Practical Musculoskeletal Ultrasound e Book 2nd Edition Ebook PDF

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Video Contents
PART 1 SHOULDER PART 2 ELBOW

Subacromial-subdeltoid bursal fluid: Partial tear Distal biceps rupture
supraspinatus
Distal biceps rupture
Hemorrhage in glenohumeral joint
Common extensor origin enthesopathy
Full thickness supraspinatus tendon tear
Full thickness leading edge tear filled with bursitis
Common extensor origin enthesopathy and tear
Bural fluid in most dependent area of bursa
Acromioclavicular joint cyst
Common flexor origin enthesopathy
Biceps tenosynovitis axial image
Biceps tendinopathy with some fluid in sheath
Biceps tenosynovitis Dilated ulnar nerve above cubital tunnel
Bursal bunching and small click on abduction Distal biceps rupture with retraction
Bursal fluid over biceps tendon Distal biceps rupture
Bursal thickening at free edge Elbow loose bodies
Subacromial-subdeltoid bursa with doppler Common extensor origin enthesopathy and small
lamellar tear
Fluid in biceps sheath
Fluid in both subacromial-subdeltoid bursa and
biceps tendon sheath Common flexor origin enthesopathy
Free edge full thickness tear supraspinatus Osteochondritis capitellum
Large hill sachs deformity Subluxing ulnar nerve
Medially subluxed biceps tendon
Mid substance supraspinatus tendon tear axial PART 3 WRIST

Mid substance supraspinatus tendon tear axial Finger flexor tenosynovitis
Rim rent partial tear Finger flexor tenosynovitis axial
Subscapularis tendon full thickness tear Extensor compartment four tenosynovitis
vii
viii Video Contents
Footballers ankle
PART 4 FINGER
Insertional Achilles tendinopathy
Metacarpophalangeal joint synovitis
Peroneal tenosynovitis
Plantar fasciitis
PART 5 HIP
Plantar fibroma
Hamstring enthesopathy
Plantaris tear
Iliopsoas partial tear
Posteromedial impingement
Iliopsoas snap
Pre Achilles bursa: Haglund’s deformity
Labral cyst
Pre Achilles bursa
Rectus femoris muscle tear
Spring ligament tear
Snapping iliotibial band
Tibialis anterior tear
Sub gluteus medius bursa with doppler
Tibialis posterior split tear
Tibialis posterior tendinopathy
PART 6 KNEE
Osteomyelitis with fluid visible in medulla through PART 8 POSTERIOR ANKLE
a cloaca
Achilles tendinopathy
Focal patellar tendinopathy with doppler
Complete Achilles tendon tear
Gastrocnemius hematoma
Complete Achilles tendon tear
Jumpers knee sagittal with intense doppler activity
Partial Achilles tendon tear
Meniscal cyst
Recurrence of complete Achilles tendon tear
Myositis ossificans
Haglund’s disease
Osgood schlatter’s disease
Subcutaneous bursitis
Osgood schlatter’s disease
Partial tear of plantaris tendon
Focal patellar tendinopathy with doppler
Popliteal cyst with synovitis
PART 9 LATERAL ANKLE
PART 7 ANKLE Retro-malleolar peroneus brevis tendon tear

Infra-malleolar peroneusbrevis tendon tear
Achilles focal tendinopathy
Small intra-tendinous peroneus brevis tendon tear
Achilles paratenonopathy
Dynamic test for examination of the superior
Achilles re rupture peroneal retinaculum
Aspirating tarsal ganglion Intern snapping of the left peroneal tendons
Calcific Achilles tendinopathy Anterior talo-fibular ligament injury
Calcific tenosynovitis Normal calcaneo-fibular ligament
Diabetic plantar fasciopathy Ruptured calcaneo-fibular ligament
Video Contents ix
Cannulatingsubacromial subdeltoid bursa

PART 10 FOOT and injection
Double Mulder’s click Cuff tear visualised during injection
Inflamed intermetatarsal bursa in rheumatoid arthritis Hip joint injection
Injecting Morton’s neuomai Forceps on FB prior to retrieval
Mortons intermetatarsal neuroma/bursitis complex Out of view approach to small joint: needle tip
in joint
Mortons intermetatarsal neuroma/bursitis complex
Pre Achilles injection
Plantar fibroma
Pulsating eggshell is supraspinatus tendon following
Small Morton’s calcium aspiration
Stress fracture second mettarsal neck Posterior approach to glenohumeral joint
Tendon sheath injection
PART 11 INTERVENTION
Fenestrating supraspinatus calcium deposit
Soft tissue biopsy

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Preface
In the last decade musculoskeletal ultrasound has progres gained. Throughout the book the authors display an aware
sively gained widespread popularity in the diagnosis and ness of what does and what doesn’t work, what is or isn’t
assessment of the musculoskeletal system. This is mainly due useful, and an appreciation of the role of ultrasound in
to advances in ultrasound technology (new generation of relation to other imaging techniques.
digital equipment and transducers, color/power doppler) The second edition is totally re-written, re-structured and
which has refined the clinician’s ability to visualise superfi revised. The previous edition had 16 chapters, this has 33
cial soft tissue structures to an extent that in some areas chapters. There is expanded coverage of the shoulder,
rivals the diagnostic capability of MR. Intrinsic musculo elbow, wrist, hand, hip, knee, foot and ankle, and interven
skeletal ultrasound advantages include easy accessibility, tional techniques. There are hundreds of new illustrations
time and cost-effectiveness, and the ability to perform a real (line drawings and ultrasound scans) help illustrate relevant
time, dynamic examination during the clinical examination. anatomy and pathology and provide the user with a com
Although the quality and consistency of the diagnostic exam prehensive visual guide to accurate interpretation and diag
is heavily dependent on the examiner’s expertise, musculo nosis. The addition of real time videos that complement the
skeletal ultrasound has become an attractive and effective images in the book and better illustrate the pathology. There
modality to image the musculoskeletal system and for some are differential diagnosis summary tables to quickly direct
conditions has established itself the first-line examination the user to the most likely clinical problem being assessed.
technique. The book is also available on the Expert Consult platform
This book provides a practical guide for those wishing to with online access to text, images and video clips. As before,
obtain an understanding of ultrasound techniques, their I am very grateful to all the contributors who once again
major applications and their role in patient diagnosis and have given their expertise and insights so willingly.
management. It offers essential guidance on how to conduct
an ultrasound examination, how best to obtain optimal Eugene G McNally
images, and on how best to interpret the information Oxford 2013
xi
List of Contributors
Hifz-ur-Rahman Aniq MBBS FRCR Philip J. O’Connor MRCP FRCR

Consultant Musculoskeletal Radiologist, Royal Liverpool Consultant Musculoskeletal Radiologist, Department of
and Broadgreen Hospitals, Honorary Lecturer, Radiology, Leeds General Infirmary, Leeds, UK
University of Liverpool, Liverpool, UK
Simon J. Ostlere FRCP FRCR
Robert Campbell MBChB DMRD FRCR Consultant Musculoskeletal Radiologist, Nuffield
Consultant Musculoskeletal Radiologist, Royal Liverpool Orthopaedic Centre and John Radcliffe Hospital,
and Broadgreen University Hospital, Liverpool, UK University of Oxford, Oxford, UK
Michel Court-Payen MD PhD Karen J. Partington MRCS FRCR

Consultant in Radiology, Department of Diagnostic Clinical Fellow, Musculoskeletal Radiology, Nuffield
Imaging, GildhÃ¸j Private Hospital, University of Orthopaedic Centre, Oxford, UK
Copenhagen, Denmark
Philip Robinson MRCP FRCR
Andrew J. Grainger MRCP FRCR Consultant Musculoskeletal Radiologist; Honorary Senior
Consultant Musculoskeletal Radiologist, Department of Lecturer, St James’s University Hospital, Leeds, UK
Radiology, Leeds General Infirmary, Leeds, UK
Emma L. Rowbotham BSc Hons MB BChir FRCR
Catherine L. McCarthy MBChB FRCR Consultant Musculoskeletal Radiologist, Radiology
Consultant Musculoskeletal Radiologist, Nuffield Department, Royal United Hospital Bath NHS Trust,
Orthopaedic Centre and John Radcliffe Hospital, Bath, UK
University of Oxford, Oxford, UK
James L. Teh MBBS BSc FRCP FRCR
Eugene G. McNally FRCR FRCPI Consultant Musculoskeletal Radiologist, Nuffield
Consultant Musculoskeletal Radiologist, Nuffield Orthopaedic Centre and John Radcliffe Hospital,
Orthopaedic Centre and John Radcliffe Hospital, University of Oxford, Oxford, UK
University of Oxford, Oxford, UK
xiii
Abbreviations/Contractions
A acetabulum/acetabular component EDT extensor digitorum tendons

AB adductor brevis Ef effusion
Acc Col Lig accessory collateral ligament EHB extensor halluces brevis
ACJ acromioclavicular joint EHL extensor halluces
ACL anterior cruciate ligament EI extensor indicis
Add adductor EO external oblique
ADM abductor digiti minimi EPB extensor pollicis brevis
AH abductor hallucis EPL extensor pollicis longus
AHB abductor hallucis brevis EPL extensor pollicis longus
AHL abductor hallucis longus ESR erythrocyte sedimentation rate
AIN anterior interosseous nerve ET extensor tendon
AL adductor longus ExP Br expollicis brevis
AM adductor magnus Ext hood extensor hood
AP abductor pollicis
APB abductor pollicis brevis FA femoral artery
APL abductor pollicis longus FCL fibular collateral ligament
APL abductor pollicis longus FCR flexor carpi radialis
ASIS anterior superior iliac spine FCU flexor carpi ulnaris
ATaFL anterior talofibular ligament FD flexor digitorum
ATFL anterior tibiofibular ligament FDB flexor digitorum brevis
AVN avascular necrosis FDL flexor digitorum longus
FDM flexor digiti minimi
CAL coracoacromial ligament FDP flexor digitorum profundus
CCL calcaneocuboid ligament FDS flexor digitorum superficialis
CEO common extensor origin Fem femoral
CFA common femoral artery FH flexor hallucis
CFL calcaneofibular FHB flexor hallucis brevis
CFO common flexor origin FHL flexor hallucis longus
CHL coracohumeral ligament FNAC fine needle aspiration cytology
CID concealed interstitial delamination FP flexor pollicis
CMCJ carpometacarpal joint FPB flexor pollicis brevis
Col Lig collateral ligament FPL flexor pollicis longus
CPN common peroneal nerve FT flexor tendon
CPPD calcium pyrophosphate deposition disease FV femoral vein
CTS carpal tunnel syndrome
G ganglion
DI dorsal interosseii GCTTS giant cell tumour of the tendon sheath
DIPJ distal interphalangeal joint GHJ glenohumeral joint
Dist P distal phalanx GL Md gluteus medius
DN digital nerve Gl Mn gluteus minimus
DRUJ distal radioulnar joint GL Mx gluteus maximus
Gr gracilis
EC extensor compartment
ECR extensor carpi radialis IEA internal epigastric artery
ECRB extensor carpi radialis brevis IEV inferior epigastric vessel
ECRL extensor carpi radialis longus INF inferior
ECU extensor carpi ulnaris INR international normalized ratio
ED extensor digitorum IO internal oblique
EDB extensor digitorum brevis IP iliopsoas
EDL extensor digitorum longus IPJ interphalangeal joint
EDM extensor digiti minimi IST infraspinatus tendon
xv
xvi Abbreviations/Contractions
L/R length/radius PIPJ proximal interphalangeal joint

L/T longitudinal/transverse Prox P proximal phalanx
Lat H lateral head Ps psoas
LCL lateral collateral ligament PB Pubic bone
LGH lateral head of gastrocnemius Pu pubis
LH long head PRF pulse repetition frequency
LM lateral malleolus
LPL lateral patellofemoral ligament Quad fem quadratus femorus
LT Lister’s tubercle QP quadratus plantae
LUCL lateral ulnar collateral ligament
RA radial artery
MC metacarpal RCL radial collateral ligament
MCJ midcarpal joint RN radial nerve
MCL medial collateral ligament RCJ radiocarpal joint
MCP metacarpophalangeal RLT radiolunotriquetral
MCPJ metacarpophalangeal joint RSL radioscapholunate
MCT N musculocutaneous nerve Rec fem rectus femoris
Med PIN medial planter nerve
Med Triceps medial triceps Sart sartorious
MG medial head of gastrocnemius Sc scaphoid
MH medial head SLAC scapholunate advanced collapse
MHG medial head of gastrocnemius SLL scapholunate ligament
Mid P middle phalanx STT scapho-trapezio-trapezoid
MN median nerve Sttj scaphotrapezium-trapezoid joint
MO myositis ossificans ScN sciatic nerve
MOM metal-on-metal SH small head
MPL medial patellofemoral ligament SASD subacromial subdeltoid
MRI magnetic resonance imaging Sub GI M B subgluteus medius bursa
MT metatarsal sct subscapularis
MTJ myotendinous junction SUP superior
MTPJ metatarsophalangeal joint SSM supraspinatus muscle
SST supraspinatus tendon
N nerve SP symphysis pubis
O oblique TT tibial tuberosity

OE obturator externis TMTJ tarsometatarsal joint
OI obturator internis TFL tensor fascia lata
ON obturator nerve TM teres minor
OP opponens pollicis TN tibial nerve
OCD osteochondritis dessecans TPT tibialis posterior tendon
TA transverse abdominis
PI palmar inteross Trap trapezius muscle
PASTA Partial Articular Supraspinatous Tendon TFCC triangular fibrocartilage complex
Avulsion
Pect pectineus UA ulnar artery
PNST peripheral nerve sheath tumour UCL ulnar collateral ligament
Per Tub peroneal tubercle UCLt ulnar collateral ligament of the thumb
PVNS pigmented villonodular synovitis UN ulnar nerve
PN plantar nerve Ulna ulnar styloid
PRP platelet-rich plasma US ultrasound
Pos position
PIN posterior interosseous nerve V vessels
PD power Doppler
PART 1
SHOULDER
1
Shoulder: Anatomy 1
and Techniques
Eugene McNally
CHAPTER OUTLINE
OVERVIEW Standard Position 6: Supraspinatus Muscle

Patient Position and Acromioclavicular Joint
Standard Position 1: Biceps Tendon DYNAMIC SHOULDER ASSESSMENT
Standard Position 2: Rotator Interval Dynamic Assessment for Cuff Tears
Standard Position 3: Subscapularis Tendon DYNAMIC ASSESSMENT OF BURSAL
Standard Position 4: Supraspinatus Tendon IMPINGEMENT
Standard Position 5: Infraspinatus and Teres JOINT SUBLUXATION
Minor Tendon
cause. Impingement is a clinical diagnosis, whereby pain

