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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 633-636
Biceps tendon tenosynovitis - a sonologic marker of shoulder joint derangement


Department of Radio diagnosis and Orthopaedics. Dr Padm D.Y. Patil Medical College.(Deemed University)Pimpri 18, India

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Date of Submission27-Jan-2006
Date of Acceptance10-Aug-2006
 

   Abstract 

Objectives: To study biceps tendon sheath fluid collection using musculoskeletal ultrasound and evaluate its cause. Materials and Methods: A total of 15 patients with biceps tendon sheath fluid collection were studied. All these patients presented with history of shoulder pain with inability of overhead abduction of arm and painful circumduction. Discussion: Ten had history of trauma, four had acute trauma and six had an old history of trauma. Five had degenerative shoulder joint disease, out of these two had osteoarthritis and three had rheumatoid arthritis with subacromiodeltoid bursitis. All cases were evaluated on B mode high frequency ultrasound. The gray scale findings were correlated with clinical and arthroscopic findings. These patients were treated conservatively and followed up sequentially. Results: Diagnosis of tendonitis prompted us for a detailed joint examination which revealed rotator cuff tear in eight patients, these tears varied from acute to chronic and partial to complete thickness tears. Five patients had arthritis, two had osteoarthritis with erosion and pitting of the bony groove and three had bursitis secondary to rheumatoid arthritis with tendonitis. Conclusion: The utility of high frequency ultrasound as an imaging technique for biceps tendon is a useful adjunct to clinical examination. The procedure is non invasive, safe without risk of exposure to harmful radiation, cost effective, dynamic and a useful aid in diagnosis. The diagnosis of biceps tendon sheath fluid must prompt a musculoskeletal sonologist for a detailed evaluation of the shoulder.

Keywords: Biceps brachii tendon, tenosynovitis, musculoskeletal ultrasound.

How to cite this article:
Kharat A, Kharat K, Singh A. Biceps tendon tenosynovitis - a sonologic marker of shoulder joint derangement. Indian J Radiol Imaging 2006;16:633-6

How to cite this URL:
Kharat A, Kharat K, Singh A. Biceps tendon tenosynovitis - a sonologic marker of shoulder joint derangement. Indian J Radiol Imaging [serial online] 2006 [cited 2014 Oct 31];16:633-6. Available from: http://www.ijri.org/text.asp?2006/16/4/633/32286

   Introduction Top


The shoulder joint is an incongruous ball and socket joint without any fixed axis of rotation; hence stability is compromised for mobility.

This anatomical defect is covered up by presence of numerous tendons and ligaments that cross the joint and provide added stability.

Pain in and around the shoulder is a common problem seen in one of 10 patients in a physical medicine practice [1].Ultrasound evaluation of the shoulder can be a helpful modality to evaluate shoulder pain. Though biceps brachii tendon is not a part of the rotator cuff it forms an integral part of the shoulder joint.

Biceps tendon is a 9 cms long tendon that crosses through the bicipital groove, this tendon acts as an mirror reflecting the status of the joint in various shoulder joint pathologies since the tendon is intra-articular extrasynovial.

The ultrasonographic appearance of tendonitis involving the biceps tendon located in the bony bicipital groove was studied in fifteen individuals of varying age groups.

Further ultrasonographic examination in this cohort of patients revealed varying joint pathology.


   Materials and Methods Top


The study was carried out on clinical and radiologically suspected cases of rotator cuff tears and painful shoulder. A total of fifteen cases were studied.

Ultrasound Scanner Specifications:

Study was carried using WIPRO- GE Logiq 400 MD TM scanner with 11 MHz linear array high frequency transducer with a small footprint.

Imaging Protocol:

Study was done with patient sitting upright with forearm supinated and flexed at the elbow. Biceps tendon was visualized in the short and long axis view and comparative study was done with the opposite shoulder. Due attention was given to the biceps tendon in the bicipital groove where most of the cases were picked up.

Examination was done in a static mode and dynamic mode. Apart from visualization of the biceps tendon a screening examination of the shoulder joint was also done for the rotator cuff tendons, posterior joint capsule and acromioclavicular joint.

Diagnostic feature:

Gray-scale high resolution ultrasonography (US) depicted the biceps tendon as an echogenic cord like tendon with fibrillar appearance due to the high collagen contents of the tendon fibers.

