65-year-old male with bilateral shoulder pain. Right shoulder symptoms have been present for approximately 20 years. Left shoulder symptoms developed approximately nine months ago following a traumatic event.
Symptoms fluctuate and are provoked particularly by activities above shoulder height and by lying on the affected side. The patient works as a self-employed automotive mechanic and experiences relevant occupational limitations, especially during overhead work.
Bilateral shoulder ultrasound demonstrates substantial but different rotator cuff abnormalities.
Left shoulder:
The supraspinatus tendon demonstrates marked degenerative tendinopathy with loss of the normal fibrillar echotexture and pronounced tendon thickening, measuring approximately 8–10 mm.
The subacromial-subdeltoid bursa is thickened and contains an increased amount of fluid, consistent with associated bursopathy.
A small partial-thickness rotator cuff tear is present at the transition between the supraspinatus and infraspinatus tendons.
The remaining sonographically examined shoulder structures demonstrate a normal anatomical appearance.
Right shoulder:
The supraspinatus tendon demonstrates severe chronic tendinopathy with marked thickening, measuring up to approximately 15 mm.
A large calcific deposit is present within the supraspinatus tendon, measuring approximately 20 × 12 mm and demonstrating a mixed type 1/type 2 appearance.
Fluid surrounds the long head of the biceps tendon, producing a biceps halo appearance. The tendon itself demonstrates no primary structural abnormality. The fluid is most consistent with extension of glenohumeral joint fluid into the biceps tendon sheath.
Posteriorly, a well-defined fluid collection is present between the infraspinatus and teres minor muscles. The appearance is suggestive of a ganglion-like or paralabral fluid collection, potentially communicating with the glenohumeral joint. Its exact intra-articular origin cannot be determined confidently with ultrasound.
1. Final diagnosis
Left: Marked degenerative supraspinatus tendinopathy with substantial tendon thickening, associated subacromial-subdeltoid bursopathy, and a small partial-thickness cuff tear at the supraspinatus-infraspinatus transition.
Right: Severe chronic supraspinatus tendinopathy with marked tendon thickening and a large mixed type 1/type 2 calcific deposit. Associated findings include increased glenohumeral joint fluid, visible around the long head of the biceps tendon, and a posterior ganglion-like fluid collection between the infraspinatus and teres minor.
Overall, the right shoulder demonstrates predominantly chronic degenerative and calcific pathology, whereas the left shoulder demonstrates degenerative tendinopathy with associated bursopathy and a small partial cuff tear following a more recent traumatic onset.
2. Differential diagnosis
Bilaterally, symptomatic rotator cuff tendinopathy is the principal consideration. On the left, the partial rotator cuff tear and reactive subacromial-subdeltoid bursopathy may contribute to symptoms. On the right, symptomatic calcific supraspinatus tendinopathy is likely, although an additional glenohumeral intra-articular pain source should be considered because of the joint-related fluid production. The posterior fluid collection may represent a ganglion or paralabral cyst, although another intra-articular origin cannot be excluded sonographically.
3. Teaching points
Bilateral shoulder symptoms may arise from different structural abnormalities and should therefore be evaluated and interpreted separately. Marked tendon thickening and loss of fibrillar architecture support advanced supraspinatus tendinopathy, while associated bursal fluid may indicate secondary mechanical or inflammatory irritation. Fluid surrounding an otherwise normal long head of the biceps tendon may reflect glenohumeral joint effusion rather than primary biceps pathology. Posterior cystic lesions adjacent to the glenohumeral joint should raise consideration of a ganglion or paralabral cyst, but ultrasound may not reliably demonstrate the intra-articular origin or associated labral pathology.
4. Injury/disease information
Rotator cuff tendinopathy is commonly associated with repetitive mechanical loading and may become particularly symptomatic during sustained or repeated overhead activity. Initial treatment is generally conservative and based on progressive exercise therapy, load modification, and restoration of functional shoulder capacity.
For the left shoulder, an ultrasound-guided subacromial corticosteroid injection may be considered when pain substantially interferes with active rehabilitation. Intratendinous injection should be avoided in the presence of a partial tendon tear.
For persistent symptomatic calcific tendinopathy of the right supraspinatus despite an adequate conservative treatment course, ultrasound-guided needling and lavage may be discussed. Because of the associated glenohumeral fluid and posterior ganglion-like collection, MRI of the right shoulder may provide additional information regarding the glenohumeral joint, labrum, and origin of the posterior fluid collection.
In occupations requiring frequent overhead work, ergonomic modification may be useful to reduce cumulative shoulder loading. A passive upper-limb support exoskeleton may be considered as an occupational ergonomic aid for prolonged overhead activities, provided its benefit is assessed during the patient’s actual work tasks and it does not replace active rehabilitation or appropriate modification of provocative workload.
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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