الفهرس 
Anatomy of the Shoulder ?Only 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 injections for rotator cuff disease remain unclear, with conflicting studies and inconclusive results of systematic reviews and meta-analyses 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 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 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