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Hi Stephen, this patient has functional issues with biceps and both subscapularis.
The LHB appears hypoechoic compared with the other side, I would call the small amount of fluid physiological but what structures have the neovascularity, they appear outside the tendon sheath?
I’m calling the subscaps tendinopathic at the moment but they look suspicious for tears. I recall you mentioning superior subscaps are the most prone for structural injury, these pictures are more inferior, any thoughts?
Thanks
Mike -
Hi Mike,
I think the right subscap has good evidence of a tear with enthesis irregularity and some collagen changes.
The left subscap is certainly tendinopathic although it is harder to see a defined tear.
The colour Doppler signal anterior and slightly lateral / medial to the biceps tendon is going to be from the SASD bursa.
I think there is also a bit of signal in the LHBT sheath.
The images I really want to see is a B-mode assessment of the more proximal LGBT in the short axis in the rotator cuff interval over the top of the humeral head and then one in the same location with colour Doppler.
From this position you can turn the transducer 90 degrees until you get the LHBT in long axis (your transducer will be pretty much in a coronal plane) then slide the transducer slightly anterior and this will show the enthesis for the very superior fibres of subscap.
It is a great trick and helps me a lot when I am looking for superior aspect subscap tears.
I have Dr Ray Chen from Taichung to thank for the inspiration behind this technique.It is a great way to see if a superior subscap tear is leading to biceps instability and symptoms.
The colour assessment of the rotator cuff interval will show if there is any synovitis of the GH joint capsule as you will see flow in the superior Glenohumeral-humeral ligament and also the coracohumeral ligaments adjacent to the LHB tendon,
Steve.
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Great, many thanks for the input. For info, I didn’t find any neovascularity at the rotator cuff interval. The supraspinatus view had a uniform thickening of its overlying bursa which I called bursosis as in that view no neovascularity showed up with PD. So with the LHB view I’ll upgrade that to bursitis.
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