A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis

MRI findings and clinical testing for preoperative diagnosis of long head of the biceps pathology

Purpose

Determine whether combining magnetic resonance imaging (MRI) observations and clinical tests could substantially improve sensitivity for diagnosis of long head of the biceps tendon (LHBT) pathology.

Methods

The authors retrospectively assessed a consecutive series of 140 patients who underwent arthroscopic rotator cuff repair for isolated supraspinatus tears. The presence of LHBT pathology was assessed preoperatively on MRI using three criteria and four clinical tests specific to shoulder injuries. Binary outcomes of MRI observations and four clinical tests were combined to identify combinations resulting in the best sensitivity using intra-operative arthroscopic findings as reference.

Results

The study cohort comprised 100 shoulders (58 men and 42 women) aged 56.6 ± 9.4 years (range, 30-76) at index surgery. A total of 29 combinations were tested to obtain the best diagnostic algorithm for LHBT pathologies. Only four combinations reached a sensitivity ≥0.75, but had a specificity <0.45. The 'Speed or Signal' combination achieved the highest sensitivity (Se: 0.88; 95% confidence interval [CI]: 0.73%-0.96%; Sp: 0.20; 95% CI: 0.10%-0.33%).

Conclusion

The most important findings of this study were that, for the diagnosis of LHBT pathology using clinical tests alone, the Speed test had the highest sensitivity (Se, 0.74), and using MRI observations alone, the signal intensity had the highest sensitivity (Se, 0.68). Combination of 'Speed test or Signal intensity' substantially improved the sensitivity (Se, 0.88) but yielded the lowest specificity (Sp, 0.20). The clinical relevance of these findings is that using the combination 'Speed or Signal' for preoperative diagnosis, 88% of pathologic LHBTs would be correctly diagnosed, while 80% of healthy LHBTs could be misdiagnosed as pathologic.

Level of Evidence

Diagnostic study, Level IV.

Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To synthesize the literature and critically appraise current evidence to determine the most accurate physical examination (clinical test or ultrasound) to detect pathologies of the long head of the biceps tendon (LHBT).

METHODS

A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of clinical tests or ultrasound versus arthroscopy for the assessment of LHBT pathologies were included.

RESULTS

Seven studies were included reporting on a total of 448 patients. One study on instability using ultrasound reported sensitivity and specificity of 1.00 and 0.96, respectively. Two studies on full-thickness tears using ultrasound reported sensitivity and specificity of 0.88-0.95 and 0.71-0.98, respectively. Four studies on partial-thickness LHBT tears reported sensitivity and specificity of 0.17-0.68 and 0.38-0.92, respectively, for clinical tests, versus 0.27-0.71 and 0.71-1.00, respectively, for ultrasound. Three studies on other LHBT pathologies reported sensitivity and specificity of 0.18-0.79 and 0.53-0.85, respectively, for clinical tests, versus 0.50 and 1.00, respectively, for ultrasound.

CONCLUSION

To detect LHBT pathologies, sensitivity is high-to-excellent using ultrasound, and moderate using Neer's sign and Speed's test, while specificity is high-to-excellent also using ultrasound, as well as the belly press, lift-off and Kibler's tests. The clinical relevance of these findings is that clinical tests are only reliable either to confirm or rule out LHBT pathologies, whereas ultrasound is reliable both to confirm and rule out LHBT pathologies. While diagnostic imaging cannot substitute for patient history and physical examination, the reliability and accessibility of ultrasound render it practical for routine use, particularly if clinical tests render unclear or contradictory findings.

LEVEL OF EVIDENCE

Level III.

