Biceps Tendon Sheath Research Articles

Sonographically detected subacromial/subdeltoid bursal effusion and biceps tendon sheath fluid: reliable signs of rotator cuff tear?

Our purpose was to determine the association between sonographically detected subacromial/subdeltoid (SA/SD) bursal and biceps tendon sheath effusions and arthrographically proven rotator cuff tears. Shoulder sonography reports and sonograms of 105 shoulders in 102 patients who also underwent arthrography were retrospectively reviewed for the presence of fluid within the biceps tendon sheath and SA/SD bursa. Reports and sonograms for 151 asymptomatic shoulders were also reviewed. Biceps tendon sheath effusion and/or bursal fluid were detected in 50 (48%) of 105 shoulders. Fifty-one patients had rotator cuff tears; 28 of them had effusions at 1 or both sites. The sensitivity, specificity, and positive predictive value (PPV) of biceps tendon sheath effusions for diagnosing rotator cuff tear were 35%, 74%, and 56%, respectively. For SA/SD bursal effusions, the sensitivity, specificity, and PPV were 8%, 94%, and 57%, respectively. For combined biceps tendon sheath and bursal effusions, the sensitivity, specificity, and PPV were 12%, 91%, and 54%, respectively. There was no statistically significant association between rotator cuff tears and effusions in the biceps tendon sheath, SA/SD bursa, or both. Among the 151 asymptomatic shoulders, 12 (7.9%) had biceps tendon sheath fluid, 5 (3.3%) had SA/SD bursal effusion, and 2 (1.3%) had both biceps tendon sheath and bursal effusions. The sonographic detection of intraarticular fluid, SA/SD bursal fluid, or both has a low sensitivity and PPV in the diagnosis of rotator cuff tears. Isolated intra-articular and/or SA/SD bursal effusions are not reliable signs of rotator cuff tear.

Neurohistology of the subacromial space.

Subacromial decompression is one of the most commonly performed shoulder procedures. Debridement of the subacromial soft tissues is a critical part of the procedure. However, the extent of soft tissue debridement is not well defined. The purpose of this study was to identify neural elements within the soft tissues composing the subacromial space. Using special immunohistochemical stains and electron microscopy, neural elements were identified within the subacromial bursa, rotator cuff tendon, biceps tendon and tendon sheath, and transverse humeral ligament. There was a significantly richer supply of free nerve fibers in the bursa compared with the other tissues. The nociceptive information relayed by these fibers may be responsible for the pain associated with impingement syndrome.

Adhesive capsulitis of the shoulder: MR diagnosis.

Adhesive capsulitis is a clinical syndrome of pain and severely decreased joint motion ("frozen shoulder") caused by thickening and contraction of the joint capsule and synovium. Although arthrographic criteria for the diagnosis have been described, to our knowledge, the MR characteristics have not been reported. Accordingly, we studied the MR findings in 10 patients with this syndrome. MR images of 25 subjects were included in the study. Nine had adhesive capsulitis documented by arthrography, and one had adhesive capsulitis proved at surgery. The MR findings in these patients were compared with those of 15 asymptomatic volunteers. Images were assessed for thickness of the joint capsule and synovium, for thickness of the coracohumeral ligament, and for volume of articular fluid. Capsule and synovium thickness was measured adjacent to the axillary recess. The volume of intraarticular fluid was calculated from direct measurements of the axillary recess and biceps tendon sheath. The rotator cuff interval was qualitatively evaluated for the presence of abnormal tissue. Thickening of capsule and synovium on MR images was characteristic of adhesive capsulitis, with a significant difference between mean thickness in patients with adhesive capsulitis (5.2 mm) and in asymptomatic volunteers (2.9 mm) (p < .01). Capsule and synovium thickness greater than 4 mm was a specific (95%) and sensitive (70%) criterion for the diagnosis of adhesive capsulitis. There was no significant difference in volume of articular fluid or thickness of the coracohumeral ligament between patients with adhesive capsulitis and asymptomatic volunteers (p > .5). The rotator cuff interval was not useful for assessing changes of adhesive capsulitis. Joint capsule and synovium thickness greater than 4 mm is a useful MR criterion for the diagnosis of adhesive capsulitis. The volume of articular fluid seen on MR images is not significantly diminished in patients with adhesive capsulitis.

Mineralization of the Supraspinatus Tendon: Clinical Observations in Seven Dogs

SummaryMineral-like densities in the supraspinatus tendon were determined to have different clinical significance according to their location. Those identified radiographically and surgically, near the biceps tendon sheath reflecting a deep location in the supraspinatus tendon, caused chronic and acute lameness in five large breed dogs. Pain in the shoulder and biceps tendon was elicited on examination in acute cases whilst chronic cases were painfree. Systemic and local anti-inflammatory treatment failed to improve any of the cases. Surgical removal was curative with slight lameness after exercise observed in some dogs during the longterm follow-up. Recurrence of lesions were not seen radiologically. It is suggested that mineralizations, located deep in the supraspinatus tendon, cause secondary tenosynovitis of the biceps brachii through mechanical irritation.Mineralizations found radiographically distant to the biceps tendon sheath in five cases reflecting a superficial location in the supraspinatus were determined not to be a primary cause of lameness.Similarities in the pathomechanism, aetiopathogenesis and clinical significance of mineralizations in the supraspinatus tendon in dogs and humans were noted.Mineralizations located deep in the supraspinatus tendon near the biceps tendon sheath caused lameness in large breed dogs. Diagnosis was established through physical examination, radiography, and surgical exploration of the lesion. Systemic steroidal and non-steroidal therapy and local steroid injection into the intertubercular groove failed to resolve any of the cases but surgical curettage of the mineralization resulted in clinical improvement. A secondary mechanical tenosynovitis of the biceps brachii as the cause of lameness, is suggested.Mineralizations located superficially in the supraspinatus tendon were found not to be a primary cause of lameness.

Rupture of the distal biceps tendon: evaluation with MR imaging.

To assess the usefulness of magnetic resonance (MR) imaging in the diagnosis of distal biceps tendon ruptures. MR images of the elbow in 20 patients with suspected distal biceps injury were retrospectively reviewed along with those of eight asymptomatic volunteers. Surgical confirmation was obtained in nine cases. MR imaging helped diagnose 10 complete ruptures with depiction of the absence of the tendon distally (n = 10), a fluid-filled tendon sheath (n = 9), an antecubital fossa mass (n = 3), muscle edema (n = 3), and atrophy (n = 2). Six partial tears were depicted with high signal intensity within the tendon (n = 6), fluid in the biceps tendon sheath (n = 6), and thinning (n = 3) or thickening (n = 3) of the distal tendon. Of the remaining patients, one each had tendinosis, tenosynovitis, a biceps hematoma, and a brachialis contusion. MR imaging helped confirm distal biceps tendon ruptures because it distinguished complete from partial ruptures and other entities that may mimic ruptures.

Arthroscopic treatment of synovial chondromatosis of the shoulder and biceps tendon sheath

We present a case of synovial chondromatosis of the shoulder in a 22-year-old man. The patient was initially treated with arthroscopic debridement and partial synovectomy of the shoulder joint. Eighteen months later, the patient returned with similar symptoms. However, repeat radiographic studies showed involvement of both the shoulder and biceps tendon sheath. The patient was taken back to the operating room for an arthroscopic debridement of the shoulder joint and debridement of the biceps tendon sheath through an open approach. Use of the arthroscope to evaluate and treat this patient allowed him to return to normal activities much sooner than a formal open synovectomy would have allowed. Additionally, the morbidity associated with arthroscopic techniques is much lower than that of open procedures. In cases of synovial chondromatosis, the results in terms of efficacy and recurrence rates of each method appear comparable.

MR imaging of the normal shoulder: variants and pitfalls.

