CASE 140
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 65-year-old male with right shoulder pain.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
The AP radiograph of the right shoulder demonstrates superior migration of the humeral head with marked narrowing of the subacromial space. The glenohumeral joint is narrowed. Acromioclavicular joint demonstrates moderate degenerative changes.
Long axis ultrasound of the right shoulder demonstrates complete full thickness tear of the supraspinatus tendon with retraction of the musculotendinous junction by approximately 3 cm.
Short axis of the biceps tendon demonstrates the biceps tendon outside of the bicipital groove the biceps tendon is also thickened and edematous [orange arrow].
DIAGNOSIS:
Full rotator cuff tear and biceps tendon dislocation.
PEARLS AND DISCUSSION:
In patients older than 40 years, the main causes of shoulder pain and/or functional deficit are adhesive capsulitis (frozen shoulder), impingement and/or rotator cuff disease. Ultrasonography has a proven role in assessing tendons of the rotator cuff. This examination is used to identify and classify pathology, and it can help clinicians in making decisions about ongoing management of the condition.
Ultrasonography is well tolerated and cost-effective. Its disadvantages include a long learning curve and reduced sensitivity in patients who are obese or who have severely restricted shoulder movement.
Long head of biceps is located inferiorly in the bicipital groove and held by the transverse humeral ligament. More superiorly it is held by the superior Glenohumeral ligament and the coracohumeral ligament. When these ligaments are gone such as in cases of rotator cuff tear that is severe enough, the tendon is dislocated medially. Or interestingly when the subscapularis is deficient in severe rotator cuff the long head of biceps will prolapse into the glenohumeral joint.
Full rotator cuff tear on ultrasound as discontinuity of the tendon fibers from the articular to the bursal surface. Both the deltoid bursa and overlying deltoid muscle will be seen dipping as in our case here massive tears such in our case are recognized with complete absence of the tendon. Space over the humeral head is filled by the deltoid muscle and subacromial subdeltoid bursa.
The reported range of sensitivity and specificity for ultrasonography in detecting FTRCTs is 57-100% and 50-100%, respectively.
FURTHER READING:
1. Kolla S, Motamedi K. Ultrasound evaluation of the shoulder. Semin Musculoskelet Radiol. 2007 Jun. 11(2):117-25. [Medline].
2. McNally EG, Rees JL. Imaging in shoulder disorders. Skeletal Radiol. 2007 Nov. 36(11):1013-6. [Medline].
3. Teefey SA, Hasan SA, Middleton WD, et al. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000 Apr. 82(4):498-504
