Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study

doi:10.1016/j.jse.2003.09.013

Journal of Shoulder and Elbow Surgery

Volume 13, Issue 1, January–February 2004, Pages 5-12

https://doi.org/10.1016/j.jse.2003.09.013 Get rights and content

Abstract

Lesions of the biceps pulley and the rotator cuff have been reported to be associated with an internal anterosuperior impingement (ASI) of the shoulder. The purpose of this study was to determine the factors influencing the development of an ASI. Eighty-nine patients with an arthroscopically diagnosed pulley lesion were prospectively included in this study. Four patterns of intraarticular lesions could be identified. Twenty-six patients (group 1) showed an isolated lesion of the superior glenohumeral ligament (SGHL). In 21 patients (group 2) an SGHL lesion and a partial articular-side supraspinatus tendon tear were found. Twenty-two patients (group 3) had an SGHL lesion and a deep surface tear of the subscapularis tendon, and in twenty patients (group 4) a lesion of the SGHL combined with a partial articular-side supraspinatus and subscapularis tendon tear was diagnosed. Of the patients, 80 (89.9%) showed involvement of the long head of the biceps tendon including synovitis, subluxation, dislocation, and partial or complete tearing. In 43.8% of all patients, ASI was observed. Whereas ASI was seen in 26.6% and 19.1% of patients in groups 1 and 2, respectively, 59.1% of patients in group 3 and 75% of patients in group 4 were found to have an ASI. ASI was significantly more often seen in patients with additional partial articular-side subscapularis tendon tears (P < .0001). In patients with acromioclavicular (AC) arthritis, ASI (62.5%) was more frequently observed than in patients without AC arthritis (P = .0309). In the multivariate analysis the stepwise selection procedure revealed only AC arthritis and the deep surface tear of the subscapularis (groups 3 and 4) to be significant influencing factors for an ASI. Our findings indicate that a progressive lesion of the pulley system, including partial tears of the subscapularis and supraspinatus tendons, contributes significantly to the development of an ASI. A pulley lesion leads to instability of the long head of the biceps tendon, causing increased passive anterior translation and upward migration of the humeral head, resulting in an ASI. In addition, a partial articular-side subscapularis and supraspinatus tendon tear reinforces the ASI.

Section snippets

Material and methods

Since 1998, 89 consecutive patients (23 women and 66 men) with a mean age of 47.7 years (range, 16-77 years) and an arthroscopically verified pulley lesion were prospectively included in this study. Twenty-two patients had a history of trauma, whereas sixty-seven had none. Clinical examination showed a positive impingement sign⁵ in 47 patients, a positive O'Brien test¹¹ in 59, and a positive palm-up test in 59. One of the tests was positive in 67 patients (75.3%), and both tests were positive

Results

In all 89 patients selected according to our study inclusion criteria (100%), a lesion of the pulley system was confirmed at arthroscopy. Four different patterns of intraarticular lesions could be identified (Figure 2) (Table II).

ASI was observed in 39 of 89 patients (43.8%). In group 1 (isolated SGHL lesion) ASI occurred in 26.9%, and in group 2 (SGHL lesion and partial articular-side lesion of the supraspinatus tendon) ASI occurred in 19.1%. The combination of an SGHL lesion and a deep

Discussion

Different forms of internal impingement of the glenohumeral joint have been described over the last decade.1, 10, 17 ASI represents a new clinical entity responsible for unexplained anterior shoulder pain.²

In a cadaveric study Valadie et al¹⁸ demonstrated contact between the articular surface of rotator cuff tendons and the anterosuperior glenoid with the arm placed in the Hawkins position. Struhl¹⁷ suggested that this contact between the rotator cuff and the superior labrum is physiologic. In

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Cited by (247)