Ultrasonic Through-Transmission Measurements of Human Musculoskeletal and Fat Properties

The study described here was aimed at investigating the feasibility of using the ultrasonic through-transmission technique to estimate human musculoskeletal and fat properties. Five hundred eighty-two volunteers were assessed by dual-energy X-ray absorptiometry (DXA) and ultrasonic transmission techniques. Bone mineral density (BMD), muscle and fat mass were measured for both legs and the whole body. Hip BMD and spine BMD were also measured. Ultrasonic transmission measurements were performed on the heel, and the measured parameters were broadband ultrasound attenuation (BUA), speed of sound (SOS), ultrasonic stiffness index (SI), T-score and Z-score, which were significantly correlated with all measured BMDs. The optimal correlation was observed between SI and left-leg BMD (p < 0.001) before and after adjustment for age, sex and body mass index (BMI). The linear and partial correlation analyses revealed that BUA and SOS were closely associated with muscle and fat mass, respectively. Multiple regressions revealed that muscle and fat mass significantly contributed to the prediction of transmission parameters, explaining up to 17.83% (p < 0.001) variance independently of BMD. The results suggest that the ultrasonic through-transmission technique could help in the clinical diagnosis of skeletal and muscular system diseases.

Arthroscopic Pan-Capsular and Transverse Humeral Ligament Release with Biceps Tenodesis for Patients with Refractory Frozen Shoulder

Arthroscopic capsular release allows direct visualization and release of inflamed tissues in refractory frozen shoulder. The reticular neural network in the long head of the biceps tendon (LHBT) and nerve endings of the transverse humeral ligament (THL) might be responsible for shoulder pain. We hypothesized that patients with painful refractory frozen shoulder benefited from pan-capsular release, THL release, and LHBT tenodesis. The LHBT tenodesis decreased the possibility of LHBT instability. The balance of the shoulder joint was maintained after such extensive release. From October 2013 to June 2019, patients with painful refractory frozen shoulder were enrolled consecutively at the same institute. All patients received arthroscopic pan-capsular, THL release, and suprapectoral LHBT tenodesis with a minimum of 2-year follow-up. Preoperative and postoperative shoulder range of motion (ROM), pain visual analog scale (PVAS), subjective shoulder value (SSV), constant score, LHBT score, acromio-humeral distance (AHD), and critical shoulder angle (CSA) were recorded. In total, 35 patients with an average age of 53.1 ± 9 years were enrolled. The average follow-up period was 24 ± 1.5 months. Forward elevation improved from 105.1° ± 17° to 147° ± 12° (p < 0.001), external rotation improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001), and internal rotation improved from L3 to T9 (p < 0.001), respectively, at final follow-up. PVAS improved from 7.3 ± 1.1 to 1.8 ± 0.6 (p < 0.001), constant score from 23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV from 27.7 ± 10.5 to 77.4 ± 3.8, respectively, at follow-up. No differences were found in AHD and CSA after surgery (p = 0.316, and p = 0.895, respectively). Patients with painful refractory frozen shoulder benefited from pan-capsular and THL release. A radiographically balanced shoulder joint was maintained even after such extensive release.

The Applicability of Provocative Functional Tests in the Diagnosis of Rotator Cuff Muscle Injuries of the Best University Athletes

Rotator cuff disease, external and internal impingement syndromes, low shoulder stability, various types of trauma, and overuse injuries are all related to sports activities. In order to check symptoms in patients with disability and shoulder pain, clinicians use different methods and diagnostic imaging assessment. The research is aimed at evaluating whether there is a difference between provocation function tests (PFT) and ultrasonographic (US) testing of muscles within the rotator cuff in elite collegiate athletes. Patients ( $n=184$ ) were recruited from university team sports selections and tested with a standardized US examination of the shoulder and five PFTs (Speed’s test, Neer’s test, Hawkins test, lift-off test, Yergason’s test). Based on the VAS pain assessment scale, 60 subjects had some pain, which was taken for further processing in the work (124 subjects did not have the presence of pain and were excluded from further processing). The US examination was conducted using Voluson 730 apparatus, by a linear probe, with the frequency in the range of 6-12 MHz. The chi-square test showed significant differences between PFT and the occurrence of shoulder muscle tendinitis for the following variables: Speed’s test and subscapularis tendinitis ( $p=0.02$ ) and Speed’s test and infraspinatus tendinitis ( $p=0.01$ ); Neer test and biceps brachii caput longum tendinitis ( $p=0.01$ ), Neer test and supraspinatus tendinitis ( $p=0.02$ ) and Neer test and infraspinatus tendinitis ( $p=0.01$ ); lift-off test and subscapularis tendinitis ( $p=0.05$ ); and Yergason’s test and biceps brachii caput longum tendinitis ( $p=0.03$ ) and Yergason’s test and subscapitis tendinitis ( $p=0.01$ ). The greatest effect of differences was observed in Neer’s test and biceps brachii caput longum tendinitis ( $\phi =0.60$ ), while the other effects can be described as medium and small in most cases. It can be concluded that functional tests are good predictors of soft tissue changes in the muscles of the rotator cuff of the shoulder. Further monitoring and analysis are needed on a larger number of athletes.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).