OVERVIEW occurs during arm abduction, as the supraspinatus tendon
and subacromial subdeltoid bursa are compressed between
The important bony landmarks in the evaluation of the the humeral head and the coracoacromial arch. This clini
supraspinatus tendon are the humeral head, the coracoid, cal scenario is also called painful arc syndrome, as pain is
the clavicle and acromium, joined at the acromioclavicular maximal in an arc of abduction between 30° and 60°. Inter
joint. The glenohumeral joint is an inherently unstable joint estingly, patients frequently complain of pain on the lateral
and depends on the surrounding soft tissues for stabilization. deltoid rather than in the region of the acromion.
Soft tissue stabilizers are divided into intrinsic and extrinsic. A complete ultrasound examination involves evaluating
The most important extrinsic soft tissues are the supraspina the four major tendons of the rotator cuff (biceps, subscapu
tus tendon superiorly, infraspinatus posteriorly and subscap laris, supraspinatus and infraspinatus), the subacromial sub
ularis anteriorly (Fig. 1.1). The important intrinsic soft tissue deltoid bursa and the acromioclavicular joint.
stabilizers are the glenohumeral joint and capsule.
The supraspinatus and infraspinatus are difficult to sepa
PATIENT POSITION
rate close to their insertions and share what is almost a
conjoined tendon. Some of the fibres crisscross each other, The easiest position in which to examine the shoulder is
making the two tendons difficult to separate. Anteriorly the with the patient seated. A stool with either no back or a low
subscapularis tendon is separated from the supraspinatus back and arms is ideal. This will allow for full access and
tendon by a gap, the rotator interval, which allows passage permit the shoulder to be moved into a range of positions.
of the long head of biceps out of the joint and into its groove It is a matter of personal preference whether the examiner
in the upper arm. The long head of biceps originates from carries out the examination standing or sitting, behind or
the superior glenoid margin. The coracohumeral ligament in front of the patient. There are minor advantages and
helps keep the long head of biceps in position within the disadvantages to each of these, but none is particularly
upper groove, by forming a sling mechanism in conjunction important and the choice is a matter of personal preference.
with the superior glenohumeral ligament. These ligaments Some variations in position are required for patients in
pass from the coracoid and glenoid respectively, and insert wheelchairs and for patients who must remain recumbent
into the humeral head on either side of the biceps tendon, whether because of illness, surgery or fear of fainting. Many
securing it in place. Another important ligament, the cora wheelchairs allow the sidearm to be removed, facilitating
coacromial ligament (CAL). Links the coracoid to the acro arm movement. If the patient is also able to sit a little
mium and forms the coracoacromial arch along with the forward in the chair then generally all of the important
bony acromium. positions can be achieved without too much difficulty.
Shoulder pain is a common complaint in the general It is important to take a history directly from the patient
population and impingement is a common underlying before the examination begins as this can often provide
3
4 PART 1 — SHOULDER
The cuff tendons, particularly supraspinatus, should be

Supraspinatus
examined both statically and dynamically. The static exami
nation is divided into six standard positions with specific
imaging goals in each position. The dynamic examination
has many components, but primarily seeks to evaluate the
behaviour of the subacromial subdeltoid bursa as it abuts
the coracoacromial arch on arm abduction.
Biceps tendon
STANDARD POSITION 1: BICEPS TENDON
IMAGING GOALS
Infraspinatus 1. Confirm that biceps tendon lies within groove.
and Teres
2. Identify abnormal fluid in the sheath and bursa.
Subscapularis 3. Identify normal internal tendon structure.
TECHNIQUE
The patient sits and places their hand on their knee palm
upwards. This induces a little external rotation sufficient to
bring the bicipital groove to an anterior position (Fig. 1.3).
The groove is easily located by placing the probe in an axial
plane on the anterior aspect of the humeral head. The
probe is then moved superiorly and inferiorly, tracing the
biceps tendon from the upper part of the groove to below
its upper musculotendinous junction. The normal tendon
has a bright speckled appearance in the axial plane, made
up of the poorly reflective tendon fibre bundles and the
hyperechoic connective tissue matrix. Care must be taken
to ensure that the probe is always held at 90° to the tendon
to remove the effects of anisotropy. Anisotropy is an artefact
whereby areas of reduced reflectivity simulating tendinopa
thy occur as a result of incident echoes arriving at angles
other than perpendicular and being reflected away from the
tendon, rather than bouncing back to the probe to help
form an image.
At its upper part, the biceps tendon sheath surrounds the
tendon. As is well known, this is an extension of the gleno
Figure 1.1 The glenohumeral joint is stabilized by a combination of
the joint capsule with its condensations, the glenohumeral ligaments
humeral joint and a small quantity of fluid is often identified
and the rotator cuff tendons. The coracoacromial arch overlies the within it. Also in its upper part, the anterior portion of the
supraspinatus comprising the coracoid, acromial and CAL. subacromial subdeltoid bursa can be seen deep to the
deltoid muscle and anterior to the biceps sheath. The ante
rior limb of the circumflex humeral artery is frequently
useful diagnostic information. The examination itself begins visible around the tendon. Distally, the relationship of the
with a brief inspection of the shoulder, useful to detect musculotendinous junction with the traversing pectoralis
muscle wasting. As with most ultrasound examinations the tendon should be noted. A number of tendon variations
probe should be held lightly with sufficient, but not exces may be identified. There are often a number of slips that
sive, contact with the skin. Holding the probe between the pass from the upper humerus to the tendon. Occasionally
thumb and adjacent fingers while resting the little finger a duplex tendon is encountered.
on the patient’s skin is an ideal way of obtaining excellent The probe is then rotated 90° so that the tendon can
contact with minimal pressure. be examined in its long axis (Fig. 1.4). Maintaining the
The cuff is examined from biceps anteriorly to teres tendon in view during this manoeuvre takes a little practice;
minor posteriorly and from the acromioclavicular joint however, if the probe falls off the tendon it is very easy to
superiorly to deltoid insertion inferiorly. The examination move a little medial or lateral to find it again, noting where
is concentrated on the four major tendons, but it is impor the reflective humeral shaft drops away as the probe crosses
tant to have a routine to ensure that none of the other the groove. In most individuals, the tendon travels deeper
important structures is overlooked. My preference is to as it passes distally. This introduces an element of anisot
begin with the biceps tendon and rotator interval anteriorly, ropy, which can be easily corrected by some gentle pressure
then move sequentially through subscapularis, supraspina at the distal end of the probe. This manoeuvre is called
tus and infraspinatus and teres in that order (Fig. 1.2). The ‘heel toeing’ and is used in several locations in musculo
examination concludes with an assessment of the posterior skeletal ultrasound. The long-axis image of the tendon is
glenohumeral joint, infraglenoid notch, supraspinatus very useful for confirming integrity; however, as with most
muscle and the acromioclavicular joint, before sweeping tendons, the internal structure is best evaluated in the axial
down to the deltoid insertion. plane.
CHAPTER 1 — Shoulder: Anatomy and Techniques 5
a b c
d e f
g h
i j
Figure 1.2 Standard ultrasound examination positions. (A, B) Dorsum of hand on patient’s knee with some shoulder extension: used to
visualise biceps tendon in short and long axis. (C, D) Shoulder extended, hand by side position for subscapularis (external rotation can also
be used). (E, F) Hand on back pocket: used for supraspinatus short and long axis. (G, H, I, J) Arm across anterior chest for teres minor long
and short axis, supraspinatus muscle belly and acromioclavicular joint.
Deltoid
CHL
Humeral head A
Short head Subscapularis
ML
b P c
Figure 1.3 Position 1: the biceps lies centrally within its groove.
A
S I
b P c
Figure 1.4 Position 2: long axis of biceps with the subacromial subdeltoid bursa just visible anterior to the superior part of the tendon.
When assessment of the long head of biceps is complete, be covered in a later section. The probe is then returned to
the probe is moved medially to locate the short head of the upper biceps to review the rotator interval.
biceps. The bony margin of the coracoid process provides a
very useful landmark. The short head arises from its inferior STANDARD POSITION 2: ROTATOR INTERVAL
margin superficial to the insertion of the pectoralis minor
and coracobrachialis tendons. The tendon of pectoralis IMAGING GOALS
major can be identified as a long, thin slip passing over the 1. Identify ligamentous sling around biceps.
biceps tendon around the level of the proximal musculoten 2. Confirm ligaments are intact.
dinous junction. The more detailed anatomy of the arm will 3. Evaluate Doppler signal.
STANDARD POSITION 3: SUBSCAPULARIS

