81-year-old patient presenting with chronic shoulder pain, marked functional limitation, and weakness. Symptoms likely longstanding with progressive loss of function.
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 muscle bellies show marked atrophy and advanced fatty infiltration, indicating chronic and likely irreversible changes.
The long head of the biceps tendon is also completely ruptured and not visualized in its normal anatomical course.
The subscapularis tendon shows severe degenerative tendinopathy with multiple small partial-thickness tears, but no complete rupture is identified.
There are clear signs of advanced glenohumeral osteoarthritis, with joint irregularity and instability. Increased intra-articular fluid is present, which communicates with the subacromial-subdeltoid (SASD) bursa, indicating a full-thickness rotator cuff defect and joint–bursa communication.
These findings are consistent with a massive rotator cuff tear with secondary cuff arthropathy.
1. Final diagnosis
Massive rotator cuff tear involving complete ruptures of the supraspinatus and infraspinatus tendons and the long head of the biceps tendon, with advanced muscle atrophy and fatty infiltration, associated with severe glenohumeral osteoarthritis and instability (cuff arthropathy).
2. Differential diagnosis
Consider chronic degenerative rotator cuff disease versus post-traumatic massive tear. The presence of advanced atrophy and fatty infiltration supports a chronic process.
3. Teaching points
A combination of multiple full-thickness tendon ruptures with muscle atrophy and fatty infiltration defines a massive rotator cuff tear. Communication between the glenohumeral joint and SASD bursa is a key sign of full-thickness cuff defects. Chronic tears often lead to cuff arthropathy with joint instability and degeneration.
4. Injury/disease information
Massive rotator cuff tears are typically the result of long-standing degenerative changes and may lead to cuff arthropathy, characterized by superior migration of the humeral head, joint instability, and progressive osteoarthritis. Muscle atrophy and fatty infiltration are important prognostic factors and often limit surgical repair 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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