Evaluation of Conventional MR Imaging of the Shoulder in the Diagnosis of Lesions of the Biceps Pulley
2024, Academic Radiology
To determine the diagnostic accuracy and reproducibility of conventional MR imaging (MRI) of the shoulder in evaluating biceps pulley lesions using arthroscopy as the standard of reference.
In a retrospective study, MR examinations of 68 patients with arthroscopically proven torn or intact biceps pulley were assessed for the presence of pulley lesions by three radiologists. The following criteria were evaluated: displacement of the long head of the biceps tendon (LHBT) relative to the subscapularis tendon (displacement sign), subluxation/dislocation of the LHBT, the integrity of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), lesions of the supraspinatus (SSP) and subscapularis (SSC) tendons adjacent to the rotator interval, presence of biceps tendinopathy and subacromial bursitis.
There were 42 patients with pulley lesions in the study group. Conventional MR imaging showed an overall sensitivity of 95.2%, 88.1% and 92.9%, a specificity of 61.5%, 73.1%, and 80.8% and an accuracy of 82.4%, 82.4% and 88.2% in the diagnosis of pulley lesions. Interobserver agreement was substantial (multirater k = 0.75).
Biceps tendinopathy (97.6%, 95.2%, 97.6%), defects of the SGHL (86.3%, 81.0%, 88.1%) and the displacement sign (88.1%, 81.0%, 85.7%) were the most sensitive diagnostic criteria. Subluxation/dislocation of the LHBT was insensitive (78.6%, 42.9%, 33.3%), but specific (69.2%, 100,0%, 96.2%).
In the diagnosis of pulley lesions, conventional MR imaging is reproducible and shows high sensitivity and accuracy but moderate specificity.
Arthroscopic subscapularis repair using the subscapularis interlocking (SICK)-stitch technique leads to restoration of clinical function with low complication and revision rates
2024, JSES International
The purpose of this study is to determine the mid-term outcome after arthroscopic subscapularis tendon (SCP) reconstruction using the subscapularis interlocking (SICK)-stitch technique. The hypotheses are that arthroscopically repaired SCP lesions using the SICK-stitch show a good restoration of shoulder function with low complication and failure rates.
This is a retrospective monocentric study of n = 199 patients (n = 106 female) with arthroscopically treated SCP tears with the interlocking (SICK) stitch technique from July 2013 to October 2018. Inclusion criteria: minimum follow-up of 2 years. Exclusion criteria: irreparable and massive cuff tears, osteoarthritis, and fractures. The postoperative assessment consisted of the range of motion, constant score, simple shoulder test, simple shoulder value, disability of the shoulder and arm score, short form 12, and patient satisfaction.
Mean age was 61 years (25-83); n = 4 (2%) patients were lost to follow-up with mean follow-up time of 63.6 months (36-96). Additional supraspinatus tendon lesions (n = 147) were repaired in n = 101 cases. SCP grading (n = 69) (35% traumatic) (Fox/Romeo): n = 113 grade II, n = 71 grade III, n = 11 grade IV. A positive preoperative lift-off test (n = 132, 68%) was corrected in n = 124 (94%) of cases. Ninety seven percent of patients would undergo surgery again with a mean satisfaction score of 14.4/15. Results at final follow-up (data: mean pre; post; P value): lexion (130; 166; .001), abduction (123;159; .001), external rotation (35;82; .001), internal rotation (52; 68; .07), constant score (50; 82; .001), disability of the shoulder and arm score (40; 19; .001), simple shoulder test (5; 10; .001), and simple shoulder value (44; 83; .001) significantly improved. The mean physical health scale short form 12 was 46 (24-63) and 51 (15-66) for mental health. Age, body mass index, SCP-grading, and supraspinatus tendon repair did not significantly affect any outcome parameter. Three (1.5%) patients underwent revision surgery, of which 1 (0.5%) had an infection.
Two years after arthroscopic SCP repair using the SICK-stitch technique, we observed excellent restoration of clinical function with low complication and revision rates. The SICK-stitch technique thus represents a good and reliable therapeutic option for the arthroscopic repair of SCP lesions.
Deep-learning-based image quality enhancement of CT-like MR imaging in patients with suspected traumatic shoulder injury
2024, European Journal of Radiology
To evaluate the diagnostic performance of CT-like MR images reconstructed with an algorithm combining compressed sense (CS) with deep learning (DL) in patients with suspected osseous shoulder injury compared to conventional CS-reconstructed images.
