Biceps and Subscap Tendon Pathology (Lecture 3b)

What is the most common reason for requesting a shoulder ultrasound?

Rotator cuff injury or disease.

TRUE or FALSE: A trace of fluid (less than 1mm) adjacent to the biceps tendon is considered normal.

TRUE: This is synovial fluid to reduce friction from biceps tendon motion.

What stabilizes the biceps pulley or sling to maintain the long head biceps tendon within the bicipital groove?

Complex capsuloligamentous structure including:

- superior glenohumeral ligament

- coracohumeral ligament

- distal attachment of the subscapularis tendon

What is joint effusion? What is the sonographic appearance of this in the biceps tendon?

- Increased fluid in a joint space, often due to injury or inflammation (effusion indicates patho somewhere else)

SF:

- Simple fluid surrounding tendon

- No vasc

What is tenosynovitis? What is its m/c cause? What is its SF?

- Inflammation of the synovial sheath (synovium) surrounding a tendon

- M/c cause: repetitive strain injury (RSI)

- SF: fluid collection w/i tendon sheath, hypervascularity

What is synovial hypertrophy? What are its SF?

Thickened synovium with increased vascularity, often associated with inflammation, infection, or trauma.

SF:

- Thickened synovium

- Inc vasc

- Complex fluid - echoes/debris within

What is the difference between tenosynovitis and synovial hypertrophy?

Tenosynovitis refers to the inflammation of the synovium. Synovial hypertrophy refers to a thickened synovium. Therefore, tenosynovitis is often a cause of synovial hypertrophy.

How can you differentiate between effusion and synovitis?

Effusion

- increased fluid in a joint with no vascularity,

- anechoic

- complex (may have debris within)

- compressible with light transducer pressure

Synovitis

- hyperemia

- focal tendon sheath distention

- more symptomatic (focal tenderness)

- NOT compressible w/ transducer pressure

What is the retinaculum?

A band of connective tissue that covers and stabilizes a tendon (seen in type 2 tendons)

What is stenosing tenosynovitis?

During tenosynovitis, there is less space for tendon to slide under retinaculum, preventing normal translocation

TRUE or FALSE: Stenosing tenosynovitis can be seen in the transverse humeral ligament and coracohumeral ligament.

TRUE

What is the significance of dynamic assessments in shoulder pathology?

They help identify tendon instability and subluxation.

(if retinaculum is lax, tendon may move out of its groove = subluxation)

What is the cause of biceps tendinosis? What is the CP? What part of the tendon is it m/c seen in? What is its SF?

- Cause: chronic repetitive overhead motion increasing friction in the bicep pulley

- CP: complaints of deep, throbbing pain over anterolateral shoulder radiating to arm

- M/c seen in first 3.5cm of biceps tendon (over humeral head/prox bicipital groove)

- SF: , enlarged, hypoechoic, thickened tendon fibres w/ no visible fibre tears (however, tendinosis predisposes to partial/full tears)

What distinguishes partial tears from complete tears of the biceps tendon sonographically?

- Partial: looks like split within tendon (anechoic area within tendon)

- Complete: looks like an empty groove (only fluid is within groove)

What are the SF of subscapularis tendinosis?

Enlarged, hypoechoic, thickened tendon fibres

TRUE or FALSE: Subscapularis tears are often acute injuries.

FALSE: Subscapularis tears are often CHRONIC injuries, associated with tendinosis or arthritis.

A subscapularis tear is rarely an isolated finding. What other tendon often also has a tear with a subscap tear?

Supraspinatus

What is calcific tendinosis? What is its SF?

- Chronic degeneration of a tendon resulting in calcium deposits due to continuous repair of microtears.

- SF: tiny echogenic foci within tendon, large calculus within tendon (looks like gallstone)

Where is the subscapularis bursa located?

It is continuous with the intra-articular GH capsule, seen under the subscap

What could cause impingement under the coracoid?

- Distended subcoracoid bursa (bursitis)

- Distended subscapularis bursa (bursitis)

- Thickened subscapularis tendon