Biceps pulley: normal anatomy and associated lesions at MR arthrography

Biceps Pulley Lesions: Diagnostic Accuracy of Nonarthrographic Shoulder MRI and the Value of Various Diagnostic Signs

BACKGROUND

There is limited data in the literature regarding the role of nonarthrographic MRI for detecting biceps pulley (BP) lesions.

PURPOSE

To assess the accuracy of nonarthrographic MRI for detecting BP lesions, and to evaluate the diagnostic value of various MRI signs (superior glenohumeral ligament discontinuity/nonvisibility, long head of biceps (LHB) displacement sign or subluxation/dislocation, LHB tendinopathy, and supraspinatus and subscapularis tendon lesions) in detecting such lesions.

STUDY TYPE

Retrospective.

POPULATION

84 patients (32 in BP-lesion group and 52 in BP-intact group-as confirmed by arthroscopy).

FIELD STRENGTH/SEQUENCE

1.5-T, T1-weighted turbo spin echo (TSE), T2-weighted TSE, and proton density-weighted TSE spectral attenuated inversion recovery (SPAIR) sequences.

ASSESSMENT

Three radiologists independently reviewed all MRI data for the presence of BP lesions and various MRI signs. The MRI signs and final MRI diagnoses were tested for accuracy regarding detecting BP lesions using arthroscopy results as the reference standard. Furthermore, the inter-reader agreement (IRA) between radiologists was determined.

STATISTICAL TESTS

Student's t-tests, Chi-squared, and Fisher's exact tests, and 4-fold table test were used. The IRA was calculated using Kappa statistics. A P-value <0.05 was considered statistically significant.

RESULTS

The sensitivity, specificity, and accuracy of nonarthrographic MRI for detecting BP lesions were 65.6%-78.1%, 90.4%-92.3%, and 81%-86.9%, respectively. The highest accuracy was noticed for the LHB displacement sign (84.5%-86.9%), and the highest sensitivity was registered for the LHB tendinopathy sign (87.5%). Furthermore, the highest specificity was observed for the LHB displacement sign and LHB subluxation/dislocation sign (98.1%-100%). The IRA regarding final MRI diagnosis and MRI signs of BP lesions was good to very good (κ = 0.76-0.98).

DATA CONCLUSION

Nonarthrographic shoulder MRI may show good diagnostic accuracy for detecting BP lesions. The LHB displacement sign could serve as the most accurate and specific sign for diagnosis of BP lesions.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Concomitant Biceps Tenodesis Does Not Compromise Arthroscopic Rotator Cuff Repair Outcomes

PURPOSE

To compare outcomes of patients who underwent rotator cuff repair (RCR) with concomitant biceps tenodesis with those who underwent an isolated RCR.

METHODS

Exclusion criteria included previous ipsilateral shoulder surgery, irreparable rotator cuff tears, rotator cuff arthropathy, calcific tendinitis, adhesive capsulitis requiring a capsular release, or advanced osteoarthritis of the glenohumeral joint. Patients were indicated for biceps tenodesis if they had any degree of tendon tearing, moderate-to-severe tenosynovitis, instability, or a significant degenerative SLAP tear. Primary outcome measures included American Shoulder and Elbow Surgeons score, Simple Shoulder Test, EuroQoL 5-Dimension 5-Level visual analog scale, EuroQoL 5-Dimension 5-Level, and a site-specific questionnaire, which focused on surgical expectations, satisfaction, and complications. Multivariate analysis of variance to analyze descriptive statistics and determine significant differences between the patient groups for subjective and objective outcome measures were performed.

RESULTS

There were no significant differences for pain/visual analog scale (0.34 ± 0.09 vs 0.47 ± 0.09, P = .31), American Shoulder and Elbow Surgeons score (96.69 ± 0.87 vs 94.44 ± 0.91, P = .07), and Simple Shoulder Test (11.42 ± 0.17 vs 10.95 ± 0.18, P = .06) between the RCR with concomitant biceps tenodesis and isolated RCR at a minimum of 2 years' postoperatively. This is despite the RCR with concomitant biceps tenodesis group having significantly larger rotator cuff tears (4.25 ± 0.30 cm2 vs 2.80 ± 0.32 cm2, P = .001) than the isolated RCR group.

CONCLUSIONS

This study revealed that concomitant biceps tenodesis does not compromise outcomes when compared with an isolated RCR at 2-year follow-up, despite this group having larger rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective case study.

Is It Time to Rethink the Relationship Between Subscapularis Tears and the Long Head of Biceps Tendon?

Introduction Pre-operative diagnosis of subscapularis tears remains a difficult challenge. Ultrasound has been shown to be ineffective at directly detecting subscapularis tears. It has been widely accepted that medial subluxation of the long head of biceps tendon (LHBT) is associated with full-thickness subscapularis tears. The aims of this study are to assess whether LHBT subluxation on ultrasound scanning has any predictive value for subscapularis tears and to determine the relationship between LHBT subluxation and subscapularis tears at arthroscopy. Methods Pre-operative ultrasound and arthroscopic findings for patients undergoing arthroscopic rotator cuff repair at our institution between March 2011 and January 2016 were analysed. The accuracy of LHBT subluxation on ultrasound and at arthroscopy as a predictor of subscapularis tears at arthroscopy was calculated. The correlation between LHBT subluxation and subscapularis tears was determined. A standardised technique was used for ultrasound scans, and the grade of the sonographer was recorded. Results Three hundred fifty-nine rotator cuff repairs were performed. Twenty-four patients had a subluxed LHBT. Ultrasound was poorly sensitive (50%), and a subluxed LHBT on ultrasound only correlated very weakly with subscapularis tears at arthroscopy (R = 0.268, p<0.001). At arthroscopy, 92 patients had full-thickness subscapularis tears. Of these, only 16 patients (17%) had a subluxed/dislocated LHBT. Of the 24 patients with a subluxed LHBT, eight had no subscapularis tears. Thus, LHBT subluxation/dislocation only correlated weakly with full-thickness subscapularis tears (R=0.252, p<0.001). Conclusion Due to their close anatomical relationship, traditional teaching suggests subscapularis tears are associated with medial LHBT subluxation. Our data indicate that, contrary to popular belief, the two are only weakly correlated. In our series, the majority of patients with subscapularis tears (83%) had their LHBT in-groove. The authors therefore recommend high vigilance during arthroscopy for the diagnosis and repair of subscapularis tears, regardless of pre-operative ultrasound findings and the intra-operative position of the LHBT.

Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation

Adhesive capsulitis is an idiopathic and disabling disorder characterized by intense shoulder pain and progressive limitation of active and passive glenohumeral joint range of motion. Although adhesive capsulitis has been traditionally considered a diagnosis of exclusion that can be established based on a suggestive medical history and the detection of supporting findings at the physical exam, imaging studies are commonly requested to confirm the diagnostic suspicion and to exclude other causes of shoulder pain. Indeed, clinical findings may be rather unspecific, and may overlap with diseases like calcific tendinitis, rotator cuff pathology, acromioclavicular or glenohumeral arthropathy, autoimmune disorders, and subacromial/subdeltoid bursitis. Magnetic resonance imaging, magnetic resonance arthrography, and high-resolution ultrasound have shown high sensitivity and accuracy in diagnosing adhesive capsulitis through the demonstration of specific pathological findings, including thickening of the joint capsule and of the coracohumeral ligament, fibrosis of the subcoracoid fat triangle, and extravasation of gadolinium outside the joint recesses. This narrative review provides an updated analysis of the current concepts on the role of imaging modalities in patients with adhesive capsulitis, with the final aim of proposing an evidence-based imaging protocol for the radiological evaluation of this condition.

Correlation between the morphological features of the biceps groove and injuries to the biceps pulley and the long head tendon of the biceps

PURPOSE

The morphometric features of the biceps groove were measured to investigate their correlation with the injury of the pulley and the long head of the biceps tendon (LHBT).

METHODS

A total of 126 patients undergoing arthroscopic rotator cuff repair surgery had their morphological features of bicipital groove evaluated on a 3D reconstruction model of the humeral head. The groove width, groove depth, opening angle, medial wall angle, and inclination angle of the bicipital groove were measured for each patient. During the surgery, the type of injury to the biceps pulley and the degree of long head of biceps tendon injury were assessed. The correlations of these injury assessments with bicipital groove measurements were analyzed.

RESULTS

The average groove width was(12.3 ± 2.1) mm. The average groove depth was(4.9 ± 1.4) mm. The average groove inclination angle was 26.3° ± 8.1°. The average opening angle was 89.8° ± 18.4°. The average medial groove wall angle was 40.6° ± 7.9°.Sixty six patients had injury of the biceps pulley structure, and their Martetschläger classifications were as follows: type I injury in 12 patients, type II injury in 18 patients, and type III injury in 36 patients. The Lafosse grades of Lesions of LHBT were as follows: 72 cases were grade 0 injury, 30 cases were grade I injury, and 24 cases were grade II injury. We found no significant correlation between the opening width, depth, inclination angle, opening angle, and medial wall angle of the morphological features of bicipital groove and injuries of the pulley and the LHBT. The correlation between pulley structure injury and lesions of LHBT was statistically significant.

CONCLUSION

Lesions of LHBT show strong correlation with pulley injuries.This study does not find a correlation between the injury of the pulley or the LHBT and bicipital groove morphology.

Imaging of Anatomical Variants of the Long Head Biceps Tendon

Anatomical variants of the long head of biceps (LHB) tendon are widely discussed in the literature. As one of the few intra-articular tendons, magnetic resonance arthroscopy can quickly evaluate the proximal part of LHB morphology. It provides good assessment of both intra-articular and extra-articular portions of the tendons. In-depth knowledge about imaging of the anatomical LHB variants discussed in this article is useful preoperatively for orthopaedists and also helps avoid potential diagnostic misinterpretations.

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Imaging of the Long Head of Biceps Tendon and Rotator Interval

This article reviews the imaging and common pathology of the long head of biceps tendon and rotator interval (RI). This area of complex anatomy plays a crucial role in normal shoulder function. Injury or abnormality of the RI may contribute to a range of shoulder pathology, such as biceps instability, tendinopathy, and frozen shoulder. Understanding the normal and pathologic appearances of the RI structures is crucial for a correct diagnosis and directing treatment.

Usefulness of ultrasound in diagnosing long head of the biceps tendon malposition in patients with rotator cuff tears

PURPOSE

This study aimed to determine the role of preoperative shoulder ultrasonography (SUS) in detecting positional abnormalities of the long head of the biceps tendon (LHBT) and predicting subscapularis (SSC) tears in patients with rotator cuff injuries.

METHODS

A total of 331 patients (365 shoulders) who had undergone arthroscopic shoulder surgery for the treatment of rotator cuff tears were included in the study. Their preoperative SUS and magnetic resonance imaging (MRI) findings were examined retrospectively to assess the presence of LHBT abnormalities at the bicipital groove. Using arthroscopic findings as the standard of reference, the sensitivity, specificity, and diagnostic accuracy of SUS and MRI were calculated for detection of LHBT malposition. Furthermore, the correlation between SSC rupture and preoperative LHBT condition was evaluated by MRI and SUS.

RESULTS

LHBT malposition was preoperatively diagnosed with a sensitivity of 92%, specificity of 90%, and accuracy of 91% with SUS, and a sensitivity of 74%, specificity of 84%, and accuracy of 80% with MRI. Preoperative SUS was significantly superior to MRI in terms of sensitivity, specificity, and accuracy (p < 0.001 each). Further, the preoperative SUS LHBT findings could predict well the presence or absence of intraoperative SSC rupture (odds ratio: 1.73, p < 0.001).

CONCLUSION

SUS is a useful diagnostic modality for preoperative detection of LHBT malposition and prediction of SSC tears in patients with rotator cuff tears.