Thirty-two patients (12 women, mean age 46 ± 14.9 years) with suspected traumatic shoulder injury were prospectively enrolled into the study. All patients received MR imaging of the shoulder, including a CT-like 3D T1-weighted gradient-echo (T1 GRE) sequence and in case of suspected fracture a conventional CT. An automated DL-based algorithm, combining CS and DL (CS DL) was used to reconstruct images of the same k-space data as used for CS reconstructions. Two musculoskeletal radiologists assessed the images for osseous pathologies, image quality and visibility of anatomical landmarks using a 5-point Likert scale. Moreover, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated.
Compared to CT, all acute fractures (n = 23) and osseous pathologies were detected accurately on the CS only and CS DL images with almost perfect agreement between the CS DL and CS only images (κ 0.95 (95 %confidence interval 0.82–1.00). Image quality as well as the visibility of the fracture lines, bone fragments and glenoid borders were overall rated significantly higher for the CS DL reconstructions than the CS only images (CS DL range 3.7–4.9 and CS only range 3.2–3.8, P = 0.01–0.04). Significantly higher SNR and CNR values were observed for the CS DL reconstructions (P = 0.02–0.03).
Evaluation of traumatic shoulder pathologies is feasible using a DL-based algorithm for reconstruction of high-resolution CT-like MR imaging.
Methods to analyse the long head of the biceps in the management of distal ruptures of the supraspinatus tendon. Part 1: the concept of the “biceps box”: dynamic rotator interval approach. Incidence of lesions of the long head of the biceps tendon
2023, Orthopaedics and Traumatology: Surgery and Research
The area encompassing the long head of the biceps (LHB) can be represented as a rectangular parallelepiped. This geometric view can be likened to a box, the “biceps box”, where the sides are the extrinsic structures and the LHB is the intrinsic structure. Since these structures are mobile in relation to each other, a dynamic “biceps box” model can modify assessments of the LHB, in its healthy or pathological state, and make the therapeutic approach to treating LHB lesions less arbitrary.
In order to describe the different sides of the “biceps box”, and to understand their possible physiological and pathological consequences, a literature review using PRISMA methodology was used.
The supraspinatus (SSP) has expansions on its anterior aspect that project anteriorly and cross the coracohumeral ligament (CHL). The most functionally important expansion is the fasciculus obliquus, which extends perpendicular to the axis of the tendon fibers of the SSP, divides the CHL into a deep and a superficial layer, and terminates on the superficial aspect of the subscapularis. The humeral insertion of the SSP may be binary, making a bridge over the LHB, with a posterior branch inserting on the greater tuberosity and an anterior branch on the lesser tuberosity. The superior glenohumeral ligament (SGHL) has a twisted course, downward and forward, and ends at the proximal opening of the bicipital groove with a flap on which the LHB rests. The bicipital pulley is not an independent structure but an arciform structure resulting from the fusion of several tissues.
The presence of structures linked together by common expansions in the 3 planes of space validates the relevance of a “biceps box” as a functional geometric model. The structure that acts as a crossroads through which all expansions pass is the CHL. An extrinsic SSP lesion can be compensated for by other “biceps box” structures, whereas an extrinsic SGHL lesion rarely exists without the presence of an intrinsic LHB lesion. The CHL constitutes a connective tissue crossed by a vasculonervous pedicle from the lateral pectoral nerve, which may explain some anterior shoulder pain attributed to the biceps.
The LHB can be likened to an intrinsic structure contained in a box whose sides are made up of different interconnected stabilizing structures defining the extrinsic structures. The concept of a dynamic “biceps box” allows LHB lesions to be accurately classified, separating extrinsic and intrinsic lesions, and thus potentially modifying therapeutic approaches to the LHB.
IV; systematic review.
Methods to analyse the long head of the biceps in the management of distal ruptures of the supraspinatus tendon. Part 1: The concept of the “biceps box”: Dynamic Rotator Interval Approach. Incidence of lesions of the long head of the biceps tendon
2023, Revue de Chirurgie Orthopedique et Traumatologique
L’environnement anatomique du tendon du long biceps (TLB) peut être modélisé sous la forme d’un parallélépipède rectangle. Cette approche géométrique peut être assimilée à une boîte, dont les faces constituent les structures extrinsèques et le TLB la structure intrinsèque. S’agissant de structures mobiles les unes par rapport aux autres, il émerge un modèle de « boîte à biceps » dynamique susceptible de modifier l’appréciation de la nature saine ou pathologique du TLB et ainsi, rendre moins arbitraire l’approche thérapeutique de ces lésions.
