68-year-old patient presenting with unilateral shoulder pain reproduced during rotational and overhead movements. Additional cervical complaints are reported.
Ultrasound examination of the shoulder demonstrates moderate to severe subcoracoid bursitis, most prominent during external rotation. During internal rotation, the bursal distension beneath the coracoid process decreases.
Dynamic assessment during active guided internal and external rotation demonstrates mild impingement of the subscapularis tendon and subcoracoid bursa against the coracoid process. This maneuver reproduces the patient’s familiar pain, supporting clinical relevance.
There are also findings consistent with subacromial pain syndrome (SAPS).
The subacromial-subdeltoid (SASD) bursa shows moderate bursitis.
The supraspinatus tendon demonstrates severe tendinopathy in the dysrepair phase, with tendon thickening and altered fibrillar architecture.
Small type 3 (soft) calcifications are present within the supraspinatus and subscapularis tendons. These are considered likely incidental and of limited clinical relevance.
Dynamic ultrasound during active abduction demonstrates mild impingement of the supraspinatus tendon and SASD bursa against the acromion and coracoacromial ligament.
Both acromioclavicular (AC) joint capsules appear clearly thickened. Given the unilateral symptom presentation, this may represent an incidental bilateral finding.
The reported cervical complaints cannot be evaluated with ultrasound, as sonography is not suitable for diagnostic assessment of the cervical spine.
1. Final diagnosis
Combined subcoracoid impingement syndrome with clinically relevant subcoracoid bursitis, together with subacromial pain syndrome caused by supraspinatus dysrepair tendinopathy and SASD bursitis.
2. Differential diagnosis
Consider referred pain from the cervical spine, AC joint pain, or mixed shoulder-cervical pain syndrome.
3. Teaching points
Dynamic ultrasound is highly valuable when pain is reproduced during provocative movement. Multiple pain generators may coexist in the same shoulder, including subcoracoid and subacromial impingement. Bilateral structural findings are not always clinically symptomatic.
4. Injury/disease information
Subcoracoid impingement occurs when the subscapularis tendon and adjacent bursa are compressed beneath the coracoid process, often during rotation. SAPS involves mechanical and inflammatory irritation of the rotator cuff and SASD bursa beneath the acromion. Coexisting cervical complaints may further complicate symptom presentation.
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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