83-year-old patient presenting with shoulder pain, swelling, and functional limitation. Symptoms likely chronic and progressive.
Ultrasound examination of the shoulder demonstrates extensive pathology involving the rotator cuff and long head of the biceps tendon.
The long head of the biceps tendon shows marked tendinopathy with features suggestive of tenosynovitis, including neovascularization. The tendon is medially dislocated from the bicipital groove, indicating failure of the stabilizing pulley system, often associated with subscapularis pathology.
There is a significant increase in glenohumeral joint fluid, which extends into the subscapularis bursa, subacromial-subdeltoid (SASD) bursa, and posterior recess, indicating substantial intra-articular effusion.
At the level of the acromioclavicular (AC) joint, a Geyser sign is present, reflecting superior migration of joint fluid through the AC joint. This finding is strongly associated with a chronic, full-thickness rotator cuff tear, particularly involving the supraspinatus tendon.
The supraspinatus tendon is still partially visualized but appears thinned, suggesting advanced degeneration and likely high-grade or near-complete tearing.
There are additional signs of generalized rotator cuff tendinopathy.
At the infraspinatus, a moderate partial tear is identified at the myotendinous junction, with disruption of the normal fibrillar pattern.
1. Final diagnosis
Massive rotator cuff pathology characterized by a chronic full-thickness supraspinatus tear (supported by Geyser sign), severe rotator cuff tendinopathy, medial dislocation and tendinopathy of the long head of the biceps with tenosynovitis, and associated glenohumeral joint effusion. Additional partial tear of the infraspinatus at the myotendinous junction.
2. Differential diagnosis
Consider cuff arthropathy given the chronicity and extent of pathology. Less likely isolated biceps pathology, as findings strongly support combined rotator cuff failure.
3. Teaching points
The Geyser sign is a classic indicator of chronic full-thickness rotator cuff tear with communication between the glenohumeral joint and AC joint. Medial dislocation of the long head of the biceps suggests pulley system failure, often involving the subscapularis. Extensive joint effusion extending into multiple bursae indicates intra-articular pathology.
4. Injury/disease information
Chronic rotator cuff tears can lead to progressive tendon degeneration, instability, and joint communication with surrounding bursae. Biceps tendon instability commonly coexists due to disruption of stabilizing structures. Advanced cases may evolve into cuff arthropathy, with significant functional impairment and limited treatment options.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at the Laurentius Hospital in Roermond, the Netherlands.
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