81-year-old patient presenting with severe shoulder dysfunction, weakness, and limited active range of motion. Symptoms are likely chronic and progressive.
Ultrasound examination of the shoulder demonstrates extensive rotator cuff pathology.
There are complete ruptures of the supraspinatus and infraspinatus tendons, with absence of normal tendon continuity. The corresponding muscles show marked atrophy and severe fatty infiltration, indicating chronic and likely irreversible changes.
The subscapularis tendon demonstrates a large full-thickness tear involving part of the tendon width (partial-width), located at its insertion.
The long head of the biceps tendon is medially (sub)luxated and appears to lie over the tuberculum minus, at the expected location of the subscapularis tendon. This reflects failure of the biceps pulley system, in association with subscapularis pathology.
There is cranial migration of the humeral head, which appears to abut the acromion, resulting in osseous (bone-on-bone) impingement.
The acromioclavicular (AC) joint demonstrates irregularity and increased capsular distension, consistent with degenerative changes.
These findings are consistent with advanced cuff arthropathy.
1. Final diagnosis
Massive rotator cuff tear involving complete ruptures of the supraspinatus and infraspinatus tendons, and a large partial-width full-thickness tear of the subscapularis tendon, with medial dislocation of the long head of the biceps, advanced muscle atrophy and fatty infiltration, and superior migration of the humeral head resulting in cuff arthropathy.
2. Differential diagnosis
Consider chronic degenerative versus post-traumatic massive rotator cuff tear. The degree of fatty infiltration and atrophy strongly supports a long-standing process.
3. Teaching points
Superior migration of the humeral head and contact with the acromion are key signs of cuff arthropathy. Medial dislocation of the biceps tendon is strongly associated with subscapularis tears. Advanced fatty infiltration is an important prognostic factor and often limits surgical repair options.
4. Injury/disease information
Massive rotator cuff tears are typically chronic and may lead to cuff arthropathy, characterized by altered joint biomechanics, instability, and progressive degeneration. Loss of rotator cuff function results in unopposed superior migration of the humeral head. These advanced stages are often associated with significant functional impairment and may require surgical solutions such as reverse shoulder arthroplasty.
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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