TENDON
IMAGING GOALS
1. Identify tendon in long axis.
2. Identify tendon in short axis.
3. Note relationship of tendon with rotator interval.
TECHNIQUE
a
Subscapularis arises, as the name suggests, from the under
surface of the scapula and is an internal rotator of the
shoulder. It is a multipennate muscle forming several
Deltoid tendons that insert as a conjoined unit on the medial border
Supraspinatus of the bicipital groove. The tendon measures approximately
8 cm from superior to inferior. Its upper margin is adjacent
Biceps
to the anterior interval. The tendon must be examined in
CHL
A both its long and short axis, as, because of the width of the
Humeral head tendon, significant tears may be present in one location, yet
SCT ML
b P other areas of the tendon will appear completely normal.
Following a successful examination of the biceps tendon
Figure 1.5 Rotator interval image. The coracohumeral ligament re-
inforced by the superior glenohumeral ligament separates supraspi-
and rotator interval, the patient is asked to move their elbow
natus from infraspinatus. posteriorly, then, keeping the elbow firmly by their side, the
shoulder is externally rotated by asking the patient to move
their hand as far as possible laterally. This draws the sub
scapularis out from beneath the coracoid, making it easier
TECHNIQUE to examine in its full extent (Fig. 1.6). Patients with adhesive
As has already been mentioned, the rotator interval is the capsulitis will find it difficult to externally rotate the shoul
name given to the space between the subscapularis and the der, an important initial clue to this diagnosis. Take care to
supraspinatus tendons through which the long head of ensure the patient doesn’t lift their arm to try and simulate
biceps passes as it exits the glenohumeral joint. Because the external rotation.
tendon undergoes a 90° turn as it enters the bicipital groove, In the axial plane, the normal bright reflective tendon
it must be supported to ensure that it does not displace should be followed from musculotendinous junction to
medially. Two ligaments in particular combine to create insertion. In some normal patients, and patients with
this support, which is also referred to as the rotator pulley chronic tendinopathy, the tendon may be very thin and dif
(Fig. 1.5). The two ligaments are the coracohumeral and ficult to separate from the surrounding bursa. If there is any
the superior glenohumeral ligaments. The pulley is also doubt as to its integrity, moving the tendon by internal/
reinforced by fibres of the subscapularis tendon passing external rotation easily separates it from surrounding struc
superficially to the coracohumeral ligament and inserting tures and isolates what is tendon and what is surrounding
on the lateral aspect of the groove. These fibres are some bursa.
times erroneously referred to as the transverse ligament. Once the axial view is completed, the probe is rotated 90°
The patient position is the same as for the biceps tendon. to assess the tendon in its short or sagittal axis. The examiner
The rotator interval is best evaluated with the probe in the should be careful not to displace the probe too far laterally
axial plane, positioned just above the upper part of the beyond the subscapularis insertion and into the supraspina
biceps groove. In this position, a rim of tissue is seen around tus tendon. In the short axis, the subscapularis tendon is
the biceps tendon, between the subscapularis medially and recognized by its multifascicular pattern (Fig. 1.7). It should
the supraspinatus laterally. This ‘rim’ represents the con be examined from upper to lower border. If the upper
joined coracohumeral and superior glenohumeral liga border cannot be clearly defined, it is brought more inferi
ments and the bridging subscapularis fibres. The margins orly by further posterior movement of the elbow. Sharp
of the coracohumeral ligament can usually be identified definition of the upper border is important, as many injuries
with good-quality equipment. It measures approximately begin at the upper border of the tendon. The normal upper
1.5 mm in thickness and should have the striated, predomi border should have a nice rounded margin and the biceps
nantly reflective appearance typical of ligaments elsewhere. tendon should lie just above and lateral to it. The relation
It should have little or no Doppler activity within it. ship of the upper border of the tendon and the rotator
On the medial aspect of the interval, particularly at its interval is also easier to appreciate in this position.
uppermost extent, the contribution from the superior gle In addition to examining the tendon, the underlying
nohumeral ligament can be identified. This is seen as a humeral head should be scrutinized; that said, it is not
nodule of tissue often inserting itself just underneath the uncommon to identify asymptomatic surface defects. The
biceps tendon and blending with the coracohumeral liga anterior compartment of the glenohumeral joint lies deep
ment, from which it is often difficult to separate. Note to the subscapularis, although visualization of the anterior
should be made of thickening or abnormal Doppler activity labrum is insufficient for reliable diagnosis. Capsular con
in and around the coracohumeral ligament, before moving densations representing the middle glenohumeral ligament
the probe medially to assess subscapularis. may be seen. Anteriorly, the subacromial subdeltoid bursa
Deltoid
ursa
SASD B
Short head
ris
ula
c ap A
bs Humeral
Su head M L
P
b c
Figure 1.6 External rotation draws the subscapularis tendon laterally out from under the coracoid. This image is obtained just below the tip
of the coracoid, demonstrating the proximal portions of short head of biceps and coracobrachialis muscle.
Bursa
SASD Subscapularis Deltoid
BT
A Humeral head
S I
b P c
Figure 1.7 In short axis, subscapularis muscle is multipennate, forming an elongated tendon that inserts in a slight depression on to the neck
of the humerus.
lies between subscapularis and deltoid, and fluid frequently

gravitates in this position. TECHNIQUE
As with tendons elsewhere, supraspinatus is examined in
STANDARD POSITION 4: SUPRASPINATUS both planes. In order to best visualize the tendon, the
TENDON patient is asked to abduct and internally rotate their shoul
der. This is best achieved by placing the palm of their hand
IMAGING GOALS on their ‘back pocket’. Alternatively, the patient can be
1. Identify the tendon in short axis. asked to put their arm in an ‘armlock’ position. These posi
2. Note the relationship with biceps tendon. tions bring supraspinatus forward and out from under the
3. Identify the tendon and long axis. cover of the coracoacromial arch (Fig. 1.8). Although
b c
Figure 1.8 Extending and internally rotating the shoulder draws the supraspinatus forward and laterally from under the coracoacromial arch.
The biceps tendon provides a key landmark identifying the rotator interval with subscapularis medially and supraspinatus laterally.
similar, the two positions do not result in an identical con

