Bifid or split tear of Long head of biceps?

[Michael Shilton]

Hi
I scanned this gentleman who is having some relatively minor shoulder impingement issues.He has some, but not profound, weakness to biceps and supraspinatus.I found a small articular surface partial tear of SSP at the anterior edge and a long head of biceps with some sheath fluid that appears bifid or is it a split? Many thanks.

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[Stephen Bird]

Hi Michael,

This is a little puzzling,

I am not a fan of the longitudinal split diagnosis for tendons in the upper limb and would need some convincing. In the lower limb weight bearing tendons (tib post and peroneus brevis as great examples) I think longitudinal splits are common, but in the upper limb I am not so sure.

I agree there is a little fluid around the tendon indicating a small joint effusion although it is really at the border for being physiological for me.

The long head of biceps does have some anatomical variations possible and what you are seeing might represent an anatomical variation. Interestingly when I see anatomical variations they are often bilateral for some reason so look at the other side.

Anatomically the collagen you are seeing just anterior / medial to the main tendon is in the area where I expect to see the coracohumeral ligament and perhaps thi is a little thickened. This can be associated with cuff injury or adhesive cap.

I would follow that other collagen area and try and determine if indeed it is the coracohumeral ligament.

another possibility is thickening of the sheath itself.

A few things to consider!

Steve

[Michael Shilton]

Thanks for the thoughts Steve.
I’ve added the interval pictures as well to see if they help. Couple of questions: so the CHL sits down in the groove as well as up in the interval area?
Fluid around the LHB could also be tenosynovitis?

Mike

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[Stephen Bird]

Nice images,

Typically the CHL sits in the interval area anterior to the LHBT and the superior glenohumeral ligament sits on the medial side of the LHBT tucked in slightly underneath it and these two structures are connected together forming the “sling”. I don’t typically expect the CHL to extend down as far as the structure in your case but do you agree it links exactly the same texture and sonographic composition.
So I am floating the idea that the structure might well be CHL and in real time you could see if you can follow it back to the CHL. It would be a little anomalous in terms of classic anatomy but nothing surprises me anymore!
The fluid does not make a diagnosis of tenosynovitis, but rather it is just GH joint fluid and may well be physiological given the volume. Tenosynovitis requires that the fluid have some synovial proliferation and vascularity. If the structure was a thick tendon sheath due to tenosynovitis it probably should have had some vascularity

Steve

[Michael Shilton]

Thanks Steve, a good one to learn from.

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