Calcific Tendinitis of the Long Head of the Biceps Brachii Distal to the Glenohumeral Joint: Plain Film

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1 1011 Calcific Tendinitis of the Long Head of the Biceps Brachii Distal to the Glenohumeral Joint: Plain Film Radiographic Findings Amy Beth Goldman1 Calcific tendinitis is a painful condition related to deposition of hydroxyapatite crystals; it favors large joints. The shoulder, specifically the tendons of the rotator cuff and the Insertion of the long head of the biceps on the superior glenoid rim, is a well-recognized location for this abnormality. The purpose of this article is to describe a second site of calcific tendinitis of the biceps, distal to the joint and corresponding to the junction of the tendon and muscle. Radiographs in 1 19 cases of calcific tendinitis of the shoulder, obtained between 1980 and 1988, were reviewed. Twenty had calcific tendinitis in the region of the tendon of the long head of the biceps (nine at the glenoid insertion and Ii adjacent to the humeral shaft). All I I patients with calcific tendinitis at the more distal site had a small, homogeneous deposit adjacent to the proximal humeral shaft. The densities In these 1 1 cases followed the normal course of the tendon of the long head of the biceps and were therefore medial to the proximal humeral shaft on the internal rotation view, lateral to the proximal humeral shaft on the external rotation view, and anterior to the proximal humeral shaft on the axillary projection. The major differential diagnosis of calcific tendinitis of the tendon of the long head of the biceps Is loose bodies trapped In the biceps tendon sheath. Although the position of the soft-tissue densities in these two entities is similar, loose bodies have an appearance of bone, and their source (degenerative arthritis or recurrent dislocations) Is usually apparent. A site of calcific tendinitis distal to the glenohumeral joint that is detectable on plain films is reviewed. Accurate diagnosis depends on understanding the anatomy of the tendon of the long head of the biceps brachii. The clinical charts of the 1 1 patients also are summarized, with emphasis on the association between the roentgen finding and bicipital tendinitis and impingement syndrome. AJR 153: , November 1989 Calcific tendinitis accounts for 40-45% of patients with shoulder pain [1]. It is most often located at the insertion of the supraspinatus tendon on the greater tuberosity [1-4], followed by the other three tendons of the rotator cuff. However, calcific tendinitis can also affect the tendon of the long head of the biceps brachiia tendon that has two vulnerable sites. Calcification at its origin on the superior glenoid labrum has been well described in previous publications [1, 3, 5, 6]. However, a more distal site near the junction of the tendon and muscle has rarely been noted in the literature. Resnick and Niwayama [1 ] and Crenshaw and Kilgore [7] illustrated this entity but did not discuss it. Another author [8] noted the presence of calcific tendinitis adjacent to the humeral shaft, but ascribed it to Received April 4, 1989: accepted after revision calcification of the teres major (a tendon that would project medially on external June 15, rotation) [9]. Presented at the annual meeting of the American This publication reviews the prevalence of calcific tendinitis of the long head of Roentgen Ray Society, New Orleans, LA, May the biceps brachii occurring distal to the glenohumeral joint (1 1 of cases of calcific tendinitis of the shoulder) and its plain film characteristics. I Department of Radiology and Nuclear Medicine, The Hospital for Special Surgery, 535 E. 70th Materials and Methods St., New York, NY X/89/ A review of plain film reports from 1980 to 1988 yielded 389 cases coded as calcific C American Roentgen Ray Society tendinitis of the shoulder. One hundred nineteen radiographs were available for review.

1012 GOLDMAN AJR:153, November 1989 Twenty of the 1 19 cases had calcific tendinitis in the region of the tendon of the long head of the biceps brachii: nine at its insertion and 1 1 adjacent to the

On the radiographs of the 1 1 patients considered to have calcific tendinitis distal to the glenohumeraljoint, a single small homogeneous density was seen adjacent to the proximal humeral shaft.

In each, the calcification was medial to the humerus on internal rotation and lateral to the humerus on external rotation, following the course of the long head of the biceps brachii.

