The aim of this book was to stress the meaning of the ultrasound examination without which we cannot imagine the differential diagnostics in the area of the shoulder joint nowadays. Mainly in rheumatologic practice we meet patients at who we can simultaneously find a few basic pathological states in the area of the shoulder girdle i.e. arthritis of the glenohumeral and acromioclavicular articulation, bursitis, tenovaginitis of the long head of the biceps, often in various combinations. The development points out that the entrance ultrasound examination in these cases will have a clear priority before any other examination. An clinical picture in the area of the shoulder is sometimes deceptive, and the ultrasound brings trustworthy findings having a basic meaning for an adequate therapy. We cannot consider in any case the anamnesis and clinical examination together with the X-ray of the shoulder joint for adequate ones for the diagnostics of the pathological state in the area of the shoulder joint. If we evaluated 4 years of our work with the ultrasound device and its contribution for our patients, we could introduce these outcomes:

A usage of the ultrasound, which must become a procedure immediately accessible in the outpatient department, is except the basic anamnesis and physical examination an entrance examination at pains of the shoulder girdle. (If for example we do not have in mind traumas with a suspicion of osseous pathology with the entrance X-ray examination).

Examining methods as MRI and arthroscopy are indicated after this examination, or the ultrasound at least more specifies on which structures these methods have to be aimed at. Our conclusion is that most frequent affected structure in the area of the shoulder girdle is the tendon of the long head of the biceps.

From other structures we began to be more interested in the acromioclavicular articulation whose role for the origin of problems is, in our opinion, underestimated.

A finding out of a present occurrence of several pathological states at the same patient was quite surprising.

A high effectiveness of a local steroid was found out also at the diagnoses as traumas of the shoulder girdle where the steroids are not used for the time being. We have of course in mind the traumas with a great inflammatory reaction, and a secondary presence of a liquid in bursae, joints with a synovial epithelium, and a tendon of the long head of the biceps. But a success of this therapy came if the steroids were applied targetably under the ultrasound, and the pathological liquid was aspirated before the peritendinous injection. At this progress the applications of steroids neither parcial ruptures of the tendons were not contraindications for us.

Not to be full only of optimism for a possible reader, we have to admit that some problems, which in our opinion deserve another attention, occurred. Exudative tenovaginitis of the long head of the biceps in the acute stage with a presence of highly inflammatory (little viscid) liquid reacted on the therapy with steroids perfectly. Unfortunately tenovaginitis of the long head of the biceps with a presence of viscid substances of a type of ganglion were resistant to this therapy. There were reoccurrences very often. We think that a solution for this state is an operation, synovectomy of the sheath of the tendon of the long head of the biceps. Results which would confirm the effectiveness of tenosynovectomy, but we do not have them at our disposal so far.

The findings of the free liquid are clear in the ultrasound device. Sensitiveness and specifity at these finding in the case of the bursa, joint, tendon of the long head of the biceps is high, minimally the same as at MRI. But we meet also findings of an effusion of soft tissues which are not so expressive that we do not risk to publish them in this book. The ultrasound possibly seems to be more sensitive than MRI. It concerns mainly the possibility of dry synovitis of the glenohumeral and acromioclavicular articulation, and sometimes also tenovaginitis of the long head of the biceps.

We do not know sufficiently clinically efficient doses of local steroids yet. It is necessary to evaluate the present rather smaller doses. When we used the targetable applications under the ultrasound, we think that the undesirable effects of steroids so far applied without looking are decreasing. Therefore we consider carefully if it is more suitable to apply at the inflammation of synovial structures bigger doses of steroids than it was in the habit, i.e. about 40 50 mg of Depo Medrol of one application.