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The Australian Journal of Ultrasound, 45 (2015): 16-22Rupture of the Long-Head of Biceps Tendon: Including Alternative Sonographic Pathologies of the Long Head of BicepsCaitlin GARDINER, BSc (BioMed) 7/8 Grad Dip Med SonoABSTRACT. Ultrasound is a wildly utilised imaging modality for the assessment of shoulder injury and pain. This case-study discussed the sonographic technique and findings of a long head of bicep tendon rupture in a 72-year old male with recent trauma to his right shoulder. Several other bicep pathologies are discussed, including bicipital tendinosis and tenosynovitis, longitudinal splits, accessory long-head of bicep tendons and bicipital subluxation. Case PresentationA 72 year old male presents with 2 weeks of right shoulder pain, reduced range of movements and limited strength. The patient experienced trauma when lifting a heavy load and felt an acute pain with an audible ‘snap.’ The patient indicates a slightly painful lump in the mid-arm and pain when pressure is applied to the anterior portion of the humeral head. Ultrasound ExaminationThe examination is undertaken in a private radiology practice on a GE Logiq E8 using a 5-12MHz linear probe with a shoulder present. The patient is explained the procedure and verbal consent is obtained. When offered a robe for comfort, the patient declines and is content to sitting topless. The patient is positioned on a rotating stool, close to the ultrasound machine. This is to achieve an ergonomic standing position allowing a neutral neck position and minimal shoulder extension and abduction for the sonographer. Ultrasound FindingsA brief clinical assessment is undertaken. The patient demonstrates good external rotation and abduction to around 90 degrees with pain. Given the patient’s mechanism of injury and report of a ‘snapping’ sensation, the patient is asked to flex his bicep muscles bilaterally. The right bicep muscle demonstrates a prominent muscle bulge compared to the contralateral side. The patient is asked to bend his elbow 90 degrees, with his palm facing upwards and his elbow by his side to commence the examination with a long-head of bicep assessment. The bicipital groove is assessed in transverse from an anterior approach, from the bony insertion through the myotendinous junction to the muscle belly. Despite awareness of the effects of anisotropy, no bicipital tendon is noted. This is confirmed in a longitudinal view. Anechoic fluid is noted within the groove (See Image Series One). Before it is confirmed there is no bicipital fibres noted, various sonographic windows and patient positions are altered. This included resting the arm by the patient side, asking him to tense his bicep muscles, a slight internal rotation and moving the probe both medially and distally angling superior and inferior with slightly altered probe-pressures. Image Series One: Transverse and Longitudinal ultrasound images of the right bicipital groove of a 72 year-old male post-trauma. No bicep tendon is visible. Distal to the bicipital groove, proximal to the bicep muscle belly is a 37*28*60mm complex haematoma (see image series two). Image Series Two: Longitudinal and transverse ultrasound images the proximal bicep muscle in a 72 year old male post-trauma. A 37*28*60mm complex haematoma is noted. In the presence of a long-head of bicep rupture, the attachment of the bicep at the radial tuberosity is assessed. The distal insertion is confirmed to be intact though surrounding free fluid is noted (See Image Three). Image Three: An ultrasound image of a right distal bicep attachment onto the radial tuberosity in a 72 year-old male with acute-onset anterior shoulder pain associated with trauma. Bicep attachment is confirmed with the presence of tracking free fluid superficial to the tendon. The rotator cuff was continues to be assessed in its entirety to reveal slight tendinopathic changes of both the infraspinatus and the supraspinatus but no other focal tears or pathology. Mild degenerative changes were noted of the AC joint, but the patient reports no focal tenderness in this region. The SAB appeared mildly thickened and real-time assessment does show slight bunching at maximum abduction of 90 degrees. A sample of images is seen in Image Series Four. Image Series Four: A long axis image of the right subscapularis, a long axis image of the right supraspinatus, the AC joint, and the subacromial bursal with the arm at 90 degrees abduction, respectively, of a 72 year-old male with recent shoulder trauma. Conclusion:An on-site radiologist confirmed rupture of the right long head of bicep tendon, with retraction of the bicep muscle distally. A 37*28*60mm complex haematoma is noted. The distal bicep attachment appears normal with free fluid surrounding. Mild tendinopathic changes were noted of the supraspinatus and infraspinatus with mild bursal thickening and impingement at maximum abduction at 90 degrees. Slight degenerative changes were noted of the AC joint. . Discussion:The long-head of bicep tendon’s origin is at the supraglenoid tubercle, with fibres arising from the superior aspect of the glenoid rim, superior labarum and the joint capsule. The proximal tendon is intra-articular and intrasynovial whilst distally traces over the humeral head within the bicipital groove. A synovial sheath surrounds the bicep as an extension of the glenohumeral joint approximately 3-4cm. The bicep muscle is a primary supinator and flexor of the elbow and stabilizer of the glenohumeral joint (Bianchii and Martinoli, 2007). Rupture of the long head of bicep tendon typically presents post-trauma with a soft-tissue lump in the middle, anterior arm, known as the ‘pop-eye sign’ with decreased strength during supination and flexion of the arm (Allen). These clinical symptoms are consistent with the presentation of the patient in this study. Since bicep rupture has very specific clinical symptoms, most resources state that US evaluation is rarely required but may be useful in challenging cases such as obese patients (Allen 2003; Bianchi and Martinoli, 2007). The referring general practitioner