Pictorial Essay
An Illustrated Tutorial of Musculoskeletal Sonography:
Part 2, Upper Extremity
S onography is a useful technique for
the assessment of many conditions
that can affect the upper extremity
because of the superficial nature of most struc-
tures in this anatomic region. As technical ad-
vances continue to improve image quality, the
role for sonography in the diagnosis of muscu-
loskeletal disorders will grow. Examination of
the rotator cuff tendons and evaluation for gan-
glion cysts of the hand and wrist are common in-
dications for sonography; other applications also
continue to gain popularity.
Shoulder
Assessment of the integrity of the rotator cuff
tendons is the primary indication for shoulder
sonography. Most commonly, the supraspinatus
tendon is affected, in isolation or in combination
with other tendons. A disruption of the normal
fibrillar pattern results in a focal hypoechoic or
anechoic defect [1].
A full-thickness tear is diagnosed when the
disruption extends from the articular to the bursal
surface of the tendon (Fig. 1). Secondary signs of
a full-thickness tear include volume loss with as-
sociated flattening or concavity of the echogenic
subdeltoid bursal fat (often accentuated with
Received December 8, 1999; accepted after revision February 10, 2000.
1
All authors: Department of Radiology, The University of Michigan Medical Center, 1500 E. Medical Center Dr., TC 2910, Ann Arbor, MI 48109-0326. Address correspondence to J. Lin.
AJR 2000;175:1071–1079 0361–803X/00/1754–1071 © American Roentgen Ray Society
AJR:175, October 2000
John Lin1, Jon A. Jacobson, David P. Fessell, William J. Weadock, Curtis W. Hayes
compression), substantial subdeltoid bursal fluid,
and cortical irregularity of the humeral tuberosity
adjacent to the tear [2–4] (Fig. 2).
A retracted tear results in a large hypo-
echoic to anechoic fluid-filled space that may
show echogenic debris (Fig. 1). The deltoid
muscle may closely approximate the humeral
head in the space normally occupied by the ro-
tator cuff tendons (Fig. 3).
Sonographic findings of a partial-thickness
tear include a focal hypoechoic defect reach-
ing either the bursal or the articular surface, but
not both, similar to criteria for MR imaging
examinations (Fig. 4). Typically, no significant
volume loss or subdeltoid contour abnormality
is seen [5].
Tendinosis is considered mucoid degenera-
tion without significant inflammation and can
be associated with a painful shoulder. Find-
ings include heterogeneity and thickening of
the tendon without discrete defects (Fig. 5).
Calcium hydroxyapatite deposition within
the rotator cuff tendons and adjacent bursa is
a cause of pain that can simulate symptoms
of a rotator cuff tear [6]. Calcifications ap-
pear as echogenic foci that typically shadow
(Fig. 6), although small calcifications may
not show shadowing.
Fluid surrounding the biceps tendon may indi-
cate simple joint effusion or biceps tenosynovitis,
especially when power Doppler sonography
shows increased flow (Fig. 7). Loose bodies in
the shoulder joint may travel into the depen-
dent bicipital sheath when an effusion is
present (Fig. 8). The long head of the biceps
tendon can be displaced from the bicipital
groove, usually in a medial direction (Fig. 9).
The tendon may be subluxed so that it is par-
tially displaced over the lesser tuberosity or
fully dislocated, often with an associated tear
of the subscapularis tendon [7]. Rupture of the
long head of the biceps tendons can also occur,
resulting in discontinuity of the tendon and as-
sociated hematoma [8] (Fig. 10).
Ganglion cysts commonly occur within the
suprascapular or spinoglenoid notch, or both,
and may cause symptoms by exhibiting a
mass effect on adjacent structures. Compres-
sion of the suprascapular nerve may cause su-
praspinatus and infraspinatus muscle atrophy.
Ganglion cysts appear as well-defined, round
or lobulated, anechoic lesions, and may show
posterior acoustic enhancement [9] (Fig. 11).
Patients are often referred for sonography to
exclude a rotator cuff tear after a traumatic epi-
sode and normal findings on radiologic exami-
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 Lin et al.