In 30 volunteers with normal shoulders, the following conclusions were made with regard to normal anatomic features at magnetic resonance (MR) imaging: (a) The supraspinatus tendon has low signal intensity, except for a 1-cm area with intermediate signal intensity in the region of the "critical zone." (b) The deltoid tendon attachment on the inferior surface of the acromion may simulate a subacromial spur if not imaged in continuity. (c) Fluid in the long head of the biceps tendon sheath is normal if not completely surrounding the tendon. (d) The anterolateral branch of the anterior humeral circumflex vessels in the proximal bicipital groove adjacent to the biceps tendon mimics fluid in the tendon sheath. (e) Continuity or obliteration of the subacromial-subdeltoid bursal fat plane is an unreliable diagnostic sign since the fat plane is often focally absent. (f) Fluid is not detected in subacromial-subdeltoid bursae. (g) Undercutting of the anterior glenoid labrum by hyaline cartilage or a closely apposed middle glenohumeral ligament may simulate an anterior labral tear.

Range of motion and arthrography in the frozen shoulder

The relationship between the range of motion and the arthrographic measurements were assessed in 91 patients with frozen shoulders. Range of motion was recorded in flexion, abduction, external rotation, and internal rotation. On the arthrogram the following parameters were measured: depth of the axillary pouch, width of the anterior ballooning, extent of the subscapularis bursa, filling of the biceps tendon sheath, and the irregularity of the capsular outline in the anteroposterior view. Both the subscapularis bursa and the biceps tendon sheath were also assessed in the scapular Y view. There were mild correlations between external rotation and the anterior ballooning and between internal rotation and the axillary pouch, but the coefficient of determination (r-square) in each correlation was small. No significant correlation was observed between flexion or abduction and any of the arthrographic measurements. Although these arthrographic findings are characteristic to frozen shoulders, none of them is a good predictor of the severity of restricted motion.

Biceps Tenosynovitis in the Dog: Radiographic and Sonographic Findings

SummaryUltrasonography of the biceps brachii tendon was prospectively evaluated as an ancillary diagnostic technique in comparison to arthrography in canine biceps tenosynovitis, in a series of six cases with surgical and histopathological confirmation of the diagnosis. Arthrographic findings, compatible with the disease, were present in all six cases, and correlated well with surgical findings. Significant differences were not found in the sonographic appearance of the affected versus the contralateral unaffected biceps brachii tendon proper. In two cases, sonography demonstrated a sonolucency surrounding the affected tendon; in one of these cases effusion within the biceps tendon sheath was noted at operation. In a third case, sonographic findings correlated with the presence of periosteal proliferation within the intertubercular groove noted on survey radio-graphs. Based on these six cases, arthrography appears to be a more sensitive ancillary diagnostic technique in this disorder than ultrasonography of the biceps brachii tendon.Ultrasonography was prospectively evaluated in comparison to arthrography as an ancillary diagnostic technique in six cases of canine biceps tenosynovitis with surgical and histopathological confirmation of the diagnosis. Results obtained indicate arthrography appears to be a more sensitive ancillary diagnostic technique than ultra-sonography in this disorder.

Resistance of a defect of the supraspinatus tendon to intraarticular hydrodynamic pressure: An experimental study on rabbits

The healing of a standardized defect of the supraspinatus tendon in a time-related series on rabbits was monitored with arthrography and simultaneous determination of the intra-articular hydrodynamic pressure of the glenohumeral joint. All normal glenohumeral joints produced a biphasic pressure versus volume curve. Rupture of a normal glenohumeral joint occurred at a pressure level of 140-170 mm Hg and was located in the area around the biceps tendon sheath. In joints with a defect of the supraspinatus tendon, leakage of the contrast medium was evident up to the sixth week, at an intra-articular pressure varying from 40 to 100 mm Hg. After week 6, no leakage of the cuff was seen during the determination of the intraarticular pressure. This was in accordance with the histological findings: the defect was covered with solid scar tissue from the ninth week onward. Resistance to hydrodynamic intraarticular pressure proved a reliable method of determining the strength of the healing of the supraspinal defects.

Calcific tendinitis of the long head of the biceps brachii distal to the glenohumeral joint: plain film radiographic findings.