was contact for education purposes to gain information on the management he will be offering the patient. The GP reports he was confident the patient had ruptured his bicep prior to the ultrasound examination, but was interested to know the integrity of the entire rotator cuff. He also stated that he wanted to obtain an ultrasound report before referring the patient to an orthopaedic surgeon for further management. US readily demonstrates tendon disruption, typically at the intra-articular level, showing an empty bicipital groove and distal retraction of the tendon. More specific findings may include the coracohumeral ligament taking on a concave profile over the humeral head. When the rupture has occurred recently, the free fluid may surround the retracted tendon (Bianchi and Martinoli, 2007). These acute findings as consistent with those noted in this case study. Chronic cases will show decreased bicep muscle volume and will be significantly more hyperechoic compared to the short belly. On occasion, a rupture bicep tendon may self-attach distally which may prevent muscle wasting (Bianchii and Martinoli, 2007). Bicep tendon are associated with supraspinatus tears in 96.2 percent or subscapularis tears in 47.1% of cases (Bianchi and Martinoli, 2007). This makes this case somewhat atypical since both the supraspinatus and subscapularis appeared intact. Though bicep tendon tears almost always occur at the intra-articular level, less common tears occur at the myotendinous junction and the distal bicep attachment. Rupture of the distal bicep tendon represents only 3% of all bicep tendon pathology. Although US, CT and MRI can be employed as effective imaging modalities, a clinical diagnosis of retraction of the muscle belly and inability to palpate the tendinous insertion at the elbow will suffice (Belli et al, 2001). Whilst it was intuitive to assess the distal bicep insertion, it was unlikely to reveal any significant pathology beyond free fluid. Management of this patient may include conservative treatments such physical therapy with nonsteroidal anti-inflammatory drugs and cold-treatment to reduce swelling or possible surgical intervention. It is likely that the patient’s age and requirements for a supination strength in daily activities may impact the decision to operate (Sutton et al, 2010). Alternative Bicep PathologyBicep Tendinopathy- Tendinosis and Tenosynovitis Both tendinosis and tenosynovitis of the long head of the biceps tendon are attributed to impingement and attrition. The tendon can become compressed between the humeral head and the acromial arc during abduction and rotation. This mechanism is further exacerbated when the supraspinatus is torn, and places increased downwards pressure onto the fibrous sheath (Bianchi and Martinoli, 2007). Ultrasonic findings of bicep tendinopathy typically includes oedematous, heterogeneous echo texture with fissurations, hyperaemia of the periphery with or without effusion in the sheath. Alternative, the tendon may appear thinned and frayed which is typical of longstanding tendinopathy (Nho et al, 2010; Bianchi and Martinoli, 2007). Refer to figure five for the sonographic appearance of bicep tendinosis. Fig Five: The above image shows a markedly oedematous, swollen long-head of biceps with subtle clefts of the posterior aspect. Images from Bicep instabilityA fibrous plate, consisting of intertwined supraspinatus and subscapularis tendon fibres and the coracohumeral ligament, lies superficial to the tendon in order to maintain the tendon within the bicipital groove. The medial head of the coracohumeral ligament and the superior gleno-humeral ligament form a flexible pulley to aid the fibrous plate in bicep tendon stability. Due to the curvilinear course of the long head of bicep tendon, it has a predisposition to displace medially during powerful contraction or extreme external rotation (Bianchi and Martinoli, 2007). Causes may include a shallow bicipital groove or a full-thickness tear of the subscapularis (Shi et al, 2014). Dynamic assessment of the bicep tendon with internal and external rotation is typically required in instable subluxation. Please refer to Figure Six. Figure Six: Medial dislocation of the long-head of bicep tendon. The bicipital groove appears empty whist the bicep tendon (arrow) appears to be in the location of the subscapularis. Underlying bony irregularity and bicep location is suggestive of a full-thickness subscapularis tear. Image from Longitudinal Biceps Tendon Tear Splits and Bifid Bicep TendonsAn anatomic variation of the bicep tendon includes an accessory head of the biceps brachii muscle. The sonographic evaluation includes a second head of bicep within the brachial groove. It is typically asymptomatic, flat, echogenic structure. It is an important variant to be aware of in order to avoid false diagnosis of longitudinal splits (Lutterback-Penna et al, 2014). Figure Seven shows the sonographic appearance of longitudinal splits within the bicep tendon. Fig Seven: Short and long axis images of the long head of bicep showing several longitudinal splits and hyperaemia. Images from ReferencesAllen L, 2013. Long Head of Biceps Tendon Anatomy, Biomechanics, Pathology, Diagnosis and Management. University of New Mexico Orthopaedics Research Journal, 21-23Belli P, Mirk P and Patore G, 2001. Sonographic Diagnosis of Distal Bicep Tendon Rupture. J Ultrasound Med, 20: 587-595Bianchi S and Martinoli C, 2007. Ultrasound of the Musculoskeletal System. Springer. Lutterbach-Penna RA, Brigido MK, Robertson B et al, 2014. Sonography of the Accessory Head of the Biceps Brachii. AIUM; 13(10): 1851-1854. Nho SJ, Strauss EJ, Lenart BA et al, 2010. Long Head of the Biceps Tendinopathy: Diagnosis and Management. J Am Acad Orthop Surg; 18(11): 645-656. Shi LL, Mullen MG, Freehill MT et al, 2014. Accuracy of Long Head of the Biceps Subluxation as a Predictor for Subscapularis Tears. Arthroscopy; 31(4): 615-619. Sutton KM, Dodds SD, Ahmad CS, Sethi PM, 2010. Surgical treatment of distal biceps rupture. J Am Acad Orthop Surg; 18(3):139-48. ................
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