Ultrasound Protocol for the Shoulder Joint: Standard Positions and Examination Technique (Step-by-Step)
According to Jacobson (Fundamentals of Musculoskeletal Ultrasound, 4th ed., 2026), adherence to the protocol ensures a comprehensive and thorough evaluation. Unlike other peripheral joints, a targeted regional approach is not recommended for the shoulder, as pain is often diffuse or referred. Each examination should conclude with a targeted evaluation of any area of point tenderness or focal symptoms to identify pathology not included in the initial protocol checklist.
Position 1: Long Head of the Biceps Brachii Tendon
The patient places their hand, usually palm up, on their thigh. This position rotates the bicipital groove anteriorly — an important bony landmark (Jacobson, 2026).
Standard Structures and Positioning (Griffith, 2025)
According to Diagnostic Ultrasound: Musculoskeletal (Griffith, 2025), a complete standardized examination is performed on all patients and covers the following structures:
| Structure | Position / Technique |
|---|---|
| Supraspinatus Muscle | Crass Position and Modified Crass Position |
| Infraspinatus and Teres Minor Muscles | Hand on the opposite shoulder or supinated on the opposite thigh |
| Biceps Tendon | Arm along the body, elbow flexed; examiner holds the wrist and gently rotates the arm to bring the bicipital groove into view |
| Subscapularis Muscle | Oriented from bottom to top; scanning in long and short axis along this plane |
| Shoulder Joint Recesses | Lateral decubitus position for the posterior recess; supine position with external rotation of the arm for the anterior recess |
Dynamic Assessment of Impingement
For the assessment of subacromial impingement, dynamic scanning is performed to reproduce the patient's pain (Griffith, 2025). The transducer is placed in the long axis at the lateral edge of the acromion or over the coracoacromial ligament. The pronated arm is raised at an angle of ~45° forward from the shoulder, assessing symptoms and the degree of impingement.
Assessment of the Posterior Joint Recess
In the longitudinal plane, the posterior part of the shoulder joint, the glenoid, labrum, and humeral head deeper than the musculotendinous junction of the infraspinatus muscle are identified. A slight passive rotation of the arm during scanning facilitates the identification of the shoulder joint (Griffith, 2025).
Note: Specific numerical norms for tendon thickness and effusion volumes are not provided in the source fragments [clarify].
Frequently asked questions
Can a targeted examination of the pain area be sufficient for shoulder ultrasound?
No. A targeted regional approach is not recommended for the shoulder, as pain is often diffuse or referred. A full standardized protocol is performed with subsequent targeted evaluation of areas of tenderness (Jacobson, 2026).
How to properly bring the bicipital groove into view?
The patient places their hand palm up on their thigh — this rotates the bicipital groove anteriorly. Alternatively: arm along the body, elbow flexed, examiner holds the wrist and gently rotates the arm to bring the groove into view (Jacobson, Griffith).
In what position should the posterior joint recess be assessed?
In the lateral decubitus position. In the longitudinal plane, the posterior part of the joint, glenoid, labrum, and humeral head deeper than the musculotendinous junction of the infraspinatus muscle are brought into view (Griffith, 2025).
How to conduct a dynamic assessment of subacromial impingement?
The transducer is placed in the long axis at the lateral edge of the acromion or over the coracoacromial ligament; the pronated arm is raised at an angle of ~45° forward, assessing symptoms and the degree of impingement. The goal is to reproduce the patient's pain (Griffith, 2025).
How to position for the assessment of the infraspinatus and teres minor muscles?
The patient's hand is placed on the opposite shoulder or supinated on the opposite thigh (Griffith, 2025).