Shoulder ultrasound report template
A structured shoulder ultrasound report template used for shoulder ultrasound. It covers 8 sections and 33 fields, and includes a one-click normal preset.
Technique
High-frequency linear transducer ultrasound of the shoulder with static and dynamic assessment.
Sample normal shoulder ultrasound report
This is the text SonoTez generates when the doctor applies the template's normal preset. Measurements are left for the doctor to enter.
Technique
High-frequency linear transducer ultrasound of the shoulder with static and dynamic assessment.
Findings
Long head of biceps
The long head of biceps tendon is normally located within the bicipital groove with no sheath effusion.
Subscapularis
The subscapularis tendon is normal in thickness and fibrillar echotexture.
Supraspinatus
The supraspinatus tendon is normal in thickness and fibrillar echotexture.
Infraspinatus and teres minor
The infraspinatus tendon is normal in thickness and fibrillar echotexture.
Subacromial-subdeltoid bursa
No subacromial-subdeltoid bursal thickening or effusion.
Smooth subacromial gliding on dynamic abduction.
Glenohumeral and AC joints
No glenohumeral joint effusion.
The acromioclavicular joint is within normal limits for age.
Impression
No sonographic evidence of rotator cuff tear, tendinopathy or bursitis.
What to include: sections and measurements
Examination
- Side examined: right · left · bilateral
- Contralateral comparison: performed · not performed
- Dynamic assessment: performed · not performed / not tolerated
Long head of biceps
- Tendon: normal · tendinopathy · calcific tendinopathy · partial-thickness tear · full-thickness tear · complete rupture
- Position: within bicipital groove · subluxed · dislocated · empty groove
- Sheath fluid: none · small · moderate
Subscapularis
- Appearance: normal · tendinopathy · calcific tendinopathy · partial-thickness tear · full-thickness tear · complete rupture
- Tear width (mm)
- Tear length / retraction / gap (mm)
- Calcific deposit (mm)
- Doppler: no hyperaemia · hyperaemia / neovascularity
- Dynamic rotation: normal · subcoracoid impingement
Supraspinatus
- Appearance: normal · tendinopathy · calcific tendinopathy · partial-thickness tear · full-thickness tear · complete rupture
- Thickness (mm)
- Tear width (mm)
- Tear length / retraction / gap (mm)
- Calcific deposit (mm)
- Doppler: no hyperaemia · hyperaemia / neovascularity
- Partial tear surface: bursal · articular · intrasubstance
- Tear depth (mm)
- Distance from biceps to tear (mm)
Infraspinatus and teres minor
- Appearance: normal · tendinopathy · calcific tendinopathy · partial-thickness tear · full-thickness tear · complete rupture
- Tear width (mm)
- Tear length / retraction / gap (mm)
- Calcific deposit (mm)
- Doppler: no hyperaemia · hyperaemia / neovascularity
- Muscle bulk: normal · atrophy / fatty infiltration
Subacromial-subdeltoid bursa
- Bursa: normal · thickened · distended with fluid · thickened with fluid
- Bursal thickness (mm)
- Dynamic abduction: smooth subacromial gliding · bursal bunching · tendon impingement · not tolerated
Glenohumeral and AC joints
- Glenohumeral joint (posterior): no effusion · effusion · paralabral / spinoglenoid cyst
- Acromioclavicular joint: normal for age · degenerative · effusion · widened / disrupted
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.