Anchoring Apparatus of Long Head of the Biceps Tendon: Ultrasonographic Anatomy and Pathologic Conditions

The long head of the biceps tendon (LHBT) has been recognized as an important generator of anterior shoulder pain, causing a significant reduction in the shoulder flexion range. Various tendinous and ligamentous structures form the anchoring apparatus of the LHBT along its course to maintain its appropriate location during shoulder movements, including the coracohumeral ligament (CHL), superior glenohumeral ligament (SGHL), subscapularis (SSC) tendon and supraspinatus (SSP) tendon as well as the less recognized tendons of pectoralis major (PM), latissimus dorsi (LD) and teres major (TM). Lesions of this stabilizing apparatus may lead to an instability of the LHBT, resulting in pain at the anterior shoulder. Ultrasonography (US) has been increasingly used in the assessment of shoulder injuries, including the anchoring apparatus of the LHBT. An accurate diagnosis of these injuries is often challenging, given the complex anatomy and wide spectrum of pathologies. In this review article, US anatomy and common pathologic conditions that affect the anchoring apparatus of the LHBT are discussed, including biceps pulley lesions, adhesive capsulitis, chronic pathology of SSC and SSP tendons, tears in the PM tendon and injuries to the LD and TM. Knowledge of a normal anatomy, an appropriate scanning technique and US findings of common pathologic conditions are the keys to accurate diagnoses.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management

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The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion.

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A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity.

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HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair.

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Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis.

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While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence.

Imaging Review of Subscapularis Tendon and Rotator Interval Pathology

As the largest rotator cuff muscle, the subscapularis plays a major role in stabilizing the glenohumeral joint, in conjunction with surrounding rotator cuff structures. Injury to the subscapularis tendon can be isolated, but more commonly is seen in conjunction with supraspinatus tendon pathology. Injury can be associated with biceps pulley instability, superior labral anterior-posterior (SLAP) tears, humeral head subluxation, and anterosuperior and coracoid impingements. The involvement of the rotator interval can lead to what is called “the hidden lesion,” due to its difficulty to diagnose during arthroscopy. Understanding the anatomical relations of the subscapularis tendon with the rest of the rotator cuff and rotator interval, as well as common patterns of injury that involve the subscapularis tendon, can aid in proper diagnosis of these injuries leading to prompt surgical repair. This review describes the anatomy of the subscapularis muscle and tendon, and the magnetic resonance imaging (MRI) patterns of subscapularis tendon injury.

MRI morphological evaluation of humeral head bone profile inside region of the biceps pulley reflection

OBJECTIVE

Evaluating humeral head bone profile inside biceps reflection pulley area in order to identify possible anatomical variants and any causes predisposing to tendon's instability of the long head of the biceps.

MATERIALS AND METHODS

This retrospective study analyzed 326 patients, 183 males and 143 females (age 15-88 years; average 51.5 years), who underwent MRI examination between 2013 and 2019. Biceps pulley reflection area morphology of 192 right shoulders and 134 left shoulders was assessed analyzing 309 MRI and 17 MR arthrography (MRA) shoulder exams. We investigated age and gender and the frequency of morphological variants among the patient groups.

RESULTS

Four possible morphological variants were identified: 95 with convex shape; 127 with flat shape; 77 with spiculated shape; and 12 with mixed morphology. Fifteen humeral bone profiles were not classifiable.

CONCLUSIONS

MRI was effective in defining humeral head anatomic variants inside the biceps pulley reflection area. The most frequent variants were flat or convex types.

Efficacy of management of associated dysfunctions on rotator cuff and long head of the biceps: systematic review

Background

The important functional role the rotator cuff (RC) and biceps play in the shoulder, the close anatomical relationship between them and the high incidence of injuries require an appropriate multidisciplinary therapeutic approach after a rigorous assessment. The objective is to identify and analyze surgical interventions, whether or not followed by a postsurgical one, of associated dysfunctions on the RC and long head of the biceps (LHB) and their effectiveness in improving shoulder functionality.

Methods

A systematic review based on PRISMA protocol was conducted using PubMed, Web of Science, PEDro, Scopus, CINAHL, and Dialnet until 22 April 2021. The main inclusion criteria were as follows: randomized clinical trials including subjects diagnosed with RC and LHB lesions who had surgical and/not post-surgical treatments. The methodological quality of trials was evaluated by the PEDro scale. Data were shown in 3 pre-established tables: (1)sample data, diagnostic methods, dysfunctions and injury frequency, interventions, outcome measures and results; (2)significance and effectiveness of interventions; and (3)comparison of the effectiveness of interventions.

Results

Eleven studies were selected. The methodological quality of ten of them was assessed as good and one excellent (PEDro scale). All articles had surgical treatments and ten had postoperative management. All trials used arthroscopy and two open surgery too. Single-row, double-row and transosseous repair were used for RC lesions, while SLAP repair, tenotomy, and tenodesis were applied to LHB injuries. Measured parameters were functionality, pain, Popeye’s sign, strength, range of motion, satisfaction degree, biceps cramping, and quality of life. All approaches in general, surgical plus postsurgical, were always effective to the parameters measured in each study. Seven trials compared tenotomy and tenodesis: four of them obtained statistically significant differences in favor of tenodesis in Popeye’s sign, cramping, satisfaction degree, and/or forearm supination strength; and one, in favor of tenotomy in cramping. All studies measured functionality using functional assessment scales. The most widely used was the Constant Score.

Conclusions

Surgical plus post-surgical interventions in associated dysfunctions on RC and LHB were effective. Tenodesis obtained better results than tenotomy in Popeye’s sign, satisfaction, and forearm supination strength. However, there was no difference regarding biceps cramping.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02621-0.

Intra-articular long head of the biceps tendon: magnetic resonance-arthrography classification and review of literature

Purpose

Anatomical variants of the long head of the biceps (LHB) and diseases of the rotator interval structures may contribute to shoulder instability. The rotator interval and the LHB tendon are closely associated anatomic structures that confer stability to the shoulder. Anatomical variants around the origins of the long head of the biceps (LHB) are reported to occur with a frequency of 1.9-7.4%. In the past years, many authors have proposed different approaches for the identification and characterization of LHB and rotators interval. Magnetic resonance (MR) arthrography is considered the reference standard in imaging to diagnose superior shoulder diseases. However, few authors have analysed the anatomical variants and the relation between those and shoulder instability. This study aimed to identify the frequency of variants observed during arthroscopic shoulder surgeries, and to classify them based on the Dierickx classification system.