Tenosynovitis was seen as to depicit a typical gray scale appearance on high resolution musculoskeletal ultrasound. These appearances were characterized by the type and age of injury and inflammation. About 85% of patients with a painful rotator cuff developed biceps tendonitis [2], this was true as in our study also.

The diagnostic feature of tenosynovitis was a well defined rim of collection around the tendon within the tendon sheath, fluid was typically seen to gravitate inferiorly and fill and bulge the inferior triangular recess.


   Discussion Top


The collection of fluid around the long head of the biceps tendon lying in the bicpital groove can vary in echogenicity from clear anechoic fluid, to isoechoic or hyperechoic. The echogenicity varies according to the age of the collection. In our study we found that chronic collection, blood, and infective fluid tends to be echogenic and therefore more likely to missed. In contrast, an acute collection is likely to be picked up easily. Tenosynovitis can be secondary to joint pathology like rheumatoid arthritis and osteoarthritis of the shoulder joint as seen in our cases. Tendon sheath collection can be secondary to trauma as seen in the remaining 10 cases.

We observed that bicipital tenosynovitis often reflected a derangement of shoulder joint, something similar to derangement of the knee.

The biceps tendon is important in the examination of the shoulder joint despite the fact that the tendon is not a constituent of the rotator cuff tendons. Its strategic anatomical location makes it a very sensitive indicator of shoulder pathology - since the long head of biceps tendon is intracapsular and extrasynovial. Thus, it is virtually involved in all joint related pathologies.

Moreover, joint collection if minimal can be missed when scanned by the posterior joint capsule approach. However it can easily be picked up if scanned at the biceps tendon as the fluid track provided by the tendon sheath is the most dependent in the upright position.

Excess fluid collection can be one of the causes of tendon subluxation which was noted in three cases of the total of 15 cases. Usually the tendon is strapped to the groove by the transverse humeral ligament. Fluid bulges the space and increases the tendency to subluxation. No evidence of tear was noted in the tendons. Most of the subluxed tendons were lying medially over the tuberosity.

Biomechanical stresses causes by torn and damaged rotator cuff produces intraarticular fluid which eventually gravitates along the tendon sheath creating a rim of fluid along the long head of biceps tendon.

Thus biceps tendon examination is of an immense diagnostic importance and should be a part of routine imaging of the painful shoulder.


   Conclusion Top


Biceps tendon tenosynovitis can be diagnosed by varying imaging modalities, high frequency transducers and multiple imaging sections. However they are best depicted on high resolution gray scale ultrasound. The accuracy of ultrasonography to evaluate the soft tissues of the shoulder and other musculoskeletal structures have been repeatedly compared to other imaging modalities such as MR [3],[4],[5].

Sonography of the musculoskeletal system is a highly researched and advanced practice of imaging the muscles, ligaments, cartilages and joints of the body [6] A diagnosis of biceps tendon sheath collection should prompt a musculoskeletal sonologist to search for other causes of joint pathologies and a detailed and careful search of the painful shoulder to search for the cause of the collection.

 
   References Top

1.Moppes F, Veldecamp O, Roorda J. Role of ultrasonography in the evaluation of the painful shoulder. European Journal of Radiology 1995;19(2):142-6.   Back to cited text no. 1    
2.Thomas C. Winter III, MD, Sharlene A. Teefey, MD, and William D.Middleton, MD: Musculoskeletal ultrasound: An update. Radiologic Clinics of North America 39:465-483,2001.  Back to cited text no. 2    
3.Role of ultrasonography in evaluation of the painful shoulder. Ibid.   Back to cited text no. 3    
4.Farin PU, Jaroma HR. Acute traumatic tears of the rotator cuff: value of sonography. Radiology October 1995;19(1):269-73.   Back to cited text no. 4    
5.Kamei K, Hanai K, Matsui N. Ultrasonic level diagnosis of lumbar disc herniation. Spine 1990;15(11):1170-4.   Back to cited text no. 5    
6.American College of Radiology Standards. Res-(56), 1996.   Back to cited text no. 6    

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DOI: 10.4103/0971-3026.32286

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
 
 
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    Abstract
    Introduction
    Materials and Me...
    Discussion
    Conclusion
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