63-year-old patient presenting with anterior and lateral shoulder pain, possibly aggravated by overhead activities and rotational movements.
Ultrasound examination of the shoulder demonstrates a small full-thickness tear of the anterior supraspinatus tendon at its insertion on the greater tuberosity (tuberculum majus). The tear involves only part of the tendon width (partial-width) and measures approximately 3.2 × 2.6 mm.
A deltoid hernia sign is present, characterized by focal concavity of the supraspinatus contour with indentation of the overlying deltoid, supporting the presence of a full-thickness defect.
The supraspinatus muscle belly appears preserved, with no signs of atrophy or fatty infiltration, suggesting a relatively recent or functionally compensated lesion.
There is medial subluxation of the long head of the biceps tendon. The tendon is displaced over the tuberculum minus and partially located beneath the subscapularis tendon.
This instability is likely secondary to a small partial-thickness tear of the subscapularis tendon and a rupture of the coracohumeral ligament (CHL) within the rotator interval, indicating disruption of the biceps pulley system.
1. Final diagnosis
Small anterior full-thickness partial-width supraspinatus tear with preserved muscle quality, associated with medial subluxation of the long head of the biceps due to subscapularis tear and rotator interval (CHL) rupture.
2. Differential diagnosis
Consider high-grade partial supraspinatus tear if full-thickness involvement is uncertain. Isolated biceps instability without complete pulley disruption is less likely.
3. Teaching points
The deltoid hernia sign is a useful indirect indicator of small full-thickness supraspinatus tears. Biceps tendon subluxation is strongly associated with subscapularis and rotator interval pathology. Preserved muscle quality is an important favorable prognostic factor.
4. Injury/disease information
Rotator cuff tears may occur in combination with biceps pulley lesions, leading to instability of the long head of the biceps tendon. Early-stage tears with preserved muscle quality have better treatment potential. Disruption of stabilizing structures such as the CHL and subscapularis can significantly alter shoulder biomechanics.
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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