Material and methods

In 326 MR arthrograms we investigated the incidence of LHB anatomical variations and their association with shoulder diseases.

Results

We found 252/326 (77.3%) cases of LHB free, 40/326(12.26%) cases of LHB adherent, 31/326(9.50%) cases of mesotenon, and 3/326(0.9%) cases of split biceps. The prevalence of rotator interval synovitis in the mesotenon group was greater than in the LHB-free group. Moreover, in the LHB-adherent group we observed increased incidence of sublabral recess and SLAP lesions compared with the LHB-free group.

Conclusions

MR-arthrography is useful in the evaluation of superior shoulder structures. A relationship exists between LHB anomalies and superior shoulder instability.

The glenohumeral ligaments: Superior, middle, and inferior: Anatomy, biomechanics, injury, and diagnosis

The three glenohumeral ligaments (superior, middle, and inferior) are discrete thickenings of the glenohumeral joint capsule and are critical to shoulder stability and function. Injuries to this area are a cause of significant musculoskeletal morbidity. A literature search was performed by a review of PubMed, Google Scholar, and OVID for all relevant articles published up until 2020. This study highlights the anatomy, biomechanical function, and injury patterns of the glenohumeral ligaments, which may be relevant to clinical presentation and diagnosis. A detailed understanding of the normal anatomy and biomechanics is a necessary prerequisite to understanding the injury patterns and clinical presentations of disorders involving the glenohumeral ligaments of the shoulder.

A new significance of an old structure: Aponeurotic expansion of supraspinatus tendon and its relationships with biceps brachii long head and rotator cuff tendons

PURPOSE

To investigate the relationship between aponeurotic expansion of supraspinatus tendon and disorders of biceps brachii long head (LHB), supraspinatus and subscapularis tendons.

METHODS

Images of 3.0 T shoulder magnetic resonance images (MRI) of a total of 154 patients and 157 shoulders (3 cases with bilateral imaging) between the ages of 18-45 were retrospectively evaluated for the presence of aponeurotic expansion. When identified it was further categorized according to its thickness. Tendinopathy and tears of LHB, supraspinatus and subscapularis tendons and LHB subluxations were evaluated individually. Statistical analyses were performed using Chi-square, Fisher's exact, Mann-Whitney U and Kruskall-Wallis tests. Odds ratio and multiple logistic regression analyses were performed when applicable. p < 0.05 was considered as statistically significant.

RESULTS

A total of 82 male and 72 female cases with a mean age of 34 (±8.2) were included. Aponeurotic expansion could be identified in 31 cases (19.8 %). MRI findings for LHB disorders in this group was significantly higher (p = 0.01). The adjusted odds ratio of having LHB tendinopathy in the presence of aponeurotic expansion was 3.25 (% 95 CI:1.29-8.19). No significant correlation was found between presence of aponeurotic expansion and subscapularis or supraspinatus tendon disorders (p = 0.66 and p = 0.792 respectively). Age was a significant variable for disorders of all three tendons (p < 0.001).

CONCLUSION

On 3.0 T MRI, findings of LHB tendon disorders were significantly more common in cases with aponeurotic expansion of supraspinatus tendon. This anatomical variation may have an unrecognized clinical significance.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the proximal biceps brachii

The biceps brachii myotendinous unit, particularly the long head of the biceps tendon and its labral attachment, is a common cause of shoulder and arm pain. Its complex anatomy and normal variations can present a challenge when interpreting MR images. The purpose of this manuscript is to review the proximal biceps anatomy, variants, pathology, and post-operative appearance as seen on MRI. Recent data regarding the accuracy of clinical examination and MRI will be summarized.

Biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion without a Hill-Sachs lesion: A case report and review of the literature

Combined injuries of the glenohumeral joint that involve biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion are extremely rare. As per our knowledge, this is the first case report that includes such combined injuries that were treated arthroscopically. We present the case of a 48-year-old male patient who sustained shoulder trauma after being thrown against the rocks by a wave, was found to have biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion.

The operative management resulted in complete restoration of the range of motion of the shoulder, and uneventful healing of the fracture. The patient recovered normal activity including his surfing.

Shoulder MR Imaging Versus Ultrasound: How to Choose

Imaging evaluation of the shoulder is performed using multiple modalities, including ultrasound (US) and MR imaging. Clinicians often wonder which modality to use to work up their patients with shoulder pain. Although MR imaging has remained the workhorse of shoulder imaging, US has increased in popularity among academic and private institutions. Both modalities offer similar diagnostic information in regards to rotator cuff pathology and other soft tissues, although they differ in their technique, indications, and interpretation. A thorough understanding of these differences is imperative to appropriately use these modalities in clinical practice, including the unique interventional opportunities available with US.

Capsular Injury and Inflammation

The capsular and ligamentous structures of the glenohumeral joint are important for stability of the shoulder. These structures are best evaluated by MR imaging. Familiarity with normal and abnormal appearance of the capsular structures of the shoulder is important to ensure that important pathology is not overlooked. Injury to the capsular structures can occur in the setting of trauma and most commonly involves the inferior glenohumeral ligament and axillary pouch. Adhesive capsulitis is a common inflammatory condition with characteristic imaging features that should be considered in the absence of alternative diagnoses.

Reliability of high-resolution ultrasound and magnetic resonance arthrography of the shoulder in patients with sports-related shoulder injuries

Introduction

The shoulder, a very complex joint, offers a wide range of pathologies. Intraarticular abnormalities and rotator cuff injuries are mainly assessed and diagnosed by magnetic resonance arthrography (MRA). In contrast to this well-established gold standard, high-resolution ultrasound (US) offers an additional easy and excellent modality to assess the shoulder joint. Therefore, the purpose of this study was to evaluate in which anatomic structures and pathologies comparable results of US and MRA could be achieved.

Materials and methods

In this IRB-approved prospective study 67 patients with clinically suspected labral lesions, rotator cuff rupture, or injury of the long head of the biceps (LHB) tendon were enrolled. Each participant was examined with high resolution US, and directly followed by MRA at 3 Tesla with a standard sequence protocol. To evaluate the agreement of the diagnostic performance between US and MRA a weighted kappa statistic was used.