figuration of the tendon and bursa. As such, moving between
them can be very useful to create changes in tension, which
can be useful diagnostically.
Just as patients with adhesive capsulitis (frozen shoulder)
may find it difficult to adopt the best position for visualiz
ing subscapularis, patients with impingement may struggle
to achieve the positions described above. In these instances,
asking the patient to let their arm hang by their side a
and internally rotate as much as they are able may be
sufficient.
Once a comfortable position is achieved, begin with the White
short axis examination. This is usually referred to as the
axial view, but in practice, the image is achieved with Supraspinatus
the probe held in a slightly tilted axial position (see Fig.
In
1.5). The biceps tendon is the key landmark. In some fr
as
patients who internally rotate particularly well, the biceps A
pi
na
Humeral head
may be very medial and out of the field of examination. ML tu
s
Gentle manipulation of the patient’s position can usually b P
bring it into better view.
Figure 1.9 The orientation of the fibres of infraspinatus is slightly
Once the biceps tendon is located, it is easy to identify different from supraspinatus. The resulting anisotropy renders the
the leading edge of supraspinatus which lies adjacent to infraspinatus fibre slightly darker than supraspinatus.
biceps on the lateral side. The supraspinatus tendon is an
oval-shape structure with a smooth round anterior border.
Occasionally this can appear particularly reflective and
mimic the appearance of the biceps tendon itself: the false tendon should be predominantly a bright, reflective, stri
biceps sign. The area of supraspinatus adjacent to the biceps ated structure until the junctional area between the supra
is also referred to as the leading edge or the free edge. It spinatus and the infraspinatus is reached. At this point,
usually lies very close to the biceps, occasionally overlapping low-reflective striations become visible. This is the anterior
them. Any significant increase in the distance between the part of infraspinatus. The fibres run in a different plane to
biceps tendon and the free edge of the supraspinatus should supraspinatus and therefore appear anisotropic and dark in
be regarded as suspicious for a free edge tear. comparison to supraspinatus.
The probe is then moved laterally, keeping it in the tilted The probe is then rotated 90° to view supraspinatus in its
axial plane, to view the midportion of the supraspinatus long axis. This is the classic image of supraspinatus, and is
(Fig. 1.9). The internal structure of the supraspinatus usually referred to as the coronal plane because the
Deltoid
Ten Supraspinatus
don
foo
tpri Art
nt icu
lar
S Car
Humeral head tila
LM ge
b I c
Figure 1.10 A slight ridge is noted between the articular surface of the humeral head and the supraspinatus footprint. Note the low-reflective
articular cartilage ending just proximal to the medial point of the insertion of supraspinatus.
ultrasound image mimics the coronal image seen on MRI The articular cartilage of the humeral head will be seen
(Fig. 1.10). It will be noted that the probe is actually held deep and medial. The cartilage is hyporeflective, though
in a tilted rather than true coronal plane, and even quite with high-resolution equipment will be noted to have a thin
sagittal in some patients, depending on the degree of shoul bright reflective surface. Deeper again, the highly reflective
der internal rotation. If there is uncertainty, the biceps surface of the humeral head is noted. The subacromial
tendon can be located anteriorly and the probe gently subdeltoid bursa lies superficially, and overlying this is the
rotated until the best longitudinal view of biceps is achieved. deltoid muscle.
The same angle is then used to examine supraspinatus in There is a modification of Position 4 whereby the forearm
the coronal plane. under examination is held further across the back in the
In the coronal position, supraspinatus has a very charac so-called armlock position. In some patients the ‘hand on
teristic appearance. Its upper border is convex with a bright pocket’ is better than the armlock for visualizing pathology
margin representing the subacromial subdeltoid bursa. The and vice versa in others. In all patients, both arm positions
tendon fibres can be seen arching towards its insertion onto should be used and the tendon should be observed under
the greater tuberosity and should have a predominantly movement as the hand passes between the two. Patients
bright, reflective, striated appearance. Two distinct layers of quickly become familiar with the names of the two positions
the tendon are frequently observed in this position. The and easily understand when movement between the two
more medial fibres have to turn more acutely than the positions is needed. The examiner can then concentrate on
lateral fibres to insert and so reflectivity at the insertion is observing the tendon during this movement. More exten
variable, usually ranging from dark medially to brighter and sive dynamic movements are also helpful to depict pathol
more normal laterally, depending on the orientation of the ogy (these will be described in a later section).
probe. This is a form of anisotropy, which can be problem Although the majority of supraspinatus fibres are orien
atic at many tendon insertions. Dynamic probe manipula tated in the coronal plane, there are some that have
tion with heel toeing, beam steering and lateral movement more transverse orientation. These are referred to as the
are combined with slight movement of the patient’s shoul rotator cable and are said to have an important role in
der and can help to overcome this problem. determining both the location and rate of propagation of
The insertion of supraspinatus in this position is called rotator cuff tears.
the footprint. It measures approximately 2 cm medial to The subacromial subdeltoid bursa overlies the supraspi
lateral. It should be examined carefully, anterior to poste natus tendon in the coronal plane. It is a low-reflective
rior, to ensure that the entire footprint has been visualized. structure itself but it is surrounded by reflective fat and con
Particular attention should be paid to the medial margin of nective tissue. The bursa should be traced laterally by
the joint surface where tears may begin. These tears are moving the probe around the greater tuberosity and into
sometimes referred to as ‘rim-rent’ tears. The coronal image the upper arm. In the seated patient, small quantities of
is best for examining the lateral margin of supraspinatus fluid gravitate in these dependent areas. Care must be taken
insertion but poor at demonstrating the leading edge. The not to apply too much pressure with the transducer and
axial image works in the opposite way. underestimate the size or presence of bursal fluid. The
Deltoid
Figure 1.11 The low-signal subacromial subdeltoid bursa is
assessed adjacent to the coracoacromial ligament. The thickness is
noted at rest and in arm abduction. Bursal bunching may be demon-
atus
strated in patients with impingement, although this is not always Infraspin
associated with symptoms. The schematic diagram demonstrates the
location and appearance of bursal bunching with thickening of the
bursa lateral and thinning inferior and medial to the coracoacromial Humeral head P
ligament. ML
A
b
bursa should also be traced medially to the lateral margin

of the acromium (posteriorly) or to the CAL (anteriorly).
In the coronal image, the ligament will be visualized in cross
section as a 1–2 mm bright, oval shaped reflective structure.
If there is difficulty in identifying it, what sometimes helps
is to locate it in long axis first and then rotate the probe to
see it in its short axis. To locate it longitudinally, place the
medial end of the probe over the reflective surface of the
coracoid and hold the probe in the axial plane. Then rotate
the lateral end of the probe upwards, keeping the medial
end still. As the lateral end reaches the acromium, a thin
linear, highly reflective, striated structure representing the
CAL comes into view. Keeping the ligament in the centre of
the image and rotating the probe brings up the ligament in c
cross section. Once the appearance in this plane has been
recognized a few times it will be more easily picked up on Figure 1.12 With the arm abducted and internally rotated, the
the conventional coronal image without having to go tendon of the infraspinatus extends quite far laterally. It has a similar
through this localization process. This is the point where appearance to the supraspinatus tendon, though is generally thinner.
bursal bunching will be sought as the patient abducts their
arm. This is discussed in more detail in the section on
dynamic shoulder examination (Fig. 1.11). of the greater tuberosity posterior to the insertion for supra
spinatus. To examine it in long axis, the patient is asked to
STANDARD POSITION 5: INFRASPINATUS AND place their arm across the front of their chest, internally
TERES MINOR TENDON rotating the humeral head and elongating infraspinatus.
The probe is placed in the axial plane with its medial border
IMAGING GOALS a little lower than lateral to align itself along the tendon.
1. Identify tendon in long access from musculotendinous The appearance of the tendon is very similar to supraspina
junction. tus, although generally smaller (anterior to posterior) (Fig.
2. Note underlying posterior labrum and glenohumeral 1.12). Its relationships are similar with the humeral head
joint. deep and deltoid muscle superficial. The tendon should
3. Find the spinoglenoid notch and neurovascular bundle. be traced medially where it becomes the central tendon
of infraspinatus muscle. The musculotendinous junction
TECHNIQUE should be carefully scrutinized as injuries may occur at this
Infraspinatus, as the name suggests, rises from the dorsal location rather than at the insertion. The tendon also passes
aspect of the scapula below its spine, and inserts on a facet over the dorsal aspect of the glenohumeral joint, where the
a a
Deltoid
Deltoid
IST
IST
TM
Triceps
P
P
ML
A S I
b b A
Figure 1.13 The spinoglenoid notch is located on the posterosupe-
rior aspect of the scapula. It is located by moving the probe a little
medially and superiorly from the position used to locate the infraspi-
natus tendon. The glenohumeral joint and glenoid labrum (postero-
superior part) are identified.
posterior labrum can be readily identified in thin patients.

