62-year-old patient presenting with right shoulder pain, with predominant complaints in the (intra)scapular region. Symptoms appear to be improving over time.
Ultrasound examination of the right shoulder was performed according to the ESSR shoulder protocol, including additional assessment of the rotator interval (SGHL, CHL) and the (intra)scapular region.
There is a small partial-thickness tear at the insertion of the supraspinatus tendon on the greater tuberosity (tuberculum majus). The cortical surface of the tuberculum appears irregular, a finding that strongly correlates with the presence of a partial tear.
The supraspinatus tendon demonstrates severe degenerative tendinopathy, with marked thickening and loss of normal fibrillar architecture.
A small type 3 (soft) calcification is present at the supraspinatus insertion. This is considered likely incidental and not clinically relevant.
Dynamic ultrasound assessment shows primary subacromial impingement, with compression of the supraspinatus tendon and subacromial-subdeltoid (SASD) bursa against the acromion and coracoacromial ligament during active abduction.
The acromioclavicular (AC) joint demonstrates significant degenerative changes, including joint space narrowing, osteophyte formation, and mild synovitis.
The (intra)scapular region, corresponding to the patient’s main area of symptoms, shows no structural abnormalities on ultrasound.
1. Final diagnosis
Degenerative supraspinatus tendinopathy with partial-thickness tear and dynamic subacromial impingement, combined with AC joint osteoarthritis.
2. Differential diagnosis
Referred pain from the glenohumeral or AC joint versus functional scapular dyskinesis or myofascial pain, given the absence of structural abnormalities in the symptomatic region.
3. Teaching points
Structural abnormalities on imaging do not always correspond to the primary pain location. Referred pain and functional disorders should be considered when imaging findings and symptom location do not match. Cortical irregularities of the greater tuberosity are strongly associated with rotator cuff tears.
4. Injury/disease information
Degenerative rotator cuff disease often presents with tendinopathy, partial tears, and impingement. AC joint osteoarthritis commonly coexists and may contribute to symptoms. Pain may be referred to surrounding regions such as the scapular area. Functional factors (e.g., muscle imbalance or altered movement patterns) can play a significant role in symptom generation.
5. Clinical note:
The absence of structural abnormalities in the (intra)scapular region suggests that the primary pain source may be referred or functional in nature. Correlation with clinical examination is essential. The reported improvement in symptoms is a positive prognostic sign.
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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