Results

Both of the investigated modalities yielded a moderate to almost perfect agreement in assessing a wide range of shoulder joint pathologies. For the rotator cuff, consistency was found in 71.64% for the supraspinatus tendon, in 95.52% for the infraspinatus tendon, in 83.58% for the subscapularis tendon, and in 98.51% for the teres minor tendon.

The diagnostic accuracy between both modalities was 80.60% for the LHB tendon, 77.61% for the posterior labroligamentous complex, 83.58% for the acromioclavicular joint, and 91.04% for the assessment of osseous irregularities and impaction fractures.

Conclusions

High resolution US is a reliable imaging modality for the rotator cuff, the LHB tendon, and the acromioclavicular joint, so for these structures we recommend a preference for US over MRA based on its diagnostic accuracy, comfortability, cost effectiveness, and availability. If the diagnosis remains elusive, for all other intraarticular structures we recommend MRA for further diagnostic assessment.

Imaging of long head biceps tendon. A multimodality pictorial essay

The aim of this is article is to provide an  imaging review of normal anatomy, most common anatomical variants and pathologies of the long head of the biceps tendon (LHB) encountered during the daily practice.

Chronic lesser tuberosity avulsion in an adolescent with an associated biceps pulley injury

We report a case of a 15-year-old boy with chronic intermittent left shoulder pain due to an undiagnosed lesser tuberosity avulsion fracture, an associated biceps pulley injury and intra-articular dislocation of the long head of the biceps tendon. Lesser tuberosity avulsion fractures are rare injuries that are difficult to detect on clinical exam and radiographically, which may lead to delayed diagnosis and chronic shoulder instability. Few reports describe dislocations or subluxations of the biceps tendon in association with lesser tuberosity avulsions in children. We utilize this case to emphasize the importance of MR not only in detecting lesser tuberosity avulsions, but also in evaluating biceps pulley injuries, which are a rarely reported, but clinically important, association.

The high frequency of superior labrum, biceps tendon, and superior rotator cuff pathologies in patients with subscapularis tears: A cohort study

BACKGROUND

The purpose of this study was to assess the frequency of superior labrum anterior posterior (SLAP) lesions, long head of biceps tendon (LHBT) pathologies, and superior rotator cuff tears accompanying subscapularis tears. We hypothesised that LHBT lesions, superior rotator cuff tears, and especially SLAP lesions were very frequent with subscapularis tears.

METHODS

The digital files of patients who underwent shoulder arthroscopy were reviewed retrospectively. One hundred and eleven patients with subscapularis tears evident on surgery videos were examined. Superior labrum, LHBT, and superior rotator cuff lesions were investigated by the authors of this study. The statistical analyses were made with SPSS statistics software, and significance was set at P < 0.05 value.

RESULTS

There were 111 patients with both subscapularis tears and surgery videos. The mean age was 58.09 ± 10.21, and 63.1% of the patients were female. 98.2% of the 111 patients had a SLAP lesion. 7.2% of those were SLAP I and 91% were SLAP II lesions while 1.8% were healthy. The 75.7% of the patients had a LHBT pathology, and 83.8% had superior cuff tear.

CONCLUSIONS

Subscapularis tears were almost always accompanied by SLAP lesions. On the other hand, biceps tendon pathologies and superior rotator cuff tears were also very frequent with subscapularis tears.

LEVEL OF EVIDENCE

Prognostic study, Level IV (retrospective cohort study).

Beyond ulcers and osteomyelitis: imaging of less common musculoskeletal complications in diabetes mellitus

Metabolic perturbations in diabetes mellitus affect various organ systems and can lead to end-organ failure. Though most musculoskeletal (MSK) complications of diabetes mellitus are usually not life-threatening, they are often the cause of significant morbidity. While some of the MSK complications have a proven association with diabetes mellitus, others have been loosely associated because of their frequent coexistence, as are the rheumatologic complications. While many of these conditions are well-known, some are overlooked in routine clinical practice. This article focuses on highlighting key imaging features of less common MSK complications and associations of diabetes mellitus.

Instability of the long head of the biceps tendon in patients with rotator cuff tear: evaluation on magnetic resonance arthrography of the shoulder with arthroscopic correlation

OBJECTIVES

To evaluate the diagnostic value of MR arthrography (MRA) in diagnosing instability of the LHBT in patients with rotator cuff tendon tear.

MATERIALS AND METHODS

The MR arthrograms of 101 patients were retrospectively reviewed and correlated with arthroscopic findings as the standard reference. Images were evaluated for (1) the integrity of the LHBT, (2) the position of the LHBT (subluxation/dislocation on axial images, inferior displacement on oblique sagittal image) and (3) the integrity of the biceps pulley (SGHL, supraspinatus and subscapularis tendon adjacent to the rotator interval).

RESULTS

The integrity of the LHBT was correctly classified in 74.3% (75/101) and 66.3% (67/101) by readers 1 and 2, respectively. The diagnosis of LHBT instability could be made on axial images with a sensitivity of 82.6% and 73.9% and specificity of 69.9% and 87.7%, whereas the displacement sign on sagittal images had a sensitivity of 73.9% and 78.3% and a specificity of 64.4% and 61.6%, respectively. Assessing the integrity of the SGHL had a sensitivity of 60.9 and 93.3% and a specificity of 70.4 and 75.0%, respectively. By combining the different image findings, the accuracy in assessing LHBT instability was 80.9 and 90.5% with a sensitivity of 60.9 and 86.7% and specificity of 83.1 and 91.8%, respectively.

CONCLUSION

Individual image findings may have a limited role in diagnosing LHBT instability in patients with rotator cuff tendon tear. The accuracy of MRA may be improved by assessing the integrity of the biceps pulley structures along with the position of the LHBT on both axial and sagittal images.

