Hi all,
This week’s VOTW is brought to you by Dr. Evans!
A 56 year old male presented with dull left shoulder pain for two days. He denied any trauma, swelling, erythema to the area or fevers. He did endorse repetitive lifting motions at work. The exam was unremarkable except for some pain w/ ROM of the shoulder. A POCUS showed…
In Clip 1, the long head of the biceps tendon is seen in the bicipital groove (between the greater and lesser tuberosity) in its short-axis surrounded by a rim of hypoechoic fluid.
Clip 2 shows the biceps tendon in its long-axis, again surrounded by a small amount of hypoechoic fluid. This is consistent with biceps tendinitis. The tendon itself appears intact without tears. The patient was discharged with NSAIDs and ortho follow up.
POCUS Shoulder Exam
We have all had patients presenting with non-traumatic shoulder pain. They get their therapeutic x-ray and you tell them to try NSAIDs and follow up with ortho.
While the POCUS shoulder exam may not be life-saving, it has the potential to quickly provide the diagnosis for a range of pathologies. Finding the answer to the patient's pain may might result in a more satisfied patient 😊. The hard part is learning and remembering this multi-step exam.
Evaluting the long head of the biceps tendon is Step 1 and is the easiest part of the shoulder exam (in my opinion), so we’ll go over that today! Stay tuned for future VOTWs for the rest of the shoulder exam.
Technique
Have patient sitting in chair or side of the bed (see below)
Use a linear high-frequency probe
Have the patient flex elbow at 90 degrees with palm facing up and arm adducted
Place the probe horizontally along the bicipital groove (proximal humerus) and find the echogenic long head of biceps tendon in transverse
Rotate the probe 90 degrees to see the tendon in its long axis
Look for disruptions in the tendon, fluid around tendon, or subluxation (tendon not in bicipital groove)
Image 1. Positioning for evaluating the biceps tendon
Artifact Corner
Tendons exhibit an artifact called anisotropy. This means the appearance of tendons can be different depending on the angle of insonation (the angle of the beam onto the object). It will look hyperechoic at one angle and hypoechoic at another angle. Don’t mistake this for a tendon tear or fluid. Fluid or tendons will not change in appearance with different angles of insonation.
So next time you have a patient with shoulder pain, take a quick look at the biceps tendon, you might find the answer right away!
Happy Scanning,
Your Sono Team