Shoulder diagnosis help

[Michael Shilton]

Hi Steve, this patient presents with 6 mths anterior shoulder pain, hurts only when she extends it. Flexion, abduction and int/ext all perfect. All cuff tendons are full strength but biceps is significantly weak. The images show a decent size SASD bursitis but I’m struggling to locate exactly the neovascularisation near to LHB. It seems to be in the bicipital groove on the lateral side and there is what appears to be sub periosteal cyst formation there too. So clinically it’s telling me it’s LHB, there are also positive image findings in that area but what is the injury? Does for example the LHB tendon have attachments actually in the groove itself? I checked carefully the anterior edge of SSP but couldn’t find a problem there.
Many thanks
Mike

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[Stephen Bird]

Hi Mike,

Was the image taken at 19:13:58 after you injected the bursa?

It looks like a fair bit of fluid in the bursa,

The other images don’t really show any definite pathology,

The small vessel and little defect in the bone are likely related to the attachment of the superior glenohumeral ligament. I occasionally see a small bony defect in that location and I don’t really consider it pathological.
The flow is interesting, but not really in the correct location to represent GH joint synovitis.
I am not seeing any clear diagnosis on the images to account for the symptoms.

Your images are great quality.

Nice scanning.

Steve

[Michael Shilton]

Hi Steve,

Many thanks for the reply, no this fluid is not post injection and I was surprised by its location too although I’ve not seen that many to be a good judge; it seemed very proximal. Thanks for the thoughts on the bicipital groove. I think I’ll refer this one on for an MRI. It’s an interesting case having so much normal ROM and strength just the dysfunctional bicep. I’ll let you know post MRI.

Regards

Mike

[Stephen Bird]

Hi Mike,

In the image with the fluid, is it in the bursa itself or in the long head of biceps sheath over the humeral head?

Either way it looks like a generous volume,

Steve

[Michael Shilton]

Hi Steve, the fluid wasn’t immediately visualised in that transverse views of the long head of biceps showed none including as far up as I could go to the rotator cuff interval. LS supraspinatus demonstrated a uniform bursal thickening and only when I moved much more proximal did it appear as significant amounts of fluid. If I remember correctly the image I’ve sent with the fluid is SSP in a neutral position rather than modified crass, I should have labelled it more carefully. So unless there’s a way of examining LHB over the humeral head other than following up to the interval that I’m not aware of I would plump for this being in the bursa not biceps.
Mike

[Stephen Bird]

Well you have too much fluid in that bursa !

Let me know what the MRI shows,

It is a complex clinical picture this one.

Steve

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