53-year-old patient, active in overhead sports (e.g., volleyball), presenting with shoulder pain and possible instability symptoms. History likely includes prior (sub)luxation event.
Ultrasound examination of the shoulder demonstrates a small bursal-sided partial-thickness tear of the posterior supraspinatus tendon, measuring approximately 2.0 × 3.4 mm.
The supraspinatus tendon shows moderate tendinopathy in the dysrepair phase, with thickening, reduced echogenicity, and loss of normal fibrillar architecture.
There is mild distension of the subacromial-subdeltoid (SASD) bursa.
During dynamic ultrasound with active abduction, there is mild subacromial impingement, with compression of the supraspinatus tendon and bursa beneath the acromion.
The subscapularis tendon demonstrates moderate to severe tendinopathy in the degenerative phase.
At the level of the humeral head, particularly in the region of the infraspinatus insertion, there is cortical irregularity consistent with a Hill-Sachs lesion. This finding suggests prior anterior glenohumeral instability, likely related to a previous (sub)luxation event. Associated labral pathology cannot be assessed with ultrasound but is likely present.
1. Final diagnosis
Posterior bursal-sided partial supraspinatus tear with moderate tendinopathy, associated with subscapularis tendinopathy, mild SASD bursitis, and dynamic subacromial impingement. Additional signs of a Hill-Sachs lesion indicating prior glenohumeral instability.
2. Differential diagnosis
Consider isolated rotator cuff tendinopathy versus instability-related pathology