75-year-old patient presenting with right shoulder pain and dysfunction. Symptoms may include anterior/superior shoulder pain, weakness, and movement-related discomfort.
Ultrasound examination of the right shoulder was performed according to the ESSR shoulder protocol, including additional assessment of the rotator interval structures such as the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL).
The long head of the biceps tendon demonstrates mild tendinopathy. Due to tendon swelling, the tendon no longer fits completely within the intertubercular groove and lies partially over the lesser tuberosity (tuberculum minus). This abnormal positioning may create friction between tendon and bone, potentially perpetuating a cycle of tendinopathy.
There is mild distension of the subacromial-subdeltoid (SASD) bursa adjacent to the subscapularis tendon.
A small articular-sided partial tear of the subscapularis tendon is present, correlating with a focal cortical irregularity at the insertion.
There is a complete rupture of the supraspinatus tendon with full retraction. The chronic nature of this lesion is supported by complete tendon retraction, irregularity of the humeral head, and moderate to severe fatty infiltration of the supraspinatus muscle. These findings suggest the tear has been present for at least one year, likely longer.
The acromioclavicular (AC) joint demonstrates mild to moderate osteoarthritic change with cortical irregularity.
In addition, the AC joint capsule is markedly thickened, consistent with active synovitis. This may represent the dominant current pain generator.
1. Final diagnosis
Chronic complete retracted supraspinatus tear with fatty degeneration, associated mild biceps tendinopathy with groove maltracking, partial subscapularis tear, mild SASD bursitis, and active AC joint synovitis superimposed on AC osteoarthritis.
2. Differential diagnosis
Consider glenohumeral arthropathy or cervical referral if symptoms are disproportionate. However, AC synovitis is a likely major symptomatic contributor.
3. Teaching points
Chronic full-thickness cuff tears may be structurally dramatic yet not always the main pain source. In longstanding tears, secondary pain generators such as AC joint synovitis, biceps pathology, or compensatory overload are common. Imaging severity and symptom severity do not always correlate.
4. Injury/disease information
Massive chronic rotator cuff tears lead to altered shoulder biomechanics, weakness, and overload of remaining stabilizers. AC joint degeneration may become inflamed and painful. Long head biceps maltracking can further contribute to anterior shoulder pain and dysfunction.
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.
More Cases from Marc Schmitz
