79-year-old female] with right shoulder complaints consisting of pain/weakness/loss of active elevation.
Ultrasound demonstrates complete full-thickness tears of both the supraspinatus and infraspinatus tendons.
The subscapularis tendon demonstrates a partial longitudinal tear, with residual tendon continuity preserved.
The teres minor tendon is intact. The long head of the biceps tendon remains normally positioned with preserved continuity.
There is marked fatty change and reduced muscle quality involving the supraspinatus and infraspinatus musculature. These muscular changes support a chronic component to the rotator cuff pathology.
During active shoulder movement, there is a clear compensatory movement pattern of the shoulder girdle.
1. Final diagnosis
Extensive rotator cuff tear with complete full-thickness rupture of the supraspinatus and infraspinatus tendons and an additional partial longitudinal tear of the subscapularis tendon. The teres minor and long head of the biceps tendon remain intact. Associated fatty degeneration of the supraspinatus and infraspinatus musculature suggests a substantial chronic component. A pronounced compensatory shoulder-girdle movement pattern is present during active motion.
2. Differential diagnosis
The overall appearance is most consistent with extensive chronic-degenerative rotator cuff disease. If there has been a recent traumatic event or sudden deterioration in shoulder function, an acute extension of a pre-existing chronic degenerative tear should be considered. The presence of fatty muscle degeneration makes an exclusively recent acute tear less likely.
3. Teaching points
Involvement of multiple rotator cuff tendons, particularly complete supraspinatus and infraspinatus tears combined with subscapularis pathology, indicates extensive cuff disease. Evaluation should extend beyond tendon continuity to include the quality of the corresponding musculature. Fatty degeneration and muscle quality loss support chronicity and may have prognostic relevance when surgical reconstruction is considered. Dynamic examination can additionally demonstrate compensatory scapulothoracic and shoulder-girdle movement when normal glenohumeral function is impaired.
4. Injury/disease information
Extensive rotator cuff tears may result in pain, weakness, loss of active elevation, and progressive compensatory recruitment of the deltoid and scapular musculature. Management depends on factors including age, general health, functional requirements, strength deficit, symptom severity, mechanism and chronicity of the tear, and patient treatment preferences.
Specialist shoulder assessment may be useful when a multi-tendon tear is associated with significant functional impairment. If operative reconstruction is being considered, MRI without contrast can provide additional information regarding tendon retraction, tear extent, muscle atrophy, and degree of fatty infiltration, all of which contribute to assessment of cuff reparability.
When a conservative approach is selected, rehabilitation generally focuses on maintaining shoulder mobility and optimising the remaining functional rotator cuff, deltoid, and scapular stabilising musculature, with the aim of improving residual shoulder function and reducing excessive compensatory movement patterns.
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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