Subscap Tears

[David Smith]

Hi Stephen,
On the webinar, there were not many examples of subscap tears. Could you please share a few examples?
Thanks,
Dave

[Stephen Bird]

Hi David,

I have had a look for a few examples of dodgy subscaps,

I think ultrasound is not as sensitive as MRI for subscapularis injuries, especially in the superior part of the insertion. When I see a long head of biceps tendon which is drifting medially I suspect a subscap tear causing long head of biceps instability. Medial migration of the LHBT may also be due to a supraspinatus tear commonly.

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[Stephen Bird]

A few more

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[Stephen Bird]

and more

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[Stephen Bird]

another one

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[Stephen Bird]

A few more.
Some are a bit old and I apologise for that, but they still make a point.

Steve

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[Stephen Bird]

More

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[Stephen Bird]

Two more

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[David Smith]

Hi Steve,
Wow, amazing. Thanks for sending these. Many of them are VERY subtle, not obvious at all. Are most of these LAX views?
Dave

[David Smith]

Hi Stephen,
IMHO, the addition of needle exploration with injection of small amounts of saline into suspicious areas might be the wave of the future to increase US sensitivity for subtle RTC tears.
Dave

[Stephen Bird]

Yes, the LAX view is still my most useful although I do look in both planes.

Injecting small amounts of saline or lignocaine into areas of concern in the rotator cuff is something that many people do as a diagnostic test and it works very well.
You can also add a little gas to the injection by adgitating the liquid prior to injecting and use the gas bubbles as contrast.

This is a well established technique.

One word of caution is that there are some areas where natural clevage planes exist such as in the area between the rotator cuff interval and the very anterior fibres of SST and injecting these areas can sometimes create a plane that looks like a tear but may be anatomical.

By all means if you see an area in the SST that looks like a possible tear and you can not be satisfied with conventional imaging in relaxed, modified crass and full crass positions a logical next step is to challenge it with an injection while you watch.

My great friend Dr Ray Chen in Taichung uses this technique regularly as does Dr Wesley Chen in Taipei.

Steve

[Diane]

Hello,

Just following along the theme… would you consider the attached images as a small delamination subscap tear? I thought there was a delamination calc too?

Thanks!

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[Stephen Bird]

HI Diane,

Absolutely,

nice example,

You might even be able to extend the length of this longitudinal tear if you tilt the lateral edge of the transducer towards the flor. You will lose the biceps tendon but be in a more perfect long axis plane for the subscap fibres showing the full length of the delimitation.
The echogenic line may have some calcium but it is mainly just scar (granulation) tissue.

Steve

[Diane]

Thanks for the tip Steve!

How do we tell the difference between delamination calc and granulation tissue?
Do you mention in your report if there is granulation tissue? Do you give measurements as well?

Thanks!

[David Smith]

What a great thread! Thanks Stephen and Diane!
Dave

[Stephen Bird]

What I mean by granulation is the healing phase of a tear.
You see it commonly in the SST and subscap,
It begins with an acute tear that often has some delimitation component to the tear.
The next thing that happens is the tendon tries to repair the defect by laying down granulation (scar) tissue. This granulation tissue appears echogenic relative tot he adjacent healthy tendon tissue. It usually looks like a longitudinal echogenic line in the tendon and also if you follow the line to the entheisis you will see a small sub-periosteal cyst (irregularity) pit in the enthesis where the delaminating began.
This granulation Aussie may or may not include some dystrophic calcification so when you x-ray it you usually don’t see calcification but on occasions there may be a small amount of calcium as part of the granulation process.
It is most important to understand that the pathophysiology here is NOTHING like hydroxyapatite deposition and must not be confused with calcific tendinosis. If this mistake is made any attempt to perform a barbotage / lavage procedure will fail.

Steve

[Diane]

Thanks Steve, I was led to believe that echogenic linear lines = linear calcifications hence why I called it a “delamination calc” but I should be very careful calling something a “linear calc”.

I have a couple of questions:

1) Are calcifications considered dystrophic IF there are signs of granulation tissue (like the 1st video labelled “subscap-calc-and-delamination”) and/or signs of tendinosis.
If it is just a sole calcification with no tendinopathy, do you just call it a hydroxyapatite deposit?

