Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Imaging

As with almost every other orthopaedic condition, the clinician should begin by obtaining a complete series of plain film radiographs. For the shoulder, these should include an anteroposterior  view, axillary view, and outlet view (or scapular-Y view). We also include a 30-degree caudal tilt view to better assess the acromioclavicular (AC) joint.

Others have described radiographic projections, which are more specific for the bicipital groove region of the proximal humerus. These include the Fisk projection and the bicipital groove view . The Fisk method has the patient hold the cassette while leaning forward on their elbows and the beam projected perpendicular to the floor (and cassette) . This view looks down the bicipital tunnel.

The bicipital groove method has the patient lie prone with the shoulder slightly abducted and the arm in external rotation. The cassette is placed on the top of the shoulder and the beam is directed up the patient’s axilla (parallel to the long axis of the humerus) and perpendicular to the plat. This view can elucidate the depth of the bicipital groove, the inclination of the walls of the groove, as well as any associated spurs within the groove.

Prior to the advent of magnetic resonance imaging (MRI), arthrography was a commonly utilized method of evaluation of the rotator cuff. It was also useful in the evaluation of the biceps tendon. The loss of a sharp delineation of the tendon can indicate biceps tendon pathology. Arthrography remains an invasive technique with possible contrast complications and this constitutes its main disadvantage.

Ultrasound has emerged as a potentially effective and noninvasive technique in the evaluation of biceps tendon pathology. Middleton et al.It compared ultrasound to arthrography for the diagnosis of biceps tendon and rotator cuff pathology. They found the two modalities equally effective in the diagnosis of rotator cuff problems, but ultrasound was superior in the evaluation of the biceps tendon.

Another study performed a biceps subluxation test and demonstrated 86% sensitivity in the diagnosis of LHB subluxation (as confirmed surgically) with ultrasound . Ultrasound has the added benefit of being a dynamic study. This allows easy evaluation with shoulder motion. In comparison to other imaging modalities, ultrasound is more operator dependent and therefore a well-trained technician is essential to obtain meaningful and helpful studies.

As with the evaluation of most other shoulder disorders, MRI has become increasingly popular. The anatomy (or patho-anatomy) of the biceps tendon and the bicipital groove is well delineated with MRI and associated findings such as rotator cuff pathology are also easily identified. Making the diagnosis of biceps tendon rupture or dislocation is relatively simple with MRI; however, biceps tendinitis and degenerative changes within the tendon are difficult to determine via MRI. Although some authors have suggested that increased fluid around the biceps is suggestive of biceps tendinitis, others report low sensitivity and specificity using this criterion.

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