The posterior recess of the joint is also visible and this is a
good location to detect joint effusion (Fig. 1.13). Cartilage
damage and marginal osteophytes should be sought here.
The spinoglenoid notch lies medial to the posterior labrum
and glenoid margin. This is a bony depression with a well
rounded margin that contains reflective fat and the supra
c
scapular neurovascular bundle. The commonest pathology
identified in this location is a ganglion cyst arising from the Figure 1.14 In short axis, the teres minor muscle is identified on the
posterior labrum which may expand within the fossa, com inferior aspect of the infraspinatus tendon, although sometimes can
press the nerve and also cause infraspinatus muscle atrophy. be difficult to differentiate from it. It has a slightly rounder contour
Increased echotexture of the muscle belly is a sign of infra than the infraspinatus.
spinatus muscle atrophy, which is more often a complication
of throwing sports. musculotendinous junction occurs at a similar location or
Keeping it in the axial plane, the probe is moved inferi perhaps slightly more laterally than infraspinatus.
orly to overlie the teres minor tendon. This tendon has a The quadrilateral space can be identified just below the
similar appearance to infraspinatus and in some patients teres minor tendon. The circumflex humeral artery is prom
can be difficult to separate from it. One feature that can inent in this location and can be used as a marker for the
assist is that the deep relation of teres minor is bone whereas axillary nerve. The probe is then rotated 90° to demonstrate
the structure deep to infraspinatus is articular cartilage. The infraspinatus and teres minor in short axis (Fig. 1.14).
STANDARD POSITION 6: SUPRASPINATUS

MUSCLE AND ACROMIOCLAVICULAR JOINT
IMAGING GOALS
1. Identify supraspinatus muscle belly.
2. Compare echotexture with trapezius.
3. Examine acromioclavicular joint for structure and
tenderness.
TECHNIQUE
The final examination position is also posterior. Having
completed the examination of teres minor in the sagittal
plane, the probe is once again rotated into the axial plane
and moved superiorly, passing above the spine of the scapula
into the area of the supraspinatus muscle belly. This is par
ticularly important in patients with rotator cuff tears, as
associated muscle atrophy can be detected here (Fig. 1.15).
a
The bulk and reflectivity of the muscle are compared with
the overlying trapezius muscle. The ease and clarity with
which the central tendon is visualized is also useful; increas
ing fatty atrophy absorbs the ultrasound beam and blurs the
margins of the central tendon, making it appear larger than Trapezius
normal. The margins of the muscle also be come less clear.
Having assessed the muscle in both long and short axes
(Fig. 1.16), the probe is moved laterally to overlie the acro
mioclavicular joint. It is easy to locate the joint by passing
the probe along the clavicle until the joint is encountered SSM
(Fig. 1.17). The normal joint margins are smooth, although
the capsule will frequently bulge a little upwards. The
margins of the joint are assessed for osteophytes and ero
sions and the joint cavity itself should be reviewed to detect
effusion and synovitis. More important than abnormal joint
morphology, gentle compression with the ultrasound probe S
over the joint may reproduce symptoms, if they arise, from ML
the joint. The acromioclavicular joint is also examined I
b
dynamically. The patient is asked to move their arm from its
position across the chest to the ipsilateral knee, then back
to the contralateral shoulder. This cycle is repeated and
note is made of the relative movement of the lateral aspect
of the clavicle with respect to the acromium. Under normal
circumstances the two bones will approximate slightly,
though some superior/inferior movement may be observed.
When subluxation is present, the lateral end of the clavicle
deviates upwards and there will be abnormal movement of
the capsule and synovial contents.
DYNAMIC SHOULDER ASSESSMENT
Dynamic assessment of the shoulder is most often used

c
to detect subacromial subdeltoid bursal impingement;
however, there are a number of other useful dynamic tech Figure 1.15 The conspicuity of the central tendon of supraspinatus
niques that can be applied to detect cuff tears, including within the supraspinatus muscle belly is used to assess for supraspi-
patient movement, probe movement, fluid movement and natus atrophy. Loss of definition or increased reflectivity around the
the use of bursography as well as dynamic manoeuvres to tendon representing a fatty replacement is an indication of atrophy.
assess glenohumeral instability.
can be observed during this movement. Changes in tissue

DYNAMIC ASSESSMENT FOR CUFF TEARS
tension with separation of fibres can all help with the diag
During the routine examination, supraspinatus should be nosis of cuff tears, and particularly the movement of tissue
examined in a number of different positions, as has previ interfaces. If an abnormality in the region of this interface
ously been outlined. With prompting, the patient can move is detected, its behaviour under movement can help with
efficiently between the optimal positions and the tendon differential diagnosis. Changes in bursal dimension may be
Clavicle Acromium
a
S
ML
b I
Trapezius
SSM
S
P A
I c
b
Figure 1.17 The acromioclavicular joint is located in long axis on
Figure 1.16 The bulk in reflectivity of supraspinatus muscle can also
the superior aspect of the shoulder. The superior coracoclavicular
be assessed in short axis. The muscle generally should fill the arch
ligament overlies, demarcating the upper aspect of the joint space.
between the spine and upper border of the body of the scapula.
The deltoid ligament attaches to the lateral aspect of the acromion.
observed and movement between the planes of supraspina If fluid is present in the bursa it can be used dynamically
tus and the subacromial subdeltoid bursa is particularly to assist in the differentiation of cuff tears. Bursal fluid
useful at differentiating bursal surface partial tears from located in the dependent position can be massaged into a
areas of bursal thickening. If the abnormal tissue moves more useful location on the superior aspect of the tendon
synchronously with the supraspinatus tendon, it is a partial with lateral compression on the outer aspect of the patient’s
tear. If the tendon moves independently of the tissue then shoulder. The patient can even be positioned in a prone
the abnormality is likely to represent an area of bursal recumbent position, although this is rarely necessary. Fluid
thickening. movement, combined with sonopalpation and patient move
In addition to using patient movement, the compress ment, may either fill a previously unrecognized tear or dem
ibility of the underlying tissue can be assessed using sono onstrate that an apparent partial tear is in fact complete, by
palpation. Sonopalpation refers to the cyclical compression showing a fluid connection between the bursa and joint.
and release of probe pressure, while observing the behaviour In addition to fluid that is already present within the
of the underlying tissue. Normal and minimally diseased bursa, if the patient undergoes diagnostic or therapeutic
tissue is poorly compressible. The fibres will respond syn bursal injection, the fluid introduced can be used to identify
chronously and continuity is preserved. With more advanced more subtle pathology, especially of the bursal surface. It is
stages of tendinopathy, the tendon becomes increasingly helpful to re-examine the biceps tendon sheath when par
compressible and the behaviour of the underlying fibre is ticulate corticosteroids are injected into the bursa. If the
more abnormal. Structural integrity is poorly preserved reflective steroid is identified in the glenohumeral joint or
during compression. the biceps tendon sheath, a full-thickness tear is confirmed.
in the same position as is used to assess infraspinatus. The