Comprehensive Shoulder US Examination: A Standardized Approach with Multimodality Correlation for Common Shoulder Disease

Shoulder pain is one of the most common musculoskeletal conditions encountered in primary care and specialty orthopedic clinic settings. Although magnetic resonance (MR) imaging is typically the modality of choice for evaluating the soft-tissue structures of the shoulder, ultrasonography (US) is becoming an important complementary imaging tool in the evaluation of superficial soft-tissue structures such as the rotator cuff, subacromial-subdeltoid bursa, and biceps tendon. The advantages of US driving its recent increased use include low cost, accessibility, and capability for real-time high-resolution imaging that enables dynamic assessment and needle guidance. As more radiologists are considering incorporating shoulder US into their practices, the development of a standardized approach to performing shoulder US should be a priority to facilitate the delivery of high-quality patient care. Familiarity with and comfort in performing a standardized shoulder US examination, as well as knowledge of the types of anomalies that can be evaluated well with US, will enhance the expertise of those working in musculoskeletal radiology practices and add value in the form of increased patient and health care provider satisfaction. This review describes the utility and benefits of shoulder US as a tool that complements MR imaging in the assessment of shoulder pain. A standardized approach to the shoulder US examination is also described, with a review of the basic technique of this examination, normal anatomy of the shoulder, common indications for shoulder US, and characteristic US findings of common shoulder diseases-with select MR imaging and arthroscopic correlation. Online supplemental material is available for this article. ^©RSNA, 2016.

The Rotator Interval - A Link Between Anatomy and Ultrasound

Shoulder pathologies of the rotator cuff of the shoulder are common in clinical practice. The focus of this pictorial essay is to discuss the anatomical details of the rotator interval of the shoulder, correlate the anatomy with normal ultrasound images and present selected pathologies. We focus on the imaging of the rotator interval that is actually the anterosuperior aspect of the glenohumeral joint capsule that is reinforced externally by the coracohumeral ligament, internally by the superior glenohumeral ligament and capsular fibers which blend together and insert medially and laterally to the bicipital groove. In this article we demonstrate the capability of high-resolution musculoskeletal ultrasound to visualize the detailed anatomy of the rotator interval. MSUS has a higher spatial resolution than other imaging techniques and the ability to examine these structures dynamically and to utilize the probe for precise anatomic localization of the patient's pain by sono-palpation.

Role of MRI in a Series of Cases with Biceps Injuries of the Shoulder

Dislocation and injury of the biceps is associated with acute and chronic trauma, degenerative changes, repetitive microtrauma, or injuries associated with recurrent and neglected cases of shoulder dislocation. The cases of displaced biceps injuries are relatively rare (only 1/6^th of all rotator cuff injuries). The dislocation of biceps is manifested with pain and restriction of movements. The X-ray shoulder is not of much help in this condition barring for ruling out the fractures of humerus and scapula. Ultrasound is an important tool in the dislocation and shows empty bicipital groove which raises the suspicion of the soft tissue injures. Ultrasound is a problem solving tool when the equivocal findings in MRI (Magnetic Resonance Imaging) in other muscular injuries also. MRI is the modality of choice in these conditions. The bone and anatomy is better visualised on the T1WI images and the pathology is better visualised on the PDFS (Proton Density Fat Saturation) and the STIR (Short Tau Inversion Recovery) images. The role of Non Contrast Computed Tomography (NCCT) is important in associated suspicious bony abnormalities as highlighted in the article. The biceps region is a hidden area and challenging on arthroscopy due to poor visualisation of the extra-articular tendon part. MRI study helps the orthopaedicians for better management of the hidden areas. This series highlights the role of each modality in the diagnosis and management of the biceps lesions.

Diagnostic accuracy of 3T conventional shoulder MRI in the detection of the long head of the biceps tendon tears associated with rotator cuff tendon tears

OBJECTIVE

To evaluate the diagnostic performance (DP) of 3T (3 Tesla field strength) conventional shoulder magnetic resonance imaging (MRI) in detecting the long head of the biceps tendon (LHBT) tears in association with rotator cuff tendon tears.

MATERIALS AND METHODS

This study included 80 consecutive patients who underwent arthroscopic surgery for rotator cuff tendon tears. Two radiologists independently evaluated the preoperative 3T shoulder MRI for the presence of LHBT tears. The DP of MRI was evaluated using the results of arthroscopy as the reference standard. We also evaluated the DP of several MR signs of LHBT in detection of partial LHBT tears.

RESULTS

Arthroscopic examination revealed 35 partial and 5 complete tears. According to the results of evaluation by reviewers 1 and 2, shoulder MRI exhibited sensitivities of 77.14 and 80 % and specificities of 71.11 and 73.33 % in detection of partial LHBT tears and sensitivities of 80 and 100 % and a specificity of 100% (both) in detection of complete LHBT tears. In detecting partial LHBT tears, increased T2 signal intensity of the LHBT exhibited high sensitivities (reviewers 1 and 2; 82.85 and 80 %, respectively) and the presence of intratendinous defects or C-signs exhibited the highest specificities (reviewers 1 and 2; 95.55 and 93.33 %, respectively), followed by abnormalities in shape and outer margins of the LHBT (reviewers 1 and 2; 91.11 and 82 %; 91.11 and 86.66 %, respectively).

CONCLUSION

Non-contrast-enhanced 3T shoulder MRI is potentially highly accurate in detection of complete LHBT tears, but moderately accurate in detection of partial LHBT tears.

What can the Radiologist do to Help the Surgeon Manage Shoulder Instability?

Imaging of the shoulder forms an important adjunct in clinical decision making in patients with shoulder instability. The typical lesions related with classic anterior and anteroinferior shoulder dislocation are an anteroinferior labral avulsion with or without bony fragment of bone loss – a (bony) Bankart lesion – and a posterolateral humeral head impaction fracture – the Hill-Sachs lesions. These are relatively straightforward to identify on imaging, although normal variants of the inferior labrum and variants of labral damage may cause confusion. Other capsuloligamentous lesions, often associated with less typical types of instability, are much more difficult to identify correctly on imaging, as they occur in the anterosuperior part of the glenohumeral joint with its many normal variants or because they result in more subtle, and therefore easily overlooked, changes in morphology or signal intensity. This paper aims at describing the appearance of the normal and pathologic glenohumeral joint related to shoulder instability. Ample reference will be given as to why identification of abnormalities, whether normal or pathologic, is important to the surgeon facing a treatment decision.