A B

Fig. 1.—Rotator cuff tear and normal anatomy.

A and B, Longitudinal (A) and transverse (B) sonograms of
64-year-old man reveal massive, complete full-thickness
tear of supraspinatus tendon with large defect extending
from articular to bursal surface (double arrow). Note
marked retraction (arrow) of torn proximal tendon end and
debris (arrowheads) present within defect. H = humeral
head, D = deltoid muscle, m = medial, l = lateral, a = anterior,
p = posterior.
C, Longitudinal sonogram of healthy 28-year-old woman
shows normal supraspinatus tendon (arrowheads). G =
greater tuberosity, l = lateral, m = medial.
C

A B
Fig. 2.—54-year-old woman with rotator cuff tear.
A and B, Longitudinal (A) and transverse (B) sonograms of supraspinatus tendon reveal full-thickness tear, confirmed at surgery. Several secondary signs of full-thickness
rotator cuff tear are present including cortical irregularity (solid arrow) of tuberosity adjacent to tendon tear, volume loss (double arrow), subacromial–subdeltoid bursal
contour deformity and flattening (open arrows), and subdeltoid bursal distention (arrowhead). l = lateral, m = medial, a = anterior, p = posterior.

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 Musculoskeletal Sonography of the Upper Extremity

Fig. 3.—80-year-old woman with rotator cuff tear. Longitu-

dinal sonogram shows chronic full-thickness tear of re-
tracted supraspinatus tendon (solid arrows). Note deltoid
muscle (D) is adjacent to humeral head (H) within space
(between open arrows and arrowheads) normally occu-
pied by distal supraspinatus tendon. l = lateral, m = medial.

A B
Fig. 4.—67-year-old man with partial-thickness rotator cuff tear.
A and B, Longitudinal (A) and transverse (B) sonograms of supraspinatus tendon show discrete bursal surface defect (black arrows) representing partial-thickness tear
with intact articular surface fibers present (white arrows). l = lateral, m = medial, a = anterior, p = posterior.

Fig. 5.—51-year-old man with supraspinatus tendinosis. Longitudinal sonogram of su- Fig. 6.—37-year-old woman with calcific tendinitis. Longitudinal sonogram of su-
praspinatus tendon shows diffuse thickening and heterogeneity (white arrows) with- praspinatus tendon reveals large irregular hyperechoic foci (black arrows) with associ-
out discrete defect, consistent with diffuse tendinosis. Note small region of relatively ated distal shadowing (white arrows), along with several smaller lesions, representing
spared normal fibrillar pattern of tendon (black arrows). m = medial, l = lateral. intrasubstance calcifications. Tendon is also focally thickened. m = medial, l = lateral.

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 Lin et al.

Fig. 7.—72-year-old woman with biceps

tenosynovitis.
A, Transverse sonogram of anterior
shoulder shows circumferential hypo-
echoic fluid (black arrows) surrounding
slightly thickened and heterogeneous
long head of biceps tendon (white ar-
rows). L = lesser tuberosity, G = greater
tuberosity.
B, Transverse sonogram with power
Doppler sonography reveals increased
flow in peripheral ring pattern repre-
senting inflammation of bicipital tendon
sheath synovium.
A B

Fig. 8.—66-year-old man with left glenohumeral joint loose bodies.
Transverse sonogram of anterior shoulder reveals several small
echogenic foci (arrowheads) medial to intraarticular portion of bi-
ceps tendon (arrows), floating within joint effusion. Echogenic foci
were mobile on real-time dynamic imaging, confirming presence of
loose bodies.
Fig. 9.—42-year-old man with pain and weakness of left shoulder. Transverse sonogram of an-
terior left shoulder shows dislocation of long head of biceps tendon (arrows) medially out of
bicipital groove (arrowheads). Subscapularis tendon was torn on sonographic examination.
Findings were confirmed at surgery. L = lesser tuberosity.