DYNAMIC ASSESSMENT OF BURSAL posterior recess of the joint is identified deep to this and
IMPINGEMENT the relationship of the round humeral head and posterior
margin of the glenoid noted. The patient is asked to draw
As has been described above, the thickness of the subacro back the arm into the late cocking position. As the humeral
mial subdeltoid bursa can be assessed as it overlies the supra head externally rotates, its effect on the posterosuperior
spinatus and other tendons. The method for locating the labrum is reviewed as posterosuperior impingement may
CAL has also already been described. Once these principal be identified. The manoeuvre is completed by asking the
structures have been located, the patient’s arm can be gently patient to simulate a forward throwing action. Any loss of
abducted, with the elbow flexed and level with the wrist, and congruity between the humeral head and the glenoid
any changes in the configuration of the bursa as it abuts the should be noted. As with any other dynamic manoeuvre, it
CAL noted. Typical findings include increased thickness of is useful to undergo several practice cycles with the patient,
the bursa as it tries to pass beneath the CAL. Occasionally, as some movement of the probe is required to keep the
thickening is sufficient to prevent further abduction, or, relevant structures in view. It is difficult, under physiological
after initial resistance, the bursa may pass under the liga conditions, to maintain visualization of the glenohumeral
ment with an audible and palpable click. The most impor joint, and the power and range of movement of the simu
tant finding during these manoeuvres is the patient’s lated throwing manoeuvre is only a fraction of a normal
response. Bursal bunching without pain is of doubtful sig dynamic throw. Consequently, it is likely that this technique
nificance but pain without bunching is an important clinical carries a significant false negative.
finding. Despite this nonspecificity, the manoeuvre can be Acromioclavicular joint subluxation is more easily
a useful adjunct to the routine examination, especially when assessed. The patient begins with their hand on the ipsilat
equivocal symptoms are present. The same findings may eral knee, then moves it to the contralateral shoulder and
also occur with the bursa impinging against the bony acro back. Under normal conditions, there is some approxima
mium; however, impingement against the CAL is more tion of the acromium at the lateral end of the clavicle. Sig
usually assessed. nificant inferior–superior movement is not detected unless
there is ligamentous laxity. As the joint moves, synovial tissue
and fluid may be extruded. In some patients with a large
JOINT SUBLUXATION quantity of fluid in the subacromial subdeltoid bursa, often
in association with a massive rotator cuff tear, a communica
Glenohumeral joint subluxation is difficult to assess with tion can exist between the bursa and the joint. Under these
ultrasound, but a number of techniques have been described. circumstances, significant quantities of fluid may pass
The examination is generally carried out from a posterior through the joint to emerge on its superior aspect, filling
approach. The probe is initially placed in the transverse a large synovial cyst. This is referred to as the geyser
plane with the arm across the anterior aspect of the chest phenomenon.
2 Shoulder 1:
Supraspinatus Tendon
Eugene McNally
CHAPTER OUTLINE
INTRODUCTION A TEAR IS DETECTED: REPORTING SIZE,

THE AETIOLOGY OF SHOULDER LOCATION AND MUSCLE ATROPHY
IMPINGEMENT NO FULL-THICKNESS TEAR DETECTED.
Bony Impingement WHAT NEXT?
SICK Scapula Other Technique Tips and Tricks:
Other Theories Associated Signs
The Rotator Cable SUPRASPINATUS TENDINOPATHY
SUPRASPINATUS TEAR NOMENCLATURE Aetiology
Partial Versus Full Thickness Clinical Features
Full-Thickness Tear Patterns, Location Image Findings
and Shape CALCIFIC TENDINOPATHY
A STEPWISE APPROACH TO THE DIAGNOSIS
OF SUPRASPINATUS TEARS: FIVE SIMPLE
STEPS
Patients with external impingement syndrome, painful

INTRODUCTION arc or, as it is more usually referred to: impingement syn
drome, typically present with insidious onset shoulder pain
Shoulder pain is one of the commonest orthopaedic pre and limitation of movement. Pain occurs in a variety of clas
sentations in the general population and subacromial sical arm positions, including working with the arm above
impingement is a common underlying cause. The glenohu the head, trying to put on a shirt or undo a bra strap or
meral joint is an intrinsically unstable joint and the tendons reaching to the backseat of a car. In the early stages, these
of the rotator cuff play an important role in stabilizing it movements induce pain that settles, but in time becomes
(Fig. 2.1). The supraspinatus tendon (SST), the most impor more persistent with repeated insult. The patient begins to
tant component of the rotator cuff, lies along the superior wake at night when they turn onto the affected shoulder,
aspect of the humeral head passing beneath the coracoac sleep is disturbed and ultimately pain becomes continuous.
romial arch. The arch is made up of a bony component Classically, the patients point to the lateral aspect of the
posteriorly, the acromion, and a soft tissue component ante deltoid as the location of symptoms. Weakness may be
riorly, the coracoacromial ligament. The other tendons of present and related to muscle disuse or tendon tears.
the rotator cuff are subscapularis, anteriorly, and infraspina The principal pathology is SASD bursitis with or without
tus and teres minor, posteriorly. supraspinatus tendinopathy or tear.
The other important anatomical structure involved in
shoulder impingement is the subacromial subdeltoid
(SASD) bursa. This is a large bursa that also passes under Key Point
neath the coracoacromial arch separating it from the rotator
cuff below. It also separates the cuff from the deltoid muscle The bursal wall becomes thickened and pain and limitation
laterally and a component extends medial to the arch of movement occur as the inflamed bursa and SST pass
between the supraspinatus muscle belly and trapezius above. under the coracoacromial arch on shoulder abduction.
Although large, the bursa is quite thin, containing only a
small quantity of fluid under normal circumstances. Its func
tion is to facilitate movement of the SST beneath the acro Put simply, the bursa and tendon become trapped within
mion and the coracoacromial ligament. this space, leading to further soft tissue swelling and further
16
CHAPTER 2 — Shoulder 1: Supraspinatus Tendon 17
it must be appreciated that not all rotator cuff tears are

Supraspinatus
symptomatic and many patients function, even at a very high
level, with torn tendons. Even when symptoms are present,
these may be due to impingement/bursitis rather than from
a tear in the tendon itself. Repair of the tendon is not always
necessary to relieve pain, and treatment of the bursitis or
surgical management of the subacromial space alone may
Biceps tendon
be adequate and less invasive. As in many other areas of
musculoskeletal ultrasound, a good understanding of local
practices, shared terminology and frequent discussion with
surgical colleagues are most important.
Infraspinatus External impingement must be distinguished from inter
and Teres
nal impingement syndromes, which generally refer to dis
Subscapularis orders of the glenoid labrum such as superior labral tear
from anterior to posterior (SLAP) tears and posterosupe
rior impingement. Pain due to sternoclavicular arthropathy
is sometimes referred to as tertiary impingement. Ultra
sound has a minimal role in the former but is useful in
detecting and treating the latter.
THE AETIOLOGY OF SHOULDER

