(10): 1137 - 1141.
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C. Martinoli, S. Bianchi, N. Prato, F. Pugliese, M. P. Zamorani, M. Valle, and L. E. Derchi
US of the Shoulder: Non-Rotator Cuff Disorders
RadioGraphics, March 1, 2003; 23(2): 381 - 401.
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P J O'Connor and A J Grainger
Ultrasound imaging of joint disease
Imaging, June 1, 2002; 14(3): 188 - 201.
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