72-year-old female with approximately seven weeks of severe right shoulder pain, particularly during elevation and overhead activities. Associated loss of strength is reported.
Ultrasound examination of the right shoulder was performed according to the ESSR shoulder protocol. Additional assessment of the rotator interval included evaluation of the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL).
There is marked distension of the subacromial-subdeltoid bursa, with synovial/proliferative changes and moderate neovascularisation.
The supraspinatus tendon demonstrates a near-complete rupture. Only a limited number of tendon fibres retain continuity, while the majority of the tendon is disrupted.
During active abduction, there is clear dynamic mechanical impingement of the supraspinatus tendon and distended subacromial-subdeltoid bursa against the acromion.
There is a small amount of fluid within the glenohumeral joint, accompanied by a mild capsular/synovial reaction.
A large osteophyte measuring 10.2 × 9.6 mm is present at the greater tuberosity of the humerus.
1. Final diagnosis
Near-complete rupture of the supraspinatus tendon, associated with marked reactive subacromial-subdeltoid bursitis demonstrating proliferative/synovial changes and moderate neovascularisation. Clear dynamic subacromial impingement is present during active abduction. Mild reactive glenohumeral joint effusion/capsular irritation is also seen. A large 10.2 × 9.6 mm osteophyte is present at the greater tuberosity.
2. Differential diagnosis
The sonographic abnormalities correlate well with the reported shoulder pain, loss of strength, and limitation during elevation and overhead activity. The marked subacromial-subdeltoid bursitis may represent an important additional pain generator. If the clinical course is atypical or if further anatomical delineation is required, additional intra-articular or rotator cuff pathology may be evaluated with MRI.
3. Teaching points
Near-complete supraspinatus rupture may leave only a small number of residual intact fibres and can be associated with substantial loss of strength and functional limitation. Dynamic ultrasound is particularly useful for demonstrating mechanical subacromial impingement during active shoulder movement. A markedly distended and hypervascular subacromial-subdeltoid bursa may contribute significantly to symptoms in addition to the underlying rotator cuff tear. Bony changes at the greater tuberosity may accompany chronic rotator cuff pathology.
4. Injury/disease information
Management of a near-complete supraspinatus rupture depends on factors including age, functional demands, symptom severity, strength loss, tear characteristics, and overall clinical condition. Specialist shoulder assessment can help determine whether conservative or operative treatment is most appropriate. When conservative management is selected, treatment commonly focuses on load modification, preservation or restoration of shoulder mobility, and progressive exercise therapy. In the presence of pronounced symptomatic subacromial-subdeltoid bursitis, ultrasound-guided subacromial-subdeltoid corticosteroid injection may be considered as part of the treatment strategy. MRI is not invariably required when clinical examination and ultrasound provide sufficient information for conservative management, but may be useful when surgical treatment is being considered or when additional anatomical detail could influence management.
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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