nation. The tomographic nature of sonography
allows imaging in multiple planes to optimally
reveal a subtle cortical disruption representing a
minimally displaced fracture, most commonly
involving the greater tuberosity [10] (Fig. 12).
Direct correlation to patient symptomatology
with transducer pressure is helpful. A Hill-Sachs
lesion can be evaluated with sonography in the
setting of anterior shoulder dislocation (Fig. 13).
Elbow
Sonography is sensitive for the detection of
a joint effusion in the elbow. The joint capsule
will be distended by hypoechoic to anechoic
fluid displacing the fat pads, seen best in the
posterior recess with the elbow flexed (Fig.
14). When there is clinical concern for septic
arthritis, sonographically guided aspiration of
the joint fluid can be performed [1].
Inflammation of the olecranon bursa is a
common condition that can be confused with
other sources of elbow pain. Characteristic
findings of olecranon bursitis include hypo-
echoic distention of the olecranon bursa with
increased power Doppler sonography flow,
typically in a rimlike fashion (Fig. 15).
The distal triceps tendon insertion onto
the posterior olecranon is well visualized
with sonography; however, the distal biceps
tendon insertion onto the radial tuberosity is
more difficult to consistently visualize [11].
Directed inspection of these structures can
reveal injuries ranging from strains to com-
plete rupture (Fig. 16).
With epicondylitis, there is thickening and
hypoechogenicity of the tendon at the attach-
ment on the epicondyle [1]. Calcification
within the tendon can indicate chronic injury
and should be correlated with radiologic find-

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 Musculoskeletal Sonography of the Upper Extremity

Fig. 10.—68-year-old man with ruptured biceps tendon and hematoma.

A and B, Longitudinal sonograms of long head of biceps tendon show
completely ruptured and retracted tendon (white arrows) with massive
fluid collection slightly more distally, representing chronic hematoma
(black arrows). Note frayed end of residual tendon (arrowheads). Image
in B was obtained just distal to A. p = proximal, d = distal.
C, Transverse sonogram shows biceps tendon (small arrow) sur-
rounded by massive liquefied hematoma (large arrows).
A

B C

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 Lin et al.

Fig. 11.—27-year-old man with spinoglenoid notch ganglion cyst. Lon-

gitudinal sonogram of posterior shoulder reveals cystic lesion (black
arrows) in spinoglenoid notch region consistent with ganglion cyst.
Note posterior scapular cortex (arrowheads) immediately beneath
scapular spine and humeral head cortex (white arrows).

A B
Fig. 12.—36-year-old man with occult greater tuberosity fracture after trauma.
A and B, Longitudinal (A) and transverse (B) sonograms of right shoulder reveal cortical disruption of greater tuberosity (arrows) at supraspinatus insertion. Fracture was
not identified on radiographs obtained a week before sonographic examination. l = lateral, m = medial, a = anterior, p = posterior.

Fig. 13.—65-year-old man with history of left anterior

shoulder dislocation. Longitudinal sonogram of posterior
shoulder shows notched defect present in posterolateral
aspect of humeral head (H) consistent with Hill-Sachs
lesion (arrowheads). Infraspinatus tendon was intact. m =
medial, l = lateral.

1076 AJR:175, October 2000

Fig. 14.—76-year-old man with elbow joint effusion. Transverse sonogramSonography
Musculoskeletal of posterior elbowof
held
the Upper Extremity
in flexed position shows large amount of fluid present in olecranon fossa, representing joint effu-
sion (asterisk). Sonographically guided aspiration of fluid revealed infection consistent with sep-
tic arthritis. Note posterior humeral cortex of posterior fossa (arrows). l = lateral, m = medial.

A B
Fig. 15.—47-year-old man with right elbow olecranon bursitis.
A, Longitudinal sonogram of elbow superficial to olecranon process (O) shows marked thickening of soft tissues with irregular anechoic fluid collection (arrows) repre-
senting distended olecranon bursa. Note dorsal cortex of olecranon (arrowheads). p = proximal, d = distal.
B, Longitudinal sonogram with power Doppler sonography shows increased flow in synovium around periphery, consistent with olecranon (O). Arrows indicate bursal fluid
collection; arrowheads indicate dorsal cortex of olecranon.

A B
Fig. 16.—20-year-old woman with partial triceps muscle tear.
A and B, Longitudinal (A) and transverse (B) sonograms of distal triceps muscle near musculotendinous junction show discrete defect involving long head of triceps mus-
cle, representing tear (arrows). p = proximal, d = distal, m = medial, l = lateral.

