Shoulder

[Nabeel Chaudhry]

Hi Steve,

I just scanned a shoulder a with a torn biceps and subscap, but the supra seems to be intact. Can this happen, or does the supra also needs to be torn due to the CHL being torn?

Nabeel

[Stephen Bird]

Hi Nabeel,

Certainly not the usual pattern, but very possible.

The long head of biceps often ruptures after the Supra has given way as it is overloaded in it’s function as a humeral depressor. But the biceps can certainly rupture in the setting of an intact supra. Remember the long head of biceps is so badly engineered with a curved course and soft tissue origin.
The subscap can also be torn with forced external shoulder rotation. This is common with falling injuries where the person tries to grab and hold an object to break their fall. The CHL does not necessarily need to be damaged. It does provide stabilisation for the long head of biceps and is intimate with the subscapularis, however it may survive in the setting you describe.

The usual pattern is for the supra to tear, the CHL is weakened, the long head of biceps migrates medially , the long head of biceps is overloaded and ruptures.

But anything is possible.

When you think the subscap is torn it is worth trying a “lift off test” . Put the back of your hand on the small of your back and try moving the hand away from the spine. Test the strength on both sides and look for a reduction on the torn subspace side.

I think what you observed is just fine. Unusual , but fine.

Steve

[Daniel Walkley]

I agree with Steve, Nabeel, it is the less common variant, but I have seen a few of these. Often you will find that the subscap tear is chronic in nature and it is usually the superior insertional fibers. This allows for the biceps pulley apparatus to become compromised on the medial aspect allowing medial migration of the LHB up and over the groove. This is the same biometrical wear pattern that Steve has described in the usual pattern – but in reverse – the biceps migrates medially, becomes overloaded and fails.

If you couldn’t fault supra, its fine

Dan

[Nabeel Chaudhry]

Great, thanks for the help guys. Appreciate it.

Nabeel

[Tina Ziaei]

Hi Steve, just wondering if you could share some info on chondrocalcinosis of the GHJ. I recently had a pt with tiny echogenic foci within the cartilage of the GHJ and called it ?chondrocalcinosis. The radiologist looked at me as if I was crazy haha!
Is this something we can diagnose on US? What are possible symptoms or clinical tests to assess this?

[Stephen Bird]

Hi Tina,
You are not crazy, you are right on the money,
What you saw is Pseudogout, or more precisely calcium pyrophosphate dehydrate deposition (CPPD) within the hyaline cartilage. It appears as crystallisation within the hyaline cartilage as opposed to gout which appears as monosodium rate deposition on the surface of the hyaline cartilage.
I see CPPD in shoulders and knees from time to time and it is a nice diagnosis. I have even seen it teaching through the capsular ligament apparatus and filling the rotator cuff cable (coracohumeral ling) with CPPD deposition.
Nice work Tina.

Steve

[Stephen Bird]

The clinical presentation will be simple shoulder pain with no restriction in range of movement,

In this setting I also consider non adhesive synovitis of the GH joint.

I am not aware of any particular clinical test for a CPPD shoulder,

but the patient will benefit from management under a rheumatologist,

Steve

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