Coracoid Process: The Lighthouse of the Shoulder

The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck. Surgeons often refer to the coracoid process as the "lighthouse of the shoulder" given its proximity to major neurovascular structures such as the brachial plexus and the axillary artery and vein, its role in guiding surgical approaches, and its utility as a landmark for other important structures in the shoulder. The coracoid also serves as a critical anchor for many tendinous and ligamentous attachments. These include the tendons of the pectoralis minor, coracobrachialis, and short head of the biceps brachii muscles, and the coracoclavicular, coracohumeral, coracoacromial, and transverse scapular ligaments. Consequently, the coracoid and its associated structures are linked to numerous shoulder pathologic conditions. This article will detail the anatomy of the coracoid and its associated structures and review the clinical and radiologic findings of corresponding pathologic conditions in this region with original illustrations and multimodality imaging examples. Highlighted in this article are the coracoclavicular joint, the classification and management of coracoid fractures, subcoracoid impingement, the coracoacromial arch and subacromial impingement, the coracohumeral ligament and the biceps pulley, the coracoclavicular ligament and its surgical reconstruction, adhesive capsulitis, the suprascapular notch and suprascapular notch impingement, subcoracoid bursitis, coracoid transfer procedures, and coracoid tumors. A brief summary of the pathophysiology, potential causes, and management options for each of the pathologic entities will also be discussed. ^©RSNA, 2016.

Morphology of the Lesser Tuberosity and Intertubercular Groove in Patients With Arthroscopically Confirmed Subscapularis and Biceps Tendon Pathology

PURPOSE

To evaluate for an association between the morphology of the lesser tuberosity and intertubercular groove and subscapularis tendon tears and biceps tendon pathology.

METHODS

Sixty-six patients with arthroscopically confirmed subscapularis tendon tears were compared with 59 demographically matched control patients who underwent magnetic resonance imaging or computed tomography arthrography examination of the shoulder. Measurements of the lesser tuberosity and intertubercular groove included maximum depth of the intertubercular groove, intertubercular groove depth at the midpoint of the glenoid, lesser tuberosity length, length from the top of the humeral head to the point of maximum depth of the intertubercular groove, length from the top of the humeral head to the top of the lesser tuberosity, and medial wall angle and depth.

RESULTS

Patients with subscapularis tears showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .01), shorter length of the lesser tuberosity (P = .002), and greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .02). There was a trend toward a decreased medial wall angle (P = .07) and greater distance from the top of the humeral head to the point of maximum intertubercular groove depth (P = .06). Patients with biceps tendon pathology showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .001), shorter length of the lesser tuberosity (P = .0003), greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .01), and decreased medial wall angle (P = .01) and depth (P = .03).

CONCLUSIONS

There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with both subscapularis tendon tears and biceps tendon pathology.

LEVEL OF EVIDENCE

Level III, case-control study.

Beyond the Cuff: MR Imaging of Labroligamentous Injuries in the Athletic Shoulder

Shoulder disease is common in the athletic population and may arise as a consequence of a single traumatic episode or multiple repeated events. Associated labroligamentous injuries can result in substantial disability. Specific athletic and occupational activities result in predictable injury patterns. Imaging in general and magnetic resonance (MR) imaging, in particular, are vital in establishing the correct diagnosis and excluding common mimicking conditions, to ensure timely and appropriate management. In this review, the utility of MR imaging and MR arthrography will be explored in evaluation of shoulder disease, taking into account normal variants of the labroligamentous complex. Subsequently, broad categories of labral lesions and instability, external and internal impingement, as well as nerve entrapment syndromes, will be discussed, while emphasizing their imaging findings in the clinical context and illustrating key features. More recent concepts of internal impingement and secondary subacromial impingement will also be clarified.

Multi-modal imaging of adhesive capsulitis of the shoulder

Adhesive capsulitis of the shoulder is a clinical condition characterized by progressive limitation of active and passive mobility of the glenohumeral joint, generally associated with high levels of pain. Although the diagnosis of adhesive capsulitis is based mainly on clinical examination, different imaging modalities including arthrography, ultrasound, magnetic resonance, and magnetic resonance arthrography may help to confirm the diagnosis, detecting a number of findings such as capsular and coracohumeral ligament thickening, poor capsular distension, extracapsular contrast leakage, and synovial hypertrophy and scar tissue formation at the rotator interval. Ultrasound can also be used to guide intra- and periarticular procedures for treating patients with adhesive capsulitis.

KEY POINTS

• Diagnosis of adhesive capsulitis is mainly based on clinical findings. • Imaging may be used to exclude articular or rotator cuff pathology. • Thickening of coracohumeral and inferior glenohumeral ligaments are common findings. • Rotator interval fat pad obliteration has 100 % specificity for adhesive capsulitis. • Ultrasound can be used to guide intra- and periarticular treatments.

Sonography of chondral print on humeral head

OBJECTIVE

The aim of this study is to determine the diagnostic accuracy of sonography in order to identify the chondral print on the humeral head.

MATERIALS AND METHODS

In total, 44 patients who had already been candidates for arthroscopic surgery were prospectively studied with ultrasound to assess the presence of humeral subchondral erosion at the level of the biceps pulley; no patient had undergone previous surgery or radiographic calcification of rotator cuff tendons. Using arthroscopy as the reference standard the sensitivity, specificity, positive predictive, negative predictive and diagnostic accuracy values were calculated.

RESULTS

Of the 44 patients, arthroscopy showed the humeral chondral print in 30 patients. Of the 30 arthroscopy proven humeral chondral prints, ultrasound identified 28 subchondral erosions at the same level, with two false negatives. One of the 14 patients without arthroscopic humeral chondral print was positive for subchondral erosion at ultrasound. The sensitivity, specificity, positive predictive, negative predictive, and diagnostic accuracy values of ultrasound were respectively of 93, 93, 96, 87 and 93%.

CONCLUSION

Ultrasound has a good diagnostic accuracy in identifying the chondral print sign.

Clinical application of radial magnetic resonance imaging for evaluation of rotator cuff tear

BACKGROUND

Magnetic resonance imaging is useful for evaluating the rotator cuff, but some tendinous insertions cannot be assessed using oblique sagittal, oblique coronal, and axial magnetic resonance (MR) images because of the presence of the partial volume effect.

