Complete tear long head of biceps tendon

Clinical information

This patient was referred to me by the orthopedic surgeon. Based on the "Popeye sign" the patient presented, the surgeon suspected a full thickness tear of the long head of the biceps in his left shoulder. Request to me if I could confirm this suspicion, what the exact status is, and if other tendons were involved in the pathology. The patient had an accident last week and had lot's of pain since then (VAS 6 to 8). He couldn't work, was disturbed in sleeping and didn't know how to hold his arm during the day.

Brief description

The transducer was placed both transverse (short-axis) and longitudinally (long-axis) over the left long head of the biceps tendon. The tendon was followed to distal until the pectoralis major tendon, but also to proximal into the rotator interval. The rotator interval was also visualized in modified Crass position. To double check the pathology findings several left/right comparisons were made. Images were analyzed by using the SonoSkills pathology checklist.

• SHAPE: The tendon in the distal intertubercular groove appears to have a larger cross-sectional area in transverse view, or thickness in longitudinal view. This enlargement continues all the way to distal. The transverse ligament bridging the groove is more convex. 
• ECHOGENICITY: The tendon part in the distal intertubercular groove and further down is more hypoechoic probably due to retracted fibres. The rotator interval appears to be very hypoechoic due to absence of the tendon. It lost it's specific appearance of having a hyperechoic oval tendon. At the original location of the tendon in the rotator interval, an small anechoic zone can be seen. 
• CONTINUITY: The proximal intertubercular groove is, at closer look, empty. The distal groove contains the retracted tendon fibres. The retraction is incomplete, most likely due to some stabilization of the tendon by it's vinculum. The rotator interval is empty indicating a complete tear of the long head of the biceps tendon. 
• DOPPLER: A minor degree of neovascularization in the proximal tendonstump can be seen. 
• FUNCTIONAL: no ultrasound guided functional test could be executed. The proximal intertubercular groove (image 3) was a pitfall: at first glance it appeared to be normal, but when following the biceps to distal and proximal the pathology became apparent.

Conclusion

Based on the ultrasound findings and SonoSkills pathology checklist analysis I concluded: \ - Complete tear of the long head of the biceps tendon. - The rotator interval is "empty". No sign of the long head of the biceps tendon. - The long head of the biceps tendon has partially retracted. It's still located in the distal intertubercular groove, probably fixated or stabilized by the tendon's vinculum (suspensory ligament). - Minor degree of neovascularization. The clinical examination findings of the orthopedic surgeon could be confirmed. Furthermore, the surgeon knows that there is a partial retraction of the long head of the biceps tendon, and that no other anatomical structures where involved. This information can help his clinical decision making.