2 1012 GOLDMAN AJR:153, November 1989 Twenty of the 1 19 cases had calcific tendinitis in the region of the tendon of the long head of the biceps brachii: nine at its insertion and 1 1 adjacent to the humeral shaft. The latter 11 patients are the focus of this publication. On the radiographs of the 1 1 patients considered to have calcific tendinitis distal to the glenohumeraljoint, a single small homogeneous density was seen adjacent to the proximal humeral shaft. Internal and external rotation views were obtained in all 1 1 cases. In each, the calcification was medial to the humerus on internal rotation and lateral to the humerus on external rotation, following the course of the long head of the biceps brachii. Seven of the 1 1 patients had axillary views demonstrating the anterior location of the calcifications corresponding to the anterior position of the biceps brachii. The radiographs of the 1 1 patients with extracapsular calcific tendinitis were reviewed with attention to (1) the side of involvement, (2) the best projection for identifying the soft-tissue density, (3) the distance between the deposit and the lesser tuberosity on the internal rotation view, (4) the size and shape of the calcification, and (5) other sites of calcific tendinitis. Clinical charts were available in all 1 1 patients in whom plain film findings were consistent with calcific tendinitis of the biceps brachii distal to its insertion. There were eight women and three men years old (average, 66). The duration of pain varied. At one end of the spectrum were three patients who had discomfort for less than 10 days; at the other end of the spectrum were three patients with symptoms described as lasting for more than 1 year. The pattern of pain also varied. Eight patients had pain that radiated from the shoulder to the humeral shaft and corresponded to the distribution of the biceps (six anterior, two lateral). Three patients had superior discomfort related to the area of the rotator cuff and acromioclavicular joint that was suggestive of impingement syndrome. On physical examination, six patients had maximal tenderness over the tuberosties, six had findings consistent with impingement syndrome, and one had evidence of a rotator cuff tear (confirmed by arthrography). Results On plain film studies, all 1 1 cases had a soft-tissue calcific deposit adjacent to the proximal humeral shaft (Figs. 1 and 2). On the internal rotation view, the density projected medial to the humerus. On the external rotation view, the calcification was lateral to the bone or superimposed on its lateral cortex. In seven patients, an additional axillary view was available, which revealed the density to be anterior in position. The left upper extremity was affected in nine cases and the right upper extremity in two. In all cases, the calcifications were shown best on the internal rotation view because the densities tended to project further away from the humerus (Fig. 2). On the internal rotation view, the calcifications were round (eight patients) (Fig. 2), ovoid (two patients) (Fig. 1), and bibbed (one patient). On the same image, the deposits were located cm (average, 6.6) below the tip of the lesser tuberosity and were mm (average, 4.0) in size. Four patients had additional calcifications in the tendons of the rotator cuff of the same shoulder (Fig. 3) and four others had calcific tendinitis adjacent to other articulations (two elbows, two hips). Discussion Painful calcific deposits in the tendon of the long head of the biceps brachii are part of the clinical entity referred to as calcific tendinitis or, more recently, hydroxyapatite deposition disease[1, 2, 10-14]. The tendon of the long head of the biceps brachii originates on the superior aspect of the glenoid adjacent to the labrum [2, 3, 6]. From its origin to the bicipital groove, the tendon passes through the top of the joint capsule [2, 3, 6]. The tendon then turns distally into the bicipital groove. Within the groove and for a variable distance below the groove, the tendon remains covered by a capsular reflection referred to as the tendon sheath [6, 1 2]. The walls of the groove are the tuberosities (Fig. 4), and its roof is the transverse humeral ligament [2, 5, 1 4]. Below the tuberosities, both the intra- and extrasheath parts ofthe tendon of the long head of the biceps Fig. 1.-Radiographs show calcific tendinitis of tendon of long head of biceps distal to glenohumeral joint in a 46-year-old woman after several months of anterior left shoulder pain that radiated distally. Physical examination revealed maximal tenderness over tuberosities and signs of impingement syndrome. A, External rotation view shows calcific deposit adjacent to lateral humeral shaft. B, Internal rotation view shows that deposit rotated and is now medial to humeral shaft and 7 cm distal to tip of lesser tuberosity. C, Axillary view indicates that calcification is anterior in position.

AJR:153, November 1989 TENDINITIS OF LONG HEAD OF BICEPS 1013 A B Fig. 2.

Physical examination revealed signs of impingement syndrome. A, Internal rotation view from an arthrogram shows a complete rotator cuff tear plus a small hazy calcific deposit (arrowheads) 6.

This case demonstrates that calcific deposit is best seen on internal rotation view because it is further from the bone.