HYPOTHESIS

The purpose of this study was to determine whether radial-slice MR images could reveal normal rotator cuff insertions and rotator cuff tears more clearly than conventional MR images.

PATIENTS AND METHODS

The study included 18 subjects with normal rotator cuffs and 30 with rotator cuff tears. MR images of rotator cuff insertions sliced into radial, oblique coronal, and axial sections were obtained. The extent to which normal rotator cuff insertions and rotator cuff tears were visualized in each of the three MR images was evaluated.

RESULTS

The top to posterior portions of the rotator cuff insertions from 0° to 120° could be visualized in the radial MR images. In comparison, the posterior portions of the rotator cuff insertions could not be visualized around 45° in both the oblique coronal and axial MR images.

DISCUSSION

These findings demonstrate that radial MR images are superior to the oblique coronal and axial MR images regarding their ability to accurately visualize rotator cuff insertions. Radial MR images also revealed greater detail around 45° in the posterior area of the rotator cuff tears than the oblique coronal and axial MR images. Radial MR images are particularly useful for visualizing clinically important posterosuperior rotator cuff tears.

LEVEL OF EVIDENCE

Level III - Diagnostic study.

Arthroscopic Changes of the Biceps Pulley in Rotator Cuff Tear and Its Clinical Significance in Relation to Treatment

Background

In the case of rotator cuff tears, the biceps pulley can be stressed by the unstable biceps tendon, and this can subsequently affect the stability of the subscapularis tendon. Therefore, it is important to distinguish between normal variations and lesions of the biceps pulley that affect anterosuperior lesions in cases of rotator cuff tears.

Methods

From January 2002 through November 2010, we observed biceps pulley and associated anterosuperior lesions in 589 of 634 cases (93%) of arthroscopic rotator cuff repair, including 72 cases (12.2%) of small tears, 219 cases (37.2%) of medium tears, 134 cases (22.8%) of large tears, and 164 cases (27.8%) of massive tears. We classified normal stretched biceps pulleys as type I, stretched biceps pulleys with mild changes as type II, those with a partial tear as type III, and torn pulleys as type IV.

Results

We were able to classify 589 cases of biceps pulleys as type I, II, III, or IV associated lesions in rotator cuff tears. Type I was seen in 91 cases (15.4%), type II in 216 cases (36.7%), type III in 157 cases (26.7%), and type IV in 101 cases (17.1%); unidentified cases numbered 24 (4.1%). Nearly three-quarters, 73.3%, of the cases (432/589) had associated anterosuperior lesions, and combined treatment for the associated lesions was administered in 29.2% (172/589) of cases.

Conclusions

Biceps pulley lesions with more than partial tears were identified in 48% of rotator cuff tear cases. The incidence and severity of pulley lesions were related to the rotator cuff tear size, the status of the long head of the biceps tendon and subscapularis tendon lesion, and the treatment methods.

Relationship between chronic pathologies of the supraspinatus tendon and the long head of the biceps tendon: systematic review

BACKGROUND

Chronic supraspinatus tendinopathy is a common clinical problem that causes functional and labor disabilities in the population. It is the most frequent cause of shoulder pain. This pathology may be frequently associated to the affectation of the long head of biceps tendon (LHBT), the main stabilizer of the glenohumeral joint together with the supraspinatus. The main aim of this work is to study the prevalence of lesions in LHBT associated to the chronic pathology of the supraspinatus tendon.

METHODS

A systematic review was carried out between May to July 2013 in the electronic databases: CINAHL, WOK, Medline, Scopus, PEDro, IME (CSIC) and Dialnet. The keywords used were: 1) in English: chronic, supraspinatus "long head of the biceps tendon", biceps, rotator cuff, tendinosis, tendinopathy, evaluation, examination; 2) in Spanish: supraespinoso, biceps, tendinopatía. Inclusion criteria of the articles included subjects with a previously diagnosed chronic pathology of rotator cuff (RC) without previous surgery or any other pathologies of the shoulder complex. The total number of articles included in the study were five.

RESULTS

The results show an epidemiological relationship between both tendons. The age of the subjects included in the review was between 35 and 80 years, and some of the studies seem to indicate that the tendinopathy is more frequent in men than in women. The sample size of the studies varies according to the design, the highest being composed of 229 subjects, and the minimum of 28. Not all the articles selected specify the diagnostic testing, though the ones most normally used are arthroscopy, ultrasound, magnetic resonance imaging and assessment tests. The percentage of associated lesions of LHBT and supraspinatus tendon is between 78.5% and 22%, with a major prevalence in the studies with a smaller sample.

CONCLUSIONS

The review of literature corroborates an association between the chronic pathology of the supraspinatus tendon and LHBT due to the epidemiological data. In addition, some authors confirm the existence of an anatomical and functional relationship between LHBT and the supraspinatus tendon, the latter being part of the LHBT pulley.

Anatomy, variants, and pathologies of the superior glenohumeral ligament: magnetic resonance imaging with three-dimensional volumetric interpolated breath-hold examination sequence and conventional magnetic resonance arthrography

The purpose of this review was to demonstrate magnetic resonance (MR) arthrography findings of anatomy, variants, and pathologic conditions of the superior glenohumeral ligament (SGHL). This review also demonstrates the applicability of a new MR arthrography sequence in the anterosuperior portion of the glenohumeral joint. The SGHL is a very important anatomical structure in the rotator interval that is responsible for stabilizing the long head of the biceps tendon. Therefore, a torn SGHL can result in pain and instability. Observation of the SGHL is difficult when using conventional MR imaging, because the ligament may be poorly visualized. Shoulder MR arthrography is the most accurately established imaging technique for identifying pathologies of the SGHL and associated structures. The use of three dimensional (3D) volumetric interpolated breath-hold examination (VIBE) sequences produces thinner image slices and enables a higher in-plane resolution than conventional MR arthrography sequences. Therefore, shoulder MR arthrography using 3D VIBE sequences may contribute to evaluating of the smaller intraarticular structures such as the SGHL.