IMPINGEMENT
As with tendinopathy elsewhere in the body, a combination

of extrinsic and intrinsic factors, coupled with misuse and
combined with a genetic predisposition, lead to tendinopa
thy and rotator cuff tears. Extrinsic factors include external
impingement on the tendon from the surrounding bony or
soft tissue components of the arch.
BONY IMPINGEMENT
Multiple factors have been implicated in the aetiology of
impingement and rotator cuff disease. Attention is fre
quently drawn to the shape of the acromion, although it is
Figure 2.1 Sagittal diagram of rotator cuff tendons. The tendons of
subscapularis, supraspinatus and infraspinatus merge together to
now generally accepted that, apart from extremes, changes
form the cuff. There is an anterior opening to allow egress of the long in the acromion are secondary to impingement rather than
head of biceps. This is called the anterior interval. a primary cause. Bony irregularity on the undersurface of
the acromion can arise as a result of enthesopathy at the
coracoacromial ligament attachment. In extreme cases,
a distinct bony spur may be present, leading to further nar
impingement. A variety of clinical tests have been described rowing of the subacromial space. Entheseal changes may
to detect impingement. These are fairly reliable in detecting also occur at the humeral insertion of the involved tendons.
a problem beneath the arch, but less reliable at determining Bony upgrowth from the humeral head combines with bony
the full extent of the problem. This then becomes the downgrowth from the acromion leading to further diminu
most important goal for imaging, differentiating patients tion in the subacromial space, increased bursal impinge
with simple bursitis from those who have progress towards ment and progressive supraspinatus tendinopathy (Fig.
tendinopathy or, more importantly, rotator cuff tears. If a 2.2). Although bony and entheseal factors have been shown
tear is present, secondary goals include determining whether to narrow the subacromial space, it is probable that they are
it is partial or full thickness, the size and full extent of the not the most important.
tear and the presence of chronic features such as muscle
atrophy and arthropathy. The importance of these second
SICK SCAPULA
ary features depends on other factors such as the age of the
patient, their activity, the acute nature of any underlying
injury and local surgical preferences. This is particularly Key Point
variable with partial thickness tears. In some countries these
are managed surgically, particularly if they involve more Two factors that are almost certainly more important than
than 50% of attending thickness, whilst in other countries acromial shape and enthesopathy in the aetiology of rotator
they are managed the same way as focal tendinopathy. cuff disease are genetic factors and scapulothoracic
Indeed, in some descriptions, the meaning of partial thick dyskinesia.
ness tear and focal tendinopathy is the same. Furthermore,
diseased tendons in the body, prominent increased vascular

ity is present. Notable examples include the Achilles and
patellar tendons. Neovascularity or angioneogenesis is not
a prominent feature in supraspinatus tendinopathy. The
underlying cause for the differences between these tendons
is unclear.
THE ROTATOR CABLE

It has been suggested that central or ‘crescent’ supraspinatus
tears are more common in older individuals as a degenerate
phenomenon. It has also been suggested that they are more
likely to occur when there is a prominent condensation of
fibres traversing the supraspinatus, called the rotator cable.
The rotator cable has not been extensively studied, but it
appears to be a condensation of tendon fibres that are ori
entated in a different plane from the remainder of the
tendon. Together they form a band of tissue that extends as
an arch from the anterior leading edge into the tendon
Figure 2.2 A down sloping acromion and/or a spur/enthesopathy
substance to the posterior margin of the tendon close to its
on the undersurface of the acromion may impinge on the bursal
space. In addition, bony enthesopathy may impinge on the undersur- insertion. The cable reinforces the anterior and posterior
face of the SST. An important factor is shoulder dyskinesia, where parts of the tendon in the same manner as a cable links the
scapular rotation and upward migration of the humeral head further struts of a suspension bridge. Between the cables, a weak
impinge on the subacromial space. area is created in the central substance of the tendon, sec
ondary to stress shielding. This area becomes more prone to
degeneration leading to a tear. The terms central, midsub
Scapulothoracic dyskinesia refers to the narrowing of the stance or cresent have all been applied to this tear pattern.
subacromial space that arises as a result of abnormal scapu It has also been suggested that the presence of a strong rota
lar motion. The term SICK scapula syndrome comprises: tor cable may explain why not all tears are symptomatic.
Scapular malposition, Inferomedial prominence, Coracoid
pain and scapular dysKinesis. The muscular imbalance
SUPRASPINATUS TEAR NOMENCLATURE
between the thoracic and cuff musculature leads to eleva
tion of the humeral head and impingement of the subacro
PARTIAL VERSUS FULL THICKNESS
mial space beneath the coracoacromial arch. Abnormal
shoulder biomechanics, termed microinstability, with or One of the issues that frequently causes confusion is the
without joint laxity, may also contribute. The aetiology of nomenclature of cuff tears, particularly the definition of
the SICK scapula is incompletely understood, but maladap partial versus full thickness versus massive rotator cuff tears.
tive postural biomechanics, possibly due to habitual poor This can be more easily understood when it is appreciated
posture or other causes, leads to the abnormal relationship that the SST is a sheet-like tendon, unlike, say, the tendons
between the scapula, thorax and humerus. The contribu of the wrist that are more tubular or string-like. As such, the
tion that scapular dyskinesia makes to impingement is supraspinatus has both thickness and width. It has a supe
important and underlines the importance of physical rior surface facing the subacromial bursa and an inferior
therapy as part of the patient’s management. surface facing the glenohumeral joint. An intact SST pre
vents communication between these two compartments. Its
anterior edge abuts the biceps/rotator interval and its pos
OTHER THEORIES
terior margin blends with the infraspinatus tendon into
An important intrinsic mechanism leading to tendon degen which tears may extend.
eration and tear is apoptosis: the intrinsic degeneration of
collagen, largely influenced by genetic factors. Like the
stress factors of bone, the state of a tendon at any one time Key Point
is a balance between damage and repair. If apoptosis is
accelerated beyond the intrinsic repair mechanism’s ability If a tear is detected, its description should include a
to heal, tears occur. A watershed area has been defined in comment on its thickness, width and location.
an area of the tendon close to, but not at the bony attach
ment, where an area of decreased vascularity may pre
dispose to cuff tear. This area is often referred to as the The thickness of a tear is described as partial or full; the
‘critical zone’. Anatomical studies, however, have not always width of a tear is described either by its dimensions
demonstrated an area of decreased vascularity, nor is it (anterior/posterior × medial/lateral) or by how much
obvious that the majority of tendon tears occur in this area. intact tendon tissue remains (standard descriptive terms are
Decreased vascularity has not been consistently demon described below).
strated and, when it is seen, it is not clear that this is not A partial thickness tear is one that involves either the joint
an effect rather than the cause of tendinopathy. In many or bursal surface alone and does not allow communication
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Book 2nd Edition, (Ebook PDF)

PART 1 SHOULDER PART 2 ELBOW

Mid substance supraspinatus tendon tear axial PART 3 WRIST

PART 7 ANKLE Retro-malleolar peroneus brevis tendon tear

Cannulatingsubacromial subdeltoid bursa

Double Mulder’s click Cuff tear visualised during injection

Inflamed intermetatarsal bursa in rheumatoid arthritis Hip joint injection

Injecting Morton’s neuomai Forceps on FB prior to retrieval

Soft tissue biopsy

Hifz-ur-Rahman Aniq MBBS FRCR Philip J. O’Connor MRCP FRCR

Michel Court-Payen MD PhD Karen J. Partington MRCS FRCR

A acetabulum/acetabular component EDT extensor digitorum tendons

L/R length/radius PIPJ proximal interphalangeal joint

O oblique TT tibial tuberosity

OVERVIEW Standard Position 6: Supraspinatus Muscle

cause. Impingement is a clinical diagnosis, whereby pain

The cuff tendons, particularly supraspinatus, should be

STANDARD POSITION 3: SUBSCAPULARIS

lies between subscapularis and deltoid, and fluid frequently

similar, the two positions do not result in an identical con­

bursa should also be traced medially to the lateral margin

posterior labrum can be readily identified in thin patients.

STANDARD POSITION 6: SUPRASPINATUS

DYNAMIC SHOULDER ASSESSMENT

Dynamic assessment of the shoulder is most often used

can be observed during this movement. Changes in tissue

in the same position as is used to assess infraspinatus. The

INTRODUCTION A TEAR IS DETECTED: REPORTING SIZE,

Patients with external impingement syndrome, painful

it must be appreciated that not all rotator cuff tears are

THE AETIOLOGY OF SHOULDER

As with tendinopathy elsewhere in the body, a combination

diseased tendons in the body, prominent increased vascular­

THE ROTATOR CABLE

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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similar, the two positions do not result in an identical con

diseased tendons in the body, prominent increased vascular