3 AJR:153, November 1989 TENDINITIS OF LONG HEAD OF BICEPS 1013 A B Fig. 2.-Radiographs show calcific tendinitis of tendon of long head of biceps distal to glenohumeral joint in a 59-year-old woman after 6 months of anterior right shoulder pain. Physical examination revealed signs of impingement syndrome. A, Internal rotation view from an arthrogram shows a complete rotator cuff tear plus a small hazy calcific deposit (arrowheads) 6.5 cm distal to tip of lesser tuberosity. B, External rotation view reveals deposit to be superimposed on lateral cortex (arrowheads). C, Axillary view shows it to be anterior to humerus (arrowhead). This case demonstrates that calcific deposit is best seen on internal rotation view because it is further from the bone. In addition, it documents the density to be distal to the biceps sheath Both bicipitaltendinitis and damage to rotator cuff are components of impingement syndrome. Fig. 3.-Radiograph shows calcific tendinitis of long head of biceps (large arrowhead) plus calcific tendinitis in supraspinatus portion of rotator cuff (small arrowhead) in a 56-year-old patient. rotate with the humeral shaft. As shown in a double-contrast shoulder arthrogram, the long head of the biceps is medial to the humerus on internal rotation but moves lateral to the humerus on external rotation (Fig. 4). On the axillary view, its anterior position is demonstrated. A review of anatomy texts [9, 1 5] failed to yield a precise measurement for the length of the tendon of the long head of the biceps. However, Gray s Anatomy [1 5] approximates the tendon muscle junction to be adjacent to the junction of the upper and middle thirds of the humerus. This location corresponds roughly to the site of calcific tendinitis observed in the extraarticular biceps (on average, 6.6 cm below the lesser tuberosity). Tendinitis of the long head of the biceps brachii is cited as a frequent cause of shoulder pain [1 6]. It may occur as an isolated entity [2, 5, 7], but often coexists with rotator cuff teams and/or the impingement syndrome (Fig. 2) [1 7-19]. In % of clinical studies [7, 1 6, 17] and 45% of the presented cases, physical findings were consistent with multiple soft-tissue abnormalities. Bicipital tendinitis affects both young and middle-aged adults [7, 1 7, 18]. In the current series, the patients ranged in age from 26 to 78 years. The prevalence increases in those whose occupations require overhead lifting [2, 18] and in patients who participate in racket sports [2, 1 7, 18]. Classically, the pain of bicipital tendinitis radiates over the anterolateral humeral head and shaft [4-7, 1 8]; maximal tenderness is adjacent to the tuberosities [1 7, 18]. However, as the entity is often a part of the impingement syndrome, other findings can be present and dominate the clinical picture. Only eight of the 1 1 reviewed cases had predominantly anterolateral pain. In the other three patients, maximal discomfort was related to the area of the rotator cuff and acmomioclavicular joint, suggestive of impingement syndrome. As in

1014 GOLDMAN AJR:153, November 1989 Fig. 5.

deposit adjacent to superior glenoid. - Fig. 4.-Anatomy of tendon of long head of biceps is seen on normal double-contrast arthrograms.

On external rotation view (A), tendon passes over top of humeral head and then turns downward and parallels lateral humeral neck (large arrowheads).

C and D, Axillary projection (C) shows anterior position of long head of biceps (arrowhead).

-Calcific bursitis caused by calcific tendinitis of supraspinatus tendon.

to humeral neck. Bursal calcification (large arrowheads) remains unchanged with rotation.

other series of bicipital tendinitis [1 1, 1 8], in the 1 1 presented cases, the duration and severity of pain varied widely.

