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Windshield Wiper in the Shoulder

Ultrasound Imaging for the Proximal Rotator Cuff Interval

Ricci, Vincenzo, MD; Özçakar, Levent, MD

American Journal of Physical Medicine & Rehabilitation: March 2019 - Volume 98 - Issue 3 - p e27
doi: 10.1097/PHM.0000000000001005
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From the Department of Biomedical and Neuromotor Science, Physical and Rehabilitation Medicine Unit, IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy (VR); and Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey (LÖ).

All correspondence should be addressed to: Vincenzo Ricci, MD, IRCCS Rizzoli Orthopaedic Institute, Department of Biomedical and Neuromotor Science, Physical and Rehabilitation Medicine Unit, Bologna, Italy.

Vincenzo Ricci is in training.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

A 28-yr-old male patient presented to our clinic with pain and a “feeling of click” in the right shoulder for the last 3 mos. He described the pain as intermittent and more severe during sport activities, such as tennis. He denied any major trauma and declared that local anti-inflammatory drugs had only been partially effective. Physical examination revealed anterior shoulder pain particularly during forward flexion for 90 degrees and internal rotation. Results of palm up and Yergason tests were positive.

Ultrasound examination was performed in accordance with the European Musculoskeletal Ultrasound Study Group/Ultrasound Task Force of International Society of Physical and Rehabilitation Medicine shoulder scanning protocol during different positionings.1

Coracoacromial view (Fig. 1A) showed a thickened and enlarged annular sling of the long head of biceps tendon (LHBT) with some fluid under the biceps pulley (Fig. 1B). No other pathological findings were identified.



A combination of high-level laser therapy and an oral nonsteroidal anti-inflammatory drug was prescribed for 12 days, followed by a personalized rehabilitation program to reduce the functional overload of the LHBT especially during overhead/sport activities. After 4 weeks, the patient reported significant pain relief and reduction in the number of painful “shoulder clicks.”

Disorders of the LHBT are recognized as common sources of shoulder pain and disability. The major causes of such pain and disability are inflammation, instability, and trauma.2

In this sense, the lesions of the pulley system have been identified as the “primum movens” in the LHBT instability cascade. Because of insufficient stabilization in the rotator cuff interval, a “windshield wiper effect” of the unstable tendon (Fig. 1C) with intermittent pain, click sensation, and progressive damage of the humeral head cartilage (“chondral print” sign) are likely to be seen.3

Of note, in the rotator cuff interval, the coracohumeral and the superior glenohumeral ligaments coalesce into an annular sling around the intra-articular segment of the LHBT to stabilize it during all range of movements.4

Although the LHBT instability is usually suspected/diagnosed clinically, it can mimic several other painful shoulder pathologies, whereby imaging can really be contributory in the differential diagnosis. Real-time visualization of any lesion in the pulley system and/or an abnormal tendon position can allow the physician to promptly manage the therapy. Moreover, an early diagnosis avoids long-term complications such as damage to the humeral head cartilage or the periarticular tendinous structures.

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1. Özçakar L, Kara M, Chang KV, et al: EURO-MUSCULUS /USPRM basic scanning protocols for shoulder. Eur J Phys Rehabil Med 2015;51:491–6
2. Zabrzyński J, Paczesny Ł, Zabrzyńska A, et al: Sonography in the instability of the long head of the biceps tendon confronted with histopathologic and arthroscopic findings. Folia Morphol (Warsz) 2018;77:583–90
3. Domos P, Neogi DS, Longo UG, et al: The chondral print sign: what does it really mean? J Shoulder Elbow Surg 2017;26:e188–92
4. Tamborrini G, Moller I, Bong D, et al: The rotator interval – a link between anatomy and ultrasound. Ultrasound Int Open 2017;3:E107–16
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