The patient has known inflammatory rheumatic disease and presents with right shoulder complaints. A complete ESSR shoulder ultrasound protocol was performed. Additional assessment included the rotator interval, including the superior glenohumeral ligament and coracohumeral ligament.
Ultrasound examination of the right shoulder demonstrates pronounced inflammatory changes of the glenohumeral joint.
There is marked distension of the glenohumeral joint, visible in the posterior and inferior recesses. The capsule and synovium are thickened and proliferative, with clear Doppler activity, consistent with active synovitis.
There is also marked proliferative tenosynovitis with prominent neovascularity. The long head of the biceps tendon itself has a normal sonographic appearance, without evidence of rupture or tendinopathy.
The acromioclavicular joint also shows capsular swelling and synovial proliferation, with mild neovascularity, indicating active inflammatory involvement.
The rotator cuff and the other assessed peri-articular soft tissues have a normal anatomical appearance. There are no sonographic signs of structural rotator cuff damage.
1. Final diagnosis
Pronounced active inflammatory synovitis of the right glenohumeral joint, with marked joint distension, synovial proliferation, and Doppler activity. Associated active inflammatory involvement of the acromioclavicular joint is present. There is proliferative tenosynovitis, while the long head of the biceps tendon itself remains structurally intact.
2. Differential diagnosis
The findings are most consistent with active inflammatory arthritis in the context of known inflammatory rheumatic disease, such as rheumatoid arthritis. Differential considerations include a flare of inflammatory or rheumatoid arthritis, crystal arthropathy such as CPPD or gout depending on clinical and laboratory findings, septic arthritis in the presence of disproportionate pain, fever, elevated inflammatory markers, or immunosuppression, and reactive or other systemic inflammatory arthritis.
3. Teaching points
Ultrasound is well suited for demonstrating synovitis, joint effusion, tenosynovitis, capsular thickening, synovial proliferation, and Doppler activity in the shoulder. Doppler signal within proliferative synovium supports active inflammation. In the shoulder, ultrasound is also clinically useful for assessing the long head of the biceps tendon, rotator cuff, bursae, and superficial joint-related abnormalities. A structurally normal rotator cuff and biceps tendon help distinguish inflammatory joint disease from primary tendon-related shoulder pathology.
4. Injury/disease information
Inflammatory shoulder synovitis may occur as part of systemic rheumatic disease and can involve both the glenohumeral and acromioclavicular joints. Active synovial proliferation with Doppler activity reflects ongoing inflammatory disease activity and may correlate with pain, stiffness, and functional limitation. In persistent or severe symptoms, rheumatological reassessment is appropriate. Ultrasound-guided aspiration and/or intra-articular corticosteroid injection of the glenohumeral joint may be considered in consultation with the rheumatologist. If infection is clinically suspected, corticosteroid injection should be avoided initially and diagnostic aspiration should be prioritized, including cell count, crystal analysis, Gram stain, and culture.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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