4 1014 GOLDMAN AJR:153, November 1989 Fig. 5.-Radiograph obtained with external rotation shows calcific tendinitis of origin of long head of biceps brachii appearing as a small, ovoid calcific deposit adjacent to superior glenoid. - Fig. 4.-Anatomy of tendon of long head of biceps is seen on normal double-contrast arthrograms. A and B, External (A) and internal (B) rotation views. Origin is identified on superior glenoid Iabrum (small arrowheads). On external rotation view (A), tendon passes over top of humeral head and then turns downward and parallels lateral humeral neck (large arrowheads). On internal rotation view (B), long head of biceps rotates medially (large arrowheads). C and D, Axillary projection (C) shows anterior position of long head of biceps (arrowhead). Both axillary (C) and bicipital groove (D) views show tendon of long head of biceps passing between greater and lesser tuberosities. Fig. 6.-Calcific bursitis caused by calcific tendinitis of supraspinatus tendon. A and B, External (A ) and internal (B) rotation radiographs show calcium within subacromialsubdeltoid bursa as a teardrop-shaped collection lateral to humeral neck. Bursal calcification (large arrowheads) remains unchanged with rotation. In this patient a small collection of calcium (small arrowheads) remains in supraspinatus tendon above tip of greater tuberosity. other series of bicipital tendinitis [1 1, 1 8], in the 1 1 presented cases, the duration and severity of pain varied widely. Radiographic findings associated with bicipital tendinitis are unusual [2, 5-7]. The majority of publications evaluate abnormalities of the bicipital groove that are suggestive but not diagnostic of tendon abnormalities [2, 6, 14, 17]. These findings include posttraumatic deformities of the tuberosities [2], irregularity of the tuberosities caused by spur formation [14, 1 6, 17], a shallow bicipital groove [2, 6, 1 4], and a prominent supratuberculam ridge [6, 14]. A bicipital groove is considered shallow if its depth is less than 3 mm as measured on the bicipital groove view (the mean depth is 4.6 mm) [14].

AJR:153, November 1989 TENDINITIS OF LONG HEAD OF BICEPS 1015 Fig. 7.

A and B, External rotation (A) and axillary (B) projections reveal narrowing of glenohumeral joint.

Osteochondral fragments are surrounded by air and contrast material, confirming their position within biceps tendon sheath. Fig. 8.

5 AJR:153, November 1989 TENDINITIS OF LONG HEAD OF BICEPS 1015 Fig. 7.-Radiographs from arthrography show loose bodies within biceps tendon sheath caused by degenerative arthritis in 65-year-old man with right shoulder pain. A and B, External rotation (A) and axillary (B) projections reveal narrowing of glenohumeral joint. Multiple osteochondral fragments are identified adjacent to proximal humeral shaft On external rotation, densities project lateral to humerus; on axillary view they are anterior to humerus. Osteochondral fragments are surrounded by air and contrast material, confirming their position within biceps tendon sheath. Fig. 8.-Radiographs show loose bodies within biceps tendon sheath caused by cartilage damage in 25-year-old man with an unstable shoulder. A, External rotation view of an arthrogram reveals a Bankart fracture with loss of inferior glenoid labrum (arrowheads) and osteochondral fragments adjacent to anterior and lateral aspects of humerus. B, Contrast-enhanced study confirms densities to be surrounded by contrast material and, therefore, within biceps tendon sheath. This normal variant renders the tendon more vulnerable to compression [1 4]. The supratubercular ridge is also a normal variant and is often associated with a shallow bicipital groove [6, 14]. A large supratubercular ridge can potentially cause elevation and lateral displacement of the tendon [2]. However, it has been estimated that 50% of the population have this variant [2], and its significance as a causative factor of bicipital tendinitis remains controversial [14]. Calcific tendinitis of the origin of the long head of the biceps brachii is uncommon but is well described in the literature [1, 3, 6, 1 2]. Deposits at this site are ovoid, and regardless of rotation remain adjacent to the superior glenoid (Fig. 5) [1, 3, 6, 1 2]. Nine examples were identified in this series of 119 cases. However, the current series shows that the most common site of calcific tendinitis of the long head of biceps brachii is not at its insertion but in the extraarticular portion of the tendon of the long head close to its junction with the muscle (1 1 of cases) (Figs. 1 and 2). The most obvious reason this entity has not been widely observed is that on many shoulder studies, the proximal humeral shaft is not included in the films. The reason that the distal tendon of the long head of the biceps is vulnerable to calcific tendinitis is uncertain. At the junction of the tendon and muscle, there are two strong fascial bands: the brachial fascia and the proximal portion of the lateral intramuscular septum [1 5]. These structures possibly result in compression of adjacent tendons. In the current study, as well as in other series of calcific tendinitis, more than one structure can be affected (Fig. 3) [1, 6, 20]. In four of the 1 1 patients with calcific tendinitis of the extraarticular part of the long head of the biceps, deposits were also present within the ipsilateral rotator cuff (Fig. 3). In another four patients, other articulations were affected (two elbows and two hips). The major radiographic differential diagnoses of calcific tendinitis of the extraarticular part of the tendon of the long head of the biceps are other soft-tissue densities that project below the tuberosities of the humerus, specifically, calcific bursitis (Fig. 6) and loose bodies trapped in the biceps tendon sheath (Figs. 7 and 8). In the early fluid state, a calcific deposit in the tendons of the rotator cuff can decompress spontaneously by rupturing into the adjacent subacromial-subdeltoid bursa (Fig. 6). The calcium collection within the bursa, unlike calcific tendinitis of the long head of the biceps, is teardropshaped, more proximal in position, and does not change with rotation. A more difficult differential diagnosis comprises loose bodies that become trapped in the biceps tendon sheath. Any density related to the biceps tendon will be medial on the

1016 GOLDMAN AJR:153, November 1989 internal rotation view, lateral on the external rotation view, and anterior on the axillary projection (Figs. 7 and 8).

