72-year-old patient with [side] shoulder pain and restricted range of motion. Clinical suspicion included frozen shoulder versus inflammatory or degenerative shoulder pathology. Relevant rheumatologic history, systemic symptoms, medication use, occupation, and sports activity are [not provided].
Ultrasound of the left shoulder demonstrates marked proliferative subacromial-subdeltoid bursitis. The bursa is extremely thickened and shows an inflammatory/proliferative appearance.
There is severe tenosynovitis of the long head of the biceps tendon, with pronounced synovial proliferation. In addition, there is clear distension and synovitis of the glenohumeral joint capsule, particularly visible in the posterior recess. This supports an active inflammatory intra-articular component. Fluid within the biceps tendon sheath may communicate with the glenohumeral joint and can therefore be an indirect sign of glenohumeral synovitis.
The rotator cuff shows degenerative tendinopathy. The supraspinatus tendon demonstrates a full-thickness partial-width tear. There are also chronic muscular changes involving the supraspinatus muscle, including fatty infiltration, atrophy, and a tear within the supraspinatus muscle.
Dynamic assessment during active abduction demonstrates marked subacromial impingement, with mechanical conflict between the supraspinatus tendon/subacromial-subdeltoid bursa and the acromion/coracoacromial ligament.
1. Final diagnosis
Severe active inflammatory shoulder arthropathy with pronounced proliferative subacromial-subdeltoid bursitis, severe long head of biceps tenosynovitis, and glenohumeral synovitis with capsular distension. The pattern is more suggestive of an inflammatory rheumatologic disorder than isolated adhesive capsulitis.
A coexisting degenerative-traumatic rotator cuff component is present, with a full-thickness partial-width supraspinatus tear, chronic supraspinatus muscle atrophy/fatty infiltration, and dynamic subacromial impingement.
2. Differential diagnosis
The main differential diagnosis is active inflammatory arthropathy, such as rheumatoid arthritis, psoriatic arthritis, or another systemic rheumatologic disorder. The combination of synovitis, tenosynovitis, and extensive proliferative bursitis strongly supports this possibility.
Adhesive capsulitis remains a differential consideration because of capsular involvement and restricted motion. However, the extreme proliferative bursitis, severe biceps tenosynovitis, and glenohumeral synovitis make a primary inflammatory arthropathy more likely than isolated frozen shoulder.
Degenerative rotator cuff disease with secondary bursitis and impingement is also present, but it does not fully explain the degree of proliferative synovial and bursae involvement.
3. Teaching points
Ultrasound is highly useful for detecting synovitis, tenosynovitis, and bursitis in inflammatory shoulder disease. In some patients, ultrasound may show more inflammatory activity than is apparent on clinical examination alone.
Fluid and synovial proliferation around the long head of the biceps tendon can reflect biceps tenosynovitis, but may also indicate glenohumeral joint synovitis because the biceps tendon sheath communicates with the glenohumeral joint.
In suspected frozen shoulder, ultrasound findings are usually centered on thickening of the coracohumeral ligament, rotator interval, and anterior capsule/recess. Extensive proliferative bursitis and severe biceps tenosynovitis should raise suspicion for inflammatory arthropathy.
4. Injury/disease information
Inflammatory arthropathy of the shoulder may involve both intra-articular and periarticular structures. Typical ultrasound findings include synovial hypertrophy, joint effusion, tenosynovitis, and bursitis. The shoulder can show combined glenohumeral synovitis, biceps tendon sheath involvement, and subacromial-subdeltoid bursitis.
Rotator cuff degeneration may coexist with inflammatory shoulder disease. A supraspinatus tear and secondary impingement can contribute to pain and functional limitation, but marked synovial and bursae proliferation suggests an additional systemic or inflammatory process.
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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