64-year-old patient presenting with shoulder pain and functional limitation.
Ultrasound examination of the shoulder demonstrates an abnormal appearance of the proximal long head of the biceps tendon. The tendon appears markedly thinned and possibly partially or completely absent proximally.
Distal to this region, and proximal to the musculotendinous junction near the pectoralis major insertion, a prominent hyperechoic structure is identified. This structure demonstrates features suggestive of either a large calcification or a cortical irregularity. The exact nature and origin of this finding are unclear, and its relationship to the long head of the biceps tendon remains uncertain.
Given the atypical location and morphology, further evaluation with radiography is recommended to differentiate between calcific deposition and osseous pathology.
Additionally, the rotator cuff tendons demonstrate moderate to severe tendinopathy, with thickening and heterogeneous echotexture.
The supraspinatus tendon shows a moderate partial-thickness tear, with focal disruption of the fibrillar architecture.
1. Final diagnosis
Abnormal proximal long head of the biceps tendon with thinning or possible partial/complete absence, associated with an adjacent calcific or cortical lesion of unclear origin. Concomitant moderate to severe rotator cuff tendinopathy and partial supraspinatus tear.
2. Differential diagnosis
Consider proximal biceps tendon rupture with retraction, calcific tendinopathy in an atypical location, or osseous fragment related to prior trauma. Radiography is advised for further characterization.
3. Teaching points
An absent or thinned biceps tendon should raise suspicion for rupture. Hyperechoic structures near tendons may represent calcifications or bony fragments and require correlation with other imaging modalities. Atypical locations warrant further evaluation.
4. Injury/disease information
Pathology of the long head of the biceps tendon often coexists with rotator cuff disease. Chronic degeneration may lead to tendon rupture and altered anatomy. Calcifications or post-traumatic bony changes may complicate the imaging appearance and require multimodal assessment.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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