6 1016 GOLDMAN AJR:153, November 1989 internal rotation view, lateral on the external rotation view, and anterior on the axillary projection (Figs. 7 and 8). However, the loose fragments are multiple and corticated; in five of six reviewed cases, the source of the loose bodies (degenemative arthritis or a Bankart deformity) was evident on the routine plain films. In one of the six cases, a contrast study was necessary to show damage to the cartilaginous glenoid labrum (Fig. 8). In all six instances, the arthrogram revealed the densities to be within the sheath (Figs. 7 and 8) and surrounded by contrast material, as opposed to the cases of calcific tendinitis that were distal to the capsular reflection (Fig. 2). In summary, calcific tendinitis of the shoulder is a common indication for plain film examination. Including a portion of the proximal humeral shaft on the studies can help identify cases that affect the tendon of the long head of the biceps brachii. REFERENCES 1. Resnick D, Niwayama G. Diagnosis of bone and joint disorders, 2nd ed. Philadelphia: Saunders, 1988: Mosley HF. Shoulder lesions, 3rd ed. Baltimore: Williams & Wilkins, 1969: vigario GD, Keats TE. Localization of calcific deposits in the shoulder. AJR : Rowe CR. Calcific tendinitis. In: AAOS Instructional Course Lectures, vol. 34. Chicago: American Academy of Orthopaedic Surgeons, 1985: Lapidus PW, Guidott FP. Common shoulder lesions-report of 493 cases. Calcifictendinitis, tendinitis ofthe long head ofthe biceps, frozen shoulder, fractures and dislocation. Bull Hosp Jt Dis Orthop Inst 1968;29: Simon WH. Soft tissue disorders of the shoulder: frozen shoulder, calcific tendinitis and bicipital tendonitis. Orthop Clin North Am 1975;6: Crenshaw AH, Kilgore WE. Surgical treatment of bicipital tenosynovitis. J Bone Joint Surg [Am] 1966;48-A: Gondos B. Observations on periarthritis calcarea. AJR 1957;77: Grant JBC. Grant s atlas ofanatomy, 5th ed. Baltimore: Williams & Wilkins, 1962: Pederson HE, Key JA. Pathology of calcareous tendinitis and subdeltoid bursitis. Arch Surg 1951;62: Faure G, Daculsi G. Calcified tendinitis: a review. Ann Rheum Dis 1983;42[suppl]: Resnick D. Shoulder pain. Orthop Clin North Am 1983;14: McCarthy DJ, Gaffer RA. Recurrent acute inflammation associated with focal apatite crystal deposition. Arthritis Rheum 1966;9: Cone RO, Danzig L, Resnick D, Goldman AB. The bicipital groove: radiographic, anatomic and pathologic study. AJR 1983;141 : Gray H, Goss CM. Anatomy of the human body, 7th ed. Philadelphia: Lea & Febiger, 1965: Booth RE Jr, Marvel JP Jr. Differential diagnosis of shoulder pain. Orthop Clln North Am 1975;6: Nevaiser RJ. Lesions of the biceps and tendinitis of the shoulder. Orthop Clln North Am 1989;1 1: Nevaiser RJ. Painful conditions affecting the shoulder. Clin Orthop 1983;1 73: Neer CS II. Impingement lesions. Clin Orthop 1983;1 73: Bland JH, Merritt JA, Boushey DR. The painful shoulder. Semin Arthritis Rheum 1977;7:21-47

US finding of the shoulder (with live demonstration) 인제의대상계백병원 안재기

US finding of the shoulder (with live demonstration) 인제의대상계백병원 안재기 Shoulder US Biceps tendon & Rotator Cuff Long Head of Biceps Tendon Subscapularis tendon Supraspinatus tendon Infraspinatus tendon Teres