48-year-old patient presenting with shoulder pain during active elevation and overhead activities. Symptoms are suggestive of subacromial pain syndrome.
Ultrasound examination of the shoulder demonstrates a small articular-sided partial-width tear of the supraspinatus tendon, measuring approximately 0.91 × 2.86 × 2.07 mm. The lesion is visualized as a focal hypoechoic defect at the deep (articular) surface with localized disruption of the fibrillar architecture.
There is a subtle cortical irregularity of the greater tuberosity (tuberculum majus), which closely correlates with the location of the supraspinatus tear.
Additionally, a deltoid hernia sign is observed, characterized by a localized concavity of the supraspinatus tendon contour with slight bulging of the overlying deltoid muscle into the defect. Both the cortical irregularity and the deltoid hernia sign strongly support the presence of a rotator cuff tear.
The subacromial-subdeltoid (SASD) bursa shows mild fluid distension without evidence of neovascularization. The fluid is located between the supraspinatus tendon and the coracoacromial ligament.
Dynamic ultrasound assessment during active movement demonstrates impingement of the supraspinatus tendon and SASD bursa against the coracoacromial ligament, due to combined swelling of the tendon and bursa.
1. Final diagnosis
Subacromial pain syndrome due to a small articular-sided partial-width tear of the supraspinatus tendon, with associated mild SASD bursitis and dynamic subacromial impingement.
2. Differential diagnosis
Consider focal tendinopathy with articular-sided degeneration, though the presence of cortical irregularity and deltoid hernia sign strongly favors a true tear. A small full-thickness tear cannot be entirely excluded if visualization is limited.
3. Teaching points
The deltoid hernia sign and cortical irregularity of the greater tuberosity are important indirect signs of supraspinatus tears. Even small articular-sided tears can be clinically significant and contribute to impingement. Dynamic ultrasound is essential to confirm functional impingement.
4. Injury/disease information
Articular-sided supraspinatus tears are common and often occur due to chronic overload and internal tensile stress. These tears may initially be small but can progress over time. Subacromial pain syndrome results from a combination of tendon pathology, bursitis, and mechanical impingement during shoulder movement.
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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