Clinical Applications of Ultrasonography in the Shoulder and Elbow

Albert Lin, MD; Gregory Gasbarro, MD; Mark Sakr, DO


J Am Acad Orthop Surg. 2018;26(9):303-312. 

In This Article

Abstract and Introduction


In the past 30 years, the use of ultrasonography in the field of orthopaedics has evolved. As ultrasonography has been refined, smaller machines with higher fidelity and better transducers have become available at a lower cost. Diagnostic and therapeutic applications of ultrasonography in the shoulder and elbow have expanded imaging options and provided alternatives to surgical management. Ultrasonography is a dynamic tool that affords immediate diagnostic assessment for clinical correlation and can be used for serial examinations and image guidance during therapeutic procedures. This imaging modality is highly reliable and accurate and may limit the need for costly imaging referrals, particularly in geographic areas where advanced imaging is not readily available. However, clinical expertise is paramount for ultrasonography, which is an operator-dependent modality. Ultrasonography is an effective educational resource; therefore, the curriculum in orthopaedic residency training programs should include education on this modality as the use of ultrasonography increases among orthopaedic surgeons.


The first report of musculoskeletal sonography was published in 1958 by Dussik et al[1] in a study that measured acoustic attenuation of articular and periarticular tissues. Technical advances and expanding indications in the 1970s popularized the use of ultrasonography in athletes.[2] In the 1980s and early 1990s, Middleton et al[3] and Harryman et al[4] first evaluated rotator cuff pathology using ultrasonography. In a more recent study, Yamaguchi et al[5] performed a longitudinal analysis of rotator cuff tears (RCTs) detected on sonograms. Ultrasonography is an operator-dependent imaging modality, and clinical expertise in its use is paramount. Even with the use of well-defined protocols, substantial interobserver variability is associated with ultrasonography, and ultrasonography performed by clinicians rather than radiologists has led to debates with regard to training and level of competence.[6] Published training guidelines indicate that clinicians must perform 150 to 300 scans under the supervision of a qualified ultrasonographer or radiologist to develop proficiency.[6]

In general, MRI is the preferred imaging modality for evaluation of the shoulder and elbow. In most patients, MRIs are comprehensive; however, arthrography often is required to improve the diagnostic accuracy of MRI for labral assessment. MRI is not well tolerated by some patients, may lead to incidental findings, and may be costly. In contrast, ultrasonography allows for rapid, dynamic examination, immediate clinical correlation, and image guidance during therapeutic procedures. Ultrasonography can be used for serial examination of soft tissues and affords real-time tissue elastography, which is a technique that allows for close monitoring of tendon and tissue quality with various muscle contraction conditions and joint positions.[7]

Ultrasonography is an excellent educational tool for orthopaedic residency training, and interest in the use of this modality as an adjunct for physical examination of the shoulder and elbow has increased in the past two decades. Other benefits of ultrasonography include portability, decreased artifact from metal hardware, and contrast-enhanced Doppler applications that allow for real-time assessment of soft-tissue vascularity.[2,8] In addition, ultrasonography is less expensive than MRI. In 2007, >80 million MRIs were performed in the United States, with a cost to the healthcare system of >$120 billion.[9] In a recent study of 146 patients who underwent ultrasonographic evaluation of shoulder pathology, Adelman and Fishman[9] reported that 35 MRIs were avoided with the use of ultrasonography, saving a predicted $17,603, which represented a 50% 1-year return on investment ($34,897) for the ultrasonography machine and equipment.

Office-based musculoskeletal ultrasonography became possible as the quality of portable ultrasonography improved. Newer generation machines, which currently are the size of a laptop computer, replaced the large ultrasonography units typically used in hospitals. The ability to own and maneuver an ultrasonography machine in a clinic in combination with higher quality sonograms allowed for increased office-based musculoskeletal ultrasonography. The processing power, transducer capabilities, and software advances of newer ultrasonography machines also played an important role in the increased office-based use of the modality. Various ultrasonography machines are available for clinicians who desire in-office musculoskeletal ultrasonographic capability. Almost all modern models meet high-quality and function standards. Selection of an appropriate machine for a clinic requires consideration of the desired capabilities of interchangeable probes, desired image resolution, ease of use, comfort with the machine/interface, and cost. To become familiar with various ultrasonography machines, clinicians can contact manufacturers to test their machines and/or attend expositions to observe demonstrations of the newest features. Clinicians can contact colleagues and/or attend educational courses to determine the advantages and disadvantages of various ultrasonography machines.