66-year-old patient with a history of operative supraspinatus tendon cuff repair. The patient is physically active and performs regular sports activity. Ultrasound was performed according to the ESSR shoulder protocol, with additional evaluation of the rotator interval including the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL). Clinical concern included postoperative cuff integrity and persistent shoulder symptoms after trauma or overload.
A complete ultrasound examination of the shoulder was performed following the ESSR shoulder protocol. Additional assessment of the rotator interval was included, with evaluation of the SGHL and CHL.
The supraspinatus tendon shows postoperative changes after cuff repair. The tendon is continuous and intact, without focal discontinuity, tendon gap, retraction, or other sonographic signs of re-rupture. Hyperechoic foci are visible within the tendon, compatible with postoperative suture or anchor material. Considering the patient’s sports-related loading, the repaired cuff appears sonographically well preserved and mechanically acceptable.
At the acromioclavicular joint, there is clear widening of the joint space. Dynamic assessment demonstrates marked instability of the AC joint. The findings are most consistent with an acromioclavicular joint injury, probably Rockwood type II, although a higher-grade lesion should be considered if substantial horizontal or vertical instability is present clinically.
There is moderate distension of the posterior recess of the glenohumeral capsule. This appearance is compatible with glenohumeral capsular distension, joint effusion, or synovial irritation. No definite recurrent supraspinatus tendon tear is demonstrated.
1. Final diagnosis
Intact supraspinatus tendon after operative cuff repair, without sonographic evidence of re-rupture. Postoperative hyperechoic reflections within the tendon are compatible with suture or anchor material. Dynamic AC joint instability with widening of the joint space, most suggestive of Rockwood type II acromioclavicular joint injury. Moderate posterior glenohumeral recess distension, consistent with glenohumeral joint irritation or effusion.
2. Differential diagnosis
The AC joint findings primarily suggest acromioclavicular joint sprain with capsuloligamentous injury, probably Rockwood type II. A higher-grade AC joint injury should be considered when there is marked horizontal or vertical instability. Posterior glenohumeral recess distension may reflect reactive synovitis, post-traumatic or overload-related joint irritation, intra-articular pathology such as labral injury or chondral irritation, or less likely a postoperative inflammatory reaction depending on the surgical date and clinical presentation.
3. Teaching points
After cuff repair, continuity of the supraspinatus tendon is the key finding to exclude re-rupture. Hyperechoic intratendinous reflections may represent postoperative suture or anchor material and should not be mistaken for calcification or tear-related artefact. Dynamic evaluation of the AC joint is essential when instability is suspected, as static images may underestimate capsuloligamentous injury. Posterior recess distension is a useful indirect sign of glenohumeral joint irritation or effusion and may indicate associated intra-articular pathology.
4. Injury/disease information
Rockwood type II AC joint injury usually involves disruption of the AC ligaments with sprain or partial injury of the coracoclavicular ligaments. Initial management is often conservative, including relative rest, temporary sports modification, pain-guided rehabilitation, scapular control training, rotator cuff strengthening, and gradual return to sport. In cases with marked instability, persistent pain, loss of strength, or sport-related limitation, further assessment by a shoulder specialist is appropriate. Additional imaging may include bilateral weighted AC joint radiographs, dynamic ultrasound, or MRI/MR arthrography when intra-articular pathology is suspected. When an AC joint or glenohumeral injection is considered, ultrasound guidance provides more accurate placement and better diagnostic and therapeutic targeting than landmark-based injection.
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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