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 Lin et al.

Fig. 17.—24-year-old man with ulnar collateral ligament

tear. Longitudinal split-screen image compares abnormal,
torn ulnar collateral ligament on left with that of normal, in-
tact ulnar collateral ligament (black arrows) on right.
Heterogeneous, relatively hypoechoic material (white ar-
rows) is in expected location of left ulnar collateral liga-
ment and represents debris and hemorrhage. Note medial
epicondyle (arrowheads) of humerus (H) and medial prox-
imal ulna (U).

Fig. 18.—73-year-old man with enlarged epitrochlear lymph nodes. Longitudi-
nal sonogram of medial elbow shows several ovoid masses representing en-
larged epitrochlear lymph nodes (arrows) from nonspecific cause.
Sonographically guided core biopsy was performed that did not reveal malig-
nancy or infection. p = proximal, d = distal.
Fig. 19.—48-year-old woman with nontender palpable mass involving snuff box region
of her hand. Longitudinal sonogram of thumb revealed superficial simple cystic lesion
(arrows) adjacent to extensor pollucis longus tendon (arrowheads) representing gan-
glion cyst. p = proximal, d = distal.

ings. Tenderness with transducer pressure is a
helpful secondary finding. Integrity of collat-
eral ligaments in the elbow, particularly the
ulnar collateral ligament, is also accessible to
sonographic examination [1] (Fig. 17).
Enlargement of the lymph nodes can be
revealed sonographically. Cat-scratch dis-
ease classically involves the medial epitroch-
lear lymph nodes of the elbow after a
superficial wound inflicted by a cat’s claw
(Fig. 18). Reactive lymph nodes maintain a
kidney bean shape with a typical echogenic
central region related to multiple interfaces.
The ulnar nerve is normally positioned in
the cubital tunnel along the posteromedial as-
pect of the distal humerus, in a groove adjacent
to the medial epicondyle. Cubital tunnel syn-
drome is a result of inflammation of the ulnar
nerve manifested by an enlarged, hypoechoic
appearance on sonography. Dynamic imaging
can reveal intermittent subluxation of the ulnar
nerve, a cause of ulnar neuritis [12].
Hand and Wrist
Ganglion cysts represent the most common
soft-tissue mass in the hand and wrist and are
generally attached to tendon sheaths, muscles,
or cartilage. Unlike synovial cysts, ganglia do
not have a synovial lining and infrequently
communicate with a joint. Sonography reveals
a hypoechoic to anechoic well-defined struc-
ture with posterior acoustic enhancement con-
sistent with a cystic lesion [13] (Fig. 19).
Tenosynovitis appears as tendon sheath dis-
tention from fluid and thickened synovium. In-
creased flow on power Doppler sonography
indicates synovial inflammation (Fig. 20). Coex-
isting tendinosis or tendon tear may be present.
Carpal tunnel syndrome is a peripheral neur-
opathy frequently related to occupational causes.
Compression of the median nerve may result in
neuropathy with pain and paresthesias in a typi-
cal distribution. Sonographically, carpal tunnel
syndrome appears as enlargement and hypo-
echogenicity of the median nerve [14] (Fig. 21).

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 Musculoskeletal Sonography of the Upper Extremity

A B
Fig. 20.—28-year-old woman with systemic lupus erythematosis and swollen, painful left index finger.
A, Transverse sonogram of flexor compartment of index finger adjacent to middle phalynx cortex (white arrows) shows hypoechoic distention of tendon sheath (black ar-
rows) and slight heterogeneity of flexor tendon (arrowheads).
B, Transverse power Doppler sonogram reveals peripheral pattern of increased flow consistent with tenosynovitis.

Fig. 21.—32-year-old woman with carpal tunnel syn-

drome. Transverse sonogram of left wrist reveals en-
larged cross-sectional area of median nerve (black
arrows), consistent with diagnosis of carpal tunnel syn-
drome. Findings were confirmed with electromyography.
Note flexor tendons (white arrows). r = radial, u = ulnar.

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