2) Is the term delamination just another word for linear/longitudinal?
Im just a bit confused because the first video has a calcification with associated granulation tissue but the calc doesn’t look linear, rather oval shape to me? Maybe I’m thinking too much in the naming of the video.

3) What is essentially the difference between granulation tissue and a true linear hydroxyapatite deposit on Ultrasound?
In the video “subscap-delammm-calcium”, the delamination calc definitely looks thicker/bulkier? Since granulation tissue is linear and extends to the enthesis, are linear hydroxyapatite deposits more randomly distributed?
Or is an x-ray absolutely required to distinguish the two?

4) Also for the case I posted above, How would you describe it? Just trying to see how I can improve my ultrasound reports.
I would put on the worksheet “There appears to be a delamination tear involving the mid subscapularis fibres measuring 3 x 1 mm. Linear granulation tissue is seen in the inferior subscapularis fibres”.
Or would you not bother writing linear granulation tissue and just classify it under general enthesopathic changes?

Thanks for reading my word vomit

🙂

[Stephen Bird]

Hi Diane,

Indeed all things that are echogenic are not necessarily calcification.

Yes indeed delimitation means the same as a longitudinal split tear of the tendon and when this occurs you often get that classic linear line of scar tissue.

I don’t think I can be perfect in always allocating the correct diagnosis to an echogenic area in a tendon. Most times I have no difficulty but there are always occasions where I sit on the fence.

With a classic small enthesis based intrasubstance tear with a linear delimitation component that has granulated I am looking for a small peck in the enthesis at the doort of an echogenic line that runs along the longitudinal axis of the tendon fibres. The line is typically thin and not densely shadowing as it represents granulation tissue. Also it is not tender on sono-palpation

Hydroxyapatite deposition is a bone salt migration from the bone to the tendon and hence it must originate at the enthesis where tenocytes and osteocytes are side by side. Hydroxyapatite is more cloud like (cumulous) in nature and less sharp and linear. In the acute stage it is not particularly attentive and may even be seen to move like a liquid with Tx pressure. It is very tender on sonopalpation and it is much bulkier that a linear granulation. When it matures it may simply become a hard dehydrated rock of calcium with dense acoustic shadowing and is typically not tender at this stage.

Dystrophic calcification is any calcification that occurs in a tendon due to a tear that is scarring up or an area of tenocyte exhaustion that has calcified. Dystrophic calcifications are within the tendon matrix and don’t need to have a relationship to the enthesis like a delimitation tear or hydroxyapatite. You see dystrophic calcification commonly in the distal patella tendon and the Achilles tendon as a result of tenocyte exhaustion and dystrophic calcification deposition. These calcifications often produce an acoustic shadow.

So as you can see there is some overlap in my mind but as general rule I think I can tell these entities apart.

The plain radiograph will also give some valuable clues.

Steve

[Diane]

Hi guys, Just continuing along the theme…

I scanned this lady where I saw an oval echogenic strucutre in the mid fibres of the subscapularis. It looked a bit bulkier than just granulation tissue. She wasn’t tender in this spot specifically. I was thinking dystrophic calc because she wasn’t tender and it had a slight shadow to it. Or could it possibly a matured hydroxyapatite deposit? (Still trying to wrap my head around the differences).

Also, What is your opinion on using colour to characterise these calcifications in the shoulder? Are they able to distinguish between dystrophic and hydroxyapatite deposits? Or doesn’t add any value?

Thanks!

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[Stephen Bird]

For me this is an example that could go either way and the clinical presentation would sway me.

The calcification / crystal deposition is close to the enthesis so it is potentially hydroxyapatite. It is not densely shadowing so it is not an enthesophyte. So we either have hydroxyapatite or a low density dystrophic calcification,
If it is dystrophic calcification it is unlikely to be tender and represents an old injury. If it is hydroxyapatite it is going to be tender.

Colour Doppler is not particularly helpful in my mind to differentiate.

I agree old , mature hydroxyapatite Vs old dystrophic calcification is not possible with ultrasound and both are unlikely to be symptomatic so it probably doesn’t matter in management terms.

As yours was tender and it is not a dense calcification I would punt on it being some hydroxyapatite.

Steve

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