Calcific tendinitis is a painful condition related to deposition of hydroxyapatite crystals; it favors large joints. The shoulder, specifically the tendons of the rotator cuff and the insertion of the long head of the biceps on the superior glenoid rim, is a well-recognized location for this abnormality. The purpose of this article is to describe a second site of calcific tendinitis of the biceps, distal to the joint and corresponding to the junction of the tendon and muscle. Radiographs in 119 cases of calcific tendinitis of the shoulder, obtained between 1980 and 1988, were reviewed. Twenty had calcific tendinitis in the region of the tendon of the long head of the biceps (nine at the glenoid insertion and 11 adjacent to the humeral shaft). All 11 patients with calcific tendinitis at the more distal site had a small, homogeneous deposit adjacent to the proximal humeral shaft. The densities in these 11 cases followed the normal course of the tendon of the long head of the biceps and were therefore medial to the proximal humeral shaft on the internal rotation view, lateral to the proximal humeral shaft on the external rotation view, and anterior to the proximal humeral shaft on the axillary projection. The major differential diagnosis of calcific tendinitis of the tendon of the long head of the biceps is loose bodies trapped in the biceps tendon sheath. Although the position of the soft-tissue densities in these two entities is similar, loose bodies have an appearance of bone, and their source (degenerative arthritis or recurrent dislocations) is usually apparent. A site of calcific tendinitis distal to the glenohumeral joint that is detectable on plain films is reviewed. Accurate diagnosis depends on understanding the anatomy of the tendon of the long head of the biceps brachii. The clinical charts of the 11 patients also are summarized, with emphasis on the association between the roentgen finding and bicipital tendinitis and impingement syndrome.

肩関節周囲炎に対するヒアルロン酸ナトリウム（ＳＰＨ）の比較臨床試験

Randomized comparative study was conducted with periarthritis scapulohumeralis to determine the efficacy, safety, and usefulness of SPH using 2.5ml of 1% SPH solution (S) or of 0.01% SPH solution (P) for intra-articular, intra-subacromial bursa or intrabiceps tendon sheath injection five times continuously in weekly intervals.1) Total number of patients examined was 152 (S: 76, P: 76). Among those patients, 139 (S: 67, P: 72) were adopted for the analysis of final global improvement and usefulness, and 150 (5: 74, P: 76) for analysis of general safety.2) With respect to final global improvement, the effective rate (more than “moderately improved”) of S group was 70.2% (47/67), and 36.1% (26/72) for P group.S group was significantly superior to P group.3) With respect to overall safety, incidence of side effects was 2.7% (2/74) for S group, 2.6% (2/76) for P group, and no significant difference was observed between S and P groups.4) With respect to usefulness, the rate of usefulness (more than “moderately useful”) of S group was 68.7% (46/67), and 38.9% (28/72) for P group.S group was significantly superior to P group.5) As for the change of global improvement and of patient's impression, S group was significantly superior to P group.As for improvement on symptoms, S group was significantly superior to P group in “rest pain, ” “pain under movement, ” “motion of washing face, ” “motion of arranging hair, ” “tying a string behind one's back, ” “put the hand on the opposite side of shoulder” and S group tended to be superior in “oppressive pain.” On the other hand, as for the range of motion, both S and P groups were equally improved, and no significant difference was observed between the two groups, but S group was superior in the rate of improvement. High effectiveness of SPH was proved in patients whose duration of symptoms is within one year and global severity is slight to moderate.With pespect to injection site, S group was superior to P group, both in subacromial bursa and biceps tendon sheath, and S group tended to be superior in glenohumeral joint.6) As an adverse side effect, slight to moderate local pain after injection of drugs was noted in 4 patients (S: 2, P: 2).No abnormality caused by the drugs was found in laboratory test values.In conclusion, SPH is considered to be useful in the treatment of periarthritis scapu-lohumeralis.

The diagnostic value of arthrography and plain radiography in rotator cuff tears.

In 26 patients with surgically verified rotator cuff tears, the findings at radiography and arthrography were analysed. Plain anteroposterior radiograms were of no value in diagnosis. In plain groove-films, the slope of the medial wall and the depth of the intertubercular groove correlated with dislocations of the biceps tendon. In arthrography, leakage of the contrast medium into the subacromial or subdeltoid bursa was a reliable sign of a full-thickness tear. There was no correlation between the size of the tear measured at arthrography and at surgery. In cases where the biceps tendon sheath was visualised, the appearance was in agreement with the surgical findings.