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Findings There are numerous findings on this case but in particular I am going to focus on the supraspinatus, subscapularis, and the long head of the biceps. There is severe supraspinatus tendinosis, full thickness disruption of the supraspinatus with a defect extending from the articular to the bursal side, a tear of the superior fibers of the subscapularis superimposed on severe tendinosis, subcoarcoid bursal fluid, severe tendinosis of the long head of the biceps, and to be described later abnormality of the long head of the biceps as well as a normal variation about the long head of the biceps.
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Diagnosis: Aponeurotic Expansion of the Supraspinatus Tendon (AEST) In earnest, the supraspinatus tear and to some degree the subscapularis tear are not the thrust of this case although the subscapularis tear is important to highlight this normal variant. The subscapularis tear in this case allows a dislocation of the long head of the biceps which is severely tendinotic. Tissue is present in the bicipital groove which on first look appears to represent the biceps tendon but with closer inspection ends at the level of the pectoralis major tendon. The structure on the axial images with ?LHBT represents the AEST. The structure with the ? what is this structure represents the dislocated and tendinotic long head of the biceps. There are many variants about the long head of the biceps . In some individuals there is an accessory attachment to the anterior or leading edge of the supraspinatus. Some people have a prominent vincula which is a thin band of connective tissue providing blood supply to the LHBT. This would be found along the anterior aspect of the tendon and attach to the tendon sheath. The AEST is a tendon like structure that extends from the far anterior supraspinatus tendon, traverses anterior and lateral to the LHBT, and inserts onto the superior aspect of the pectoralis major tendon. This is imperative to recognize and not mistake for the LHBT as the dislocated LHBT will frequently require surgical management to eradicate patient symptoms.
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References The aponeurotic expansion of the supraspinatus tendon: anatomy and prevalence in a series of 150 shoulder MRIs. Thomas P. Moser Étienne Cardinal, Nathalie J. Bureau, Raphaël Guillin, Pascale Lanneville & Detlev Grabs. Skeletal Radiol 44, 223–231 (2015). https://doi.org/10.1007/s00256014-1993-4
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