0:00

So, these are MR images on a 58-year-old who has pain and limited

0:05

range of motion, no prior trauma.

0:09

And the first finding that jumps to our eye on the axial images is

0:14

the position of the long head of biceps tendon.

0:17

The tendon is completely out of the groove.

0:20

We have here the lesser tuberosity, greater tuberosity,

0:25

the neurovascular bundle inside the biceps groove,

0:29

the vessels, and then the tendon is outside,

0:33

completely outside of the groove medially.

0:36

If we track the tendon up and down, and we are going to do that now,

0:41

we can see it's outlined by fluid that is

0:44

loculated fluid within the biceps tendon sheath that's compatible

0:49

with associated tenosynovitis.

0:53

The is pretty thickened.

0:55

When I see that,

0:57

I think about chronic tenosynovitis.

1:01

And as we go approximately towards the origin of the biceps

1:06

from the superior glenoid intraarticular portion,

1:10

you can see the biceps is actually dislocating.

1:13

It has come off from the biceps groove and is located

1:18

within the anterior shoulder joint recess in this patient who has

1:23

an injury to the biceps pulley.

1:26

So, a biceps pulley is going to keep the biceps stand in place.

1:29

In this patient,

1:31

all the medial stabilizing structures,

1:33

including the superior glenohumeral ligament,

1:36

the medial band of the coracohumeral ligament,

1:41

as well as the subscapularis tendon,

1:45

have to be disrupted for the biceps to dislocate inside the joint space.

1:50

In these patients, we often see,

1:53

and that's why we are here looking at the oblique coronal sequence,

1:56

we often see longitudinal split here.

1:59

So, that's something that we want to look for,

2:02

the presence of these intra-substance, higher signal intensity,

2:08

areas that correspond to longitudinally splitting due to

2:13

the tendon coming in and out of the groove and having friction-related

2:18

trauma that elicits this type of injury.

2:23

So key elements in this type of injury,

2:27

presence of subscapularis tendon tear,

2:32

disruption of the medial stabilizing structures.

2:35

Always, always check your subcortical space

2:38

when there is isolated injury to

2:41

the subscapularis tendon, because this could be a case of

2:45

subcoracoid impingement where the tendon is getting macerated

2:50

between the coracoid and the lesser tuberosity.

2:53

So in these cases, I,

2:55

I am not a radiologist with a ruler, but sometimes

2:59

it helps.

3:00

And so if we measure that distance in this patient, is 7 mm.

3:04

It is slightly narrow as compared to 11 mm,

3:09

which is the average distance between the coracoid

3:13

and the lesser tuberosity.

3:14

Now, here on the sagittal images,

3:17

I just want to show you that space.

3:19

So, we have the coracoid process and the lesser tuberosity.

3:24

And so, this is the subcoracoid space right here.

3:28

We have the subcoracoid space,

3:30

and people who have a narrow subcoracoid space

3:34

can develop subcoracoid impingement

3:36

with tears of the subscapularis tendon,

3:39

injury to the medial stabilizing structures of the biceps

3:43

sternum pulley.

3:45

And then, that's going to result in what this patient has,

3:48

medial dislocation,

3:50

intraarticular dislocation of the long head of biceps tendon.