Afin de décrire les différentes faces de la « boîte à biceps », et comprendre leur possible implication physiopathologique, une méthode PRISMA de revue de la littérature a été appliquée.
Le supra spinatus (SSP) présente sur son bord antérieur des expansions qui se projettent en avant dans le ligament coraco-humeral (LCH). L’expansion la plus importante sur un plan fonctionnel est le fasciculus obliquus dont la direction est perpendiculaire à l’axe des fibres tendineuses du SSP, qui clive le LCH en un feuillet profond et un feuillet superficiel et qui se termine à la face superficielle du sous scapulaire. L’insertion du SSP sur l’humérus peut être double passant en pont au-dessus du TLB avec une branche postérieure s’insérant sur le tubercule majeur et une branche antérieure sur le tubercule mineur. Le Ligament glénohuméral supérieur (LGHS) présente un trajet torsadé vers le bas et l’avant et termine au niveau de l’orifice proximal de la gouttière bicipitale par un feuillet sur lequel repose le TLB. La poulie bicipitale n’est pas une structure indépendante mais une structure arciforme issue de la fusion de plusieurs tissus.
La présence de structures reliées entre-elles par des expansions communes dans les 3 plans de l’espace valide la pertinence d’une « boîte à biceps » en tant que modèle géométrique fonctionnel. La structure clé est le LCH, véritable carrefour traversé par l’ensemble des expansions. Une atteinte extrinsèque du SSP peut être compensée par d’autres structures de la « boîte à biceps », alors qu’une atteinte extrinsèque du LGHS est quasi-systématiquement associée à une lésion intrinsèque du TLB. Le LCH constitue une lame porte-vaisseau avec une innervation propre par le nerf pectoral latéral dont la mise en contrainte pourrait expliquer certaines douleurs antérieures de l’épaule attribuées au biceps.
Le TLB peut être assimilé à une structure intrinsèque contenue dans une boîte dont les faces, constituées de différentes structures stabilisatrices interconnectées, définissent des structures extrinsèques. Le modèle théorique d’une « boîte à biceps » dynamique ouvre la voie à un démembrement lésionnel du TLB, séparant les lésions extrinsèques des lésions intrinsèques, pouvant modifier notre approche thérapeutique du TLB.
IV ; revue de la littérature.
Efficacy of biceps-radial-slice magnetic resonance images for the diagnosis of biceps and pulley lesions
2023, Journal of Shoulder and Elbow Surgery
Injuries to the biceps reflection pulley lead to instability of the long head of the biceps tendon (LHBT). However, conventional magnetic resonance (MR) imaging (MRI) has low diagnostic accuracy for LHBT and pulley lesions. Here, we investigated the usefulness of novel biceps-radial MRI for evaluating LHBT and pulley lesions.
Biceps-radial MR images of 84 patients (84 shoulders) were prospectively analyzed. The biceps-radial MRI protocol includes sequences acquired in radial planes perpendicular to the LHBT in the shoulder joint. All patients underwent shoulder arthroscopy, and the intraoperative LHBT and pulley lesion findings were compared to the preoperative evaluations. The diagnostic accuracies of the biceps-radial MR images and conventional MR images were determined.
A normal LHBT was observed in 30 (31.6%) patients, partial tears in 43 (52.6%), and complete tears in 11 (15.8%). Normal LHBT stability was present in 54 (61.4%) patients, subluxation in 24 (31.6%), and dislocation in 6 (7.0%). The biceps-radial MR (kappa coefficient: 0.94) and conventional MR (kappa coefficient: 0.68) images accurately identified LHBT tears. The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.91), whereas the conventional MR images poorly agreed (kappa coefficient: 0.17) regarding LHBT instability. A normal medial wall of the pulley was observed in 26 (31.0%) patients, partial tears in 30 (35.7%), and complete tears in 28 (33.3%). A normal lateral wall of the pulley was observed in 30 (35.7%) patients, partial tears in 21 (25.0%), and complete tears in 33 (39.3%). The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.89), whereas the conventional MR images moderately agreed (kappa coefficient: 0.50) regarding medial pulley lesions. The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.95) and the conventional MR images moderately agreed (kappa coefficient: 0.56) regarding lateral pulley lesions.
Biceps-radial MRI allows for tracking of the LHBT and pulley from the supraglenoid tuberosity to the bicipital groove in the glenohumeral joint and accurate evaluations of LHBT and pulley lesions.

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Original articleAnterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study

Abstract

Section snippets

Material and methods

Results

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Original article
Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study