POCUS That Shoulder
By Stuart Butler
A patient walks into clinic with a familiar story: a painful arc, night pain, and tenderness over the anterolateral shoulder. The clinical picture is consistent with subacromial bursitis. Yet there’s also an unexpected weakness in abduction that doesn’t quite fit. Is this just pain inhibition, or is there a more significant rotator cuff pathology lurking underneath?
This is where point of care ultrasound (POCUS) can help. Used alongside a thorough history and examination, ultrasound provides an immediate window into the shoulder that helps confirm or challenge our working hypothesis. In this case, it allows us to visualise the subacromial bursa while also ruling out a full-thickness cuff tear. Crucially, it does not stand alone. POCUS should be viewed as an extension of the clinical examination, not as a substitute for diagnostic sonography.
When assessing the shoulder, POCUS allows comparison with the contralateral side and reinforces an important truth: imaging findings are common in asymptomatic shoulders, and clinical correlation remains paramount [2].
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What is POCUS and Why the Shoulder?
POCUS refers to the use of ultrasound imaging by the treating clinician in clinic to complement clinical reasoning and guide management decisions. It is distinct from sonography performed by radiographers or radiologists, where the purpose is to generate a formal diagnostic report. For physiotherapists, POCUS is not about competing with imaging departments but about adding real-time information to the assessment process.
The shoulder is a natural candidate for POCUS. It is relatively superficial, the tendons and bursa are easily accessible, and many pathologies can be dynamically assessed in a way that other imaging modalities cannot replicate. The rotator cuff, the subacromial-subdeltoid bursa, the long head of biceps tendon, and even joint effusions can all be evaluated quickly at the point of care.
The clinical value lies not just in visualising tissue but in refining decision-making. Does this patient need a referral for further imaging? Can we safely commence a rehabilitation programme without fear of missing a tear? Is the patient’s pain consistent with what we see on screen? These are the practical, shoulder-specific questions POCUS help to answer.
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CSP Guidance: Setting the Standard
In 2022, the Chartered Society of Physiotherapy (CSP) published professional guidance on the use of POCUS in physiotherapy practice [1]. This was a landmark moment, giving the profession a clear framework on how ultrasound should be used safely, effectively, and within scope .
The key messages are: