Wk 5, Case 5 - Review

Patient History
58-year-old male with left shoulder pain, weakness, and decreased range of motion. No known injury.

Findings
ROTATOR CUFF: Generalized interstitial swelling and tendinopathy altering the morphology of the deep fibers of the supraspinatus is noted in the region of the footprint and critical zone. Diminutive concealed interstitial delamination of the footprint. Infraspinatus intact. Delamination and attachment of the outer or superficial fibers of the subscapularis have allowed the biceps to interstitially sublux into it. Teres minor normal.

SUBACROMIAL/SUBDELTOID BURSA: Mildly swollen.

MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Mild volumetric atrophy without fatty replacement.

BICEPS TENDON: Biceps dislocation accompanied by tear of the transverse humeral ligament along with its coracohumeral ligament contribution. Biceps has subluxed into the interstitium of the subscapularis sitting atop or superficial to an intact middle glenohumeral ligament. Extraarticular longitudinal biceps sheath fluid distended.

AC JOINT: Moderate hypertrophy and mild inflammation slightly greater than expected age.

CORACOCLAVICULAR LIGAMENTS: Intact conoid and trapezoid ligaments.

SUBACROMIAL ARCH/OUTLET: Mild tapering or spurring at the takeoff of the coracoacromial ligament from the acromion seen in the sagittal projection.

SUBCORACOID ARCH: Coracohumeral distance is mildly narrowed due to hypertrophic change of the lesser tuberosity. Delaminated superficial fibers of the subscapularis and its contribution to the transverse ligament along with that of the coracohumeral ligament is torn resulting in biceps pulley mechanism failure and biceps medial interstitial dislocation.

GLENOHUMERAL JOINT: Mild craniad decentering of the humeral head. No anteroposterior decentering. No penetrating chondromalacia.

GLENOID LABRUM: Normal. No SLAP lesions.

SKELETON: Hypertrophy of the lesser tuberosity. Shallow broad bicipital groove may contribute to biceps pulley mechanism failure.

SUBCUTANEOUS SOFT TISSUES: Capsular fluid is aggregated in the subcoracoid bursa but no soft tissue mass is identified.

AXILLA: Normal. No adenopathy. No entrapment neuropathy.

Impressions
Biceps pulley mechanism failure includes interstitial dislocation of the biceps long head, tear of the transverse humeral ligament, and delamination or detachment of the superficial component of the subscapularis.