الفهرس 
ANATOMY OF THE SHOULDEROnly 14 pages are availabe for public view
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Abstract
Rotator cuff tears are regarded as the most common cause of
shoulder pain, with an incidence that increases with age and among
occupations involving movements with repetitive strain, the current
agreed upon model for rotator cuff tears is multifactorial, spanning
many intrinsic and extrinsic factors that contribute to its
etiopathogenesis.
Musculoskeletal ultrasound is an established modality in the
diagnosis of shoulder pathologies in general and rotator cuff tears in
particular, a role further solidified by the significant technologic
advances in the ultrasound devices and image processing software
that have impacted its usage, making ultrasound a valuable diagnostic
tool that is comparable to MRI as regards accuracy, combined with
low cost and wide availability makes ultrasound an ideal tool for
assessment of RCTs
Furthermore, Ultrasound has been found to be increasingly
valuable in guiding musculoskeletal interventions. In the case of
rotator cuff tears, this mainly comprises rotator cuff injections, used as
a standalone therapy or adjuvant to operative intervention; several
injectable substances have been proposed for the management of
rotator cuff tears.
Corticosteroids have been found to be beneficial in the short
term in decreasing pain and inflammation and improving range of
motion in some studies, this effect was augmented when combined
with local anesthetic such as xylocaine, however despite extensive
research and common usage, evidence for the effectiveness of steroid
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injections for rotator cuff disease remain unclear, with conflicting
studies and inconclusive results of systematic reviews and metaanalyses
that were hindered by the inhomogeneity of the study
methodologies
Viscosupplementation with hyaluronic acid is another
postulated therapy for rotator cuff tears that is commercially available
and currently in use when initial pain relief strategies are ineffective.
Hyaluronic acid displays anti-inflammatory properties and fibroblast
stimulant properties that may play a supporting role in the rotator cuff
healing process. The efficacy of Viscosupplementation is however
still a topic of ongoing debate after several studies and meta-analyses
showed contradicting results. Hyaluronic acid injections may
constitute a valid tool in pain relief and functional recovery in elderly
patients with massive rotator cuff tear arthropathy, noncomplete
rotator cuff tears, mild osteoarthrosis (Kellgren– Lowrence II–III) and
supraspinatus tendinosis, but more consistent studies are needed to
further evaluate this new approach
Platelet rich plasma injections have also been suggested for the
treatment of rotator cuff injuries, PRP is a whole blood fraction which
on activation releases growth factors which participate in the process
of tissue repair by inhibiting the inflammatory effects of interleukin
that correlates with rotator cuff degeneration and stimulating TGF-
β production which enhances rotator cuff tendon healing. There are
several formulations available and their use to promote rotator cuff
healing has gained popularity over the recent years. But despite the
good theoretical basis for its use there remains a controversy
regarding its use, which is fueled by a deficient, controversial body of
research, lack and non-uniformity of the studies performed. More
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studies are required to validate the role of PRP in the treatment for
rotator cuff diseases
The use of stem cells is the newest frontier in the treatment of
rotator cuff tears. Mesenchymal stem cells are mainly used and are
extracted from the bone marrow and their use has been examined in
various animal models, until this moment only one small human study
has been carried out with promising results, further research is critical
for further evaluation of this biological approach
Although the techniques for shoulder injections are already
well described, the use of ultrasound guidance has only been recently
reported, rotator cuff injections typically employ a subacromial
approach and a freehand approach is also commonly used where one
hand holds the probe while the other directs the needle. A trial run
may be made to determine appropriate course and angle of entry of
the needle before injecting the substance, hydrodissection by injection
with fluid or microbubbles may also aid needle visualization,
The needle orientation used can be parallel or perpendicular to
the probe, selection of approach is often a matter of personal
preference but each approach has its own advantages and
disadvantages. As regarding the visualization of the needle within
tissue, several factors come into play: gauge of needle, beam
orientation, depth of tissue and orientation used. The most commonly
used approach is the postero-lateral approach, though anterior and
lateral approaches have also been used. Complications of injections
are related to technique of injection or substance used, and it is the
responsibility of the physician to inform the patient of possibility of
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complications and provide him with contact information in case of
need, most side effects are temporary and not major.
Conclusion:
In the hands of a well-trained radiologist, Ultrasound
constitutes a very valuable tool in the diagnosis of rotator cuff tears
with a sensitivity that is comparable to MRI, in addition to its very
useful utilization in the guidance of rotator cuff injections, many
injectable options are available according to desired effect, however
more consistent, standardized and uniform studies are required for
better evaluation of these substances and the determination of their
effectiveness