MATERIALS AND METHODS

A search was performed on PubMed, Embase^®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded.

RESULTS

Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.

CONCLUSION

To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.

LEVEL OF EVIDENCE

III.

Diagnostic ultrasound in patients with shoulder pain: An inter-examiner agreement and reliability study among Dutch physical therapists

STUDY DESIGN

A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care.

BACKGROUND

musculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears.

OBJECTIVES

To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain.

METHODS

Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's).

RESULTS

Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy.

CONCLUSIONS

Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.

Clinical Tests of the Shoulder: Accuracy and Extension Using Dynamic Ultrasound

Shoulder pain is a common musculoskeletal disorder that has a significant impact on the patient's quality of life and functional health. Because the shoulder joint is a complex structure, the relevant symptoms of shoulder pain may not directly reflect the underlying pathology. Hence, several shoulder tests have been developed to examine shoulder problems, and their diagnostic accuracy varies. Familiarization with the performance of those physical tests and their strength and limitation are of utmost importance for physicians dealing with shoulder disorders. Therefore, the present narrative review focuses on summarizing the most commonly used tests in physical examination and their diagnostic performance on several shoulder pathologies. This article also discusses how ultrasound imaging can serve as an extension of those tests.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study

OBJECTIVE

The aim was to assess diagnostic accuracy of 15 shoulder special tests for rotator cuff tears.

DESIGN

From February 2011 to December 2012, 208 participants with shoulder pain were recruited in a cohort study.

RESULTS

Among tests for supraspinatus tears, Jobe test had a sensitivity of 88% (95% confidence interval [CI], 80%-96%), specificity of 62% (95% CI, 53%-71%), and likelihood ratio of 2.30 (95% CI, 1.79-2.95). The full can test had a sensitivity of 70% (95% CI, 59%-82%) and a specificity of 81% (95% CI, 74%-88%). Among tests for infraspinatus tears, external rotation lag signs at 0 degrees had a specificity of 98% (95% CI, 96%-100%) and a likelihood ratio of 6.06 (95% CI, 1.30-28.33), and the Hornblower sign had a specificity of 96% (95% CI, 93%-100%) and likelihood ratio of 4.81 (95% CI, 1.60-14.49).

CONCLUSIONS

Jobe test and full can test had high sensitivity and specificity for supraspinatus tears, and Hornblower sign performed well for infraspinatus tears. In general, special tests described for subscapularis tears have high specificity but low sensitivity. These data can be used in clinical practice to diagnose rotator cuff tears and may reduce the reliance on expensive imaging.

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps

BACKGROUND

Clinical examination of the shoulder joint has gained attention as clinicians aim to use an evidence-based examination of the biceps tendon, with the desire for a proper diagnosis while minimizing costly imaging procedures. The purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing long head of biceps (LHB) pathology.

METHODS

A literature review of Level I and II diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of PubMed, Medline, Ovid, and Cochrane Review databases. Tests were combined in series and parallel to determine sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pretest probability. The "gold standard" for diagnosis in all included studies was arthroscopy or arthrotomy.

RESULTS

The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test.

CONCLUSION

Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy (practical, evidence-based, comprehensive examination). A decision tree analysis aides in the practical, evidence-based, comprehensive examination diagnostic accuracy post-testing based on the ordinal scale pretest probability.

Role and Correlation of High Resolution Ultrasound and Magnetic Resonance Imaging in Evaluation of Patients with Shoulder Pain

Background

The study aimed to evaluate of the role of high-resolution ultrasound and magnetic resonance imaging in patients with shoulder pain.

Material/Methods

This prospective study included 50 patients referred for ultrasound and MRI because of shoulder pain. All patients were examined clinically, followed by radiography of the affected shoulder. High-resolution ultrasound examination of the involved shoulder was performed together with an examination of the contralateral normal shoulder, followed by MRI of the symptomatic shoulder in all 50 patients.

Results

In the present study, the majority of patients were in age group 56–65 years, 56% were males and 44% were females (of a total of 50 patients). A total of 40 patients were diagnosed as having rotator cuff tears on ultrasound (USG) and MRI. USG showed complete-thickness tears in 25 patients and partial-thickness tears in 15 patients. MRI detected 28 complete- and 12 partial-thickness tears of the rotator cuff. In the diagnosis of rotator cuff tears, the strength of agreement between ultrasound and magnetic resonance imaging was good (kappa coefficient=0.79).

Conclusions

Ultrasonography of the shoulder shows promising results in the diagnosis of rotator cuff tears and in differentiating partial from complete tears. A wide availability, cost effectiveness and better tolerability of ultrasonography make it a modality of first choice for evaluating rotator cuff tears.

Quantitative ultrasound facilitates the exploration of morphological association of the long head biceps tendon with supraspinatus tendon full thickness tear

Backgrounds

Pathology of the long head biceps tendon (LHBT) is associated with rotator cuff tears but whether the LHBT texture changes following supraspinatus tendon full thickness tear (SSFT) can be detected at the extra-articular segment remains unknown. This cross-sectional study aimed to explore the morphological differences of the LHBT in shoulders with and without deficient rotator cuffs by using quantitative ultrasound.

Materials and Methods

We selected 145 cases with SSFT and 145 age-and- gender-matched controls. The width, thickness, flattening ratio, cross-sectional area, and echogenicity ratio of the LHBT were measured and a general linear model was used to clarify the relationship between rotator cuff pathology and LHBT morphology. The receiver operating characteristic curves of each parameter were constructed for SSFT discrimination and the maximal Youden indexes were used to define the best cut-off points.

Results

We found increased thickness and cross-sectional area but decreased flattening ratio in shoulders with SSFT, and no between-group differences in the width and echogenicity ratio. The LHBT appearance was modified by biceps peritendinous effusion and medial subluxation, but not by the size of SSFT. The flattening ratio was the best discriminator for SSFT with an area under curve of 0.81 (95% confidence interval, 0.76–0.86). The cut-off values to differentiate between the non-tear and tear groups were 2.00 mm of the thickness, 1.73 of the flattening ratio and 10.53 mm² of the cross-sectional area.

Conclusion

Quantitative ultrasound facilitated the detection of the LHBT morphological changes following SSFT and demonstrated its potential utility in discriminating rotator cuff deficiency.

Quantitative diagnostic method for biceps long head tendinitis by using ultrasound

Objective. To investigate the feasibility of grayscale quantitative diagnostic method for biceps tendinitis and determine the cut-off points of a quantitative biceps ultrasound (US) method to diagnose biceps tendinitis. Design. Prospective cross-sectional case controlled study. Setting. Outpatient rehabilitation service. Methods. A total of 336 shoulder pain patients with suspected biceps tendinitis were recruited in this prospective observational study. The grayscale pixel data of the range of interest (ROI) were obtained for both the transverse and longitudinal views of the biceps US. Results. A total of 136 patients were classified with biceps tendinitis, and 200 patients were classified as not having biceps tendinitis based on the diagnostic criteria. Based on the Youden index, the cut-off points were determined as 26.85 for the transverse view and 21.25 for the longitudinal view of the standard deviation (StdDev) of the ROI values, respectively. When the ROI evaluation of the US surpassed the cut-off point, the sensitivity was 68% and the specificity was 90% in the StdDev of the transverse view, and the sensitivity was 81% and the specificity was 73% in the StdDev of the longitudinal view to diagnose biceps tendinitis. Conclusion. For equivocal cases or inexperienced sonographers, our study provides a more objective method for diagnosing biceps tendinitis in shoulder pain patients.