71-year-old patient presenting with shoulder pain and long-standing limitation in abduction. The patient reports a history of fracture of the greater tuberosity (tuberculum majus) approximately 30 years ago, with persistent functional impairment since that time.
Ultrasound examination of the shoulder demonstrates a full-thickness tear of the supraspinatus tendon involving part of the tendon width (partial-width), measuring approximately 3.9 × 5.0 × 5.8 mm.
The supraspinatus tendon shows marked degenerative tendinopathy, with significant thickening, hypoechogenicity, and loss of the normal fibrillar architecture. Multiple smaller partial- or micro-ruptures are also present within the tendon, indicating advanced chronic degeneration.
The greater tuberosity (tuberculum majus) demonstrates an abnormal morphology and position, with features consistent with a prior fracture. Based on the clinical history, this likely represents a chronic post-traumatic deformity rather than an acute finding.
While the altered position of the tuberculum majus is not directly responsible for the current tendon tear, it is likely functionally relevant, as it may contribute to long-standing limitation in shoulder abduction due to altered biomechanics of the rotator cuff.
1. Final diagnosis
Partial-width full-thickness tear of the supraspinatus tendon with advanced degenerative tendinopathy and additional microtears, in the setting of a chronic post-traumatic deformity of the greater tuberosity.
2. Differential diagnosis
Consider high-grade partial-thickness tear if full-thickness continuity is difficult to confirm. The tuberosity deformity should not be mistaken for an acute fracture.
3. Teaching points
Chronic bony deformities, such as malunited greater tuberosity fractures, can significantly alter shoulder biomechanics and contribute to long-term dysfunction. Rotator cuff tears often develop on a background of degenerative tendinopathy. It is important to distinguish incidental structural abnormalities from clinically relevant findings.
4. Injury/disease information
Supraspinatus tears commonly occur in degenerative tendons and may be influenced by altered biomechanics. Malunion of a greater tuberosity fracture can change the lever arm and orientation of the rotator cuff, potentially leading to chronic functional limitation and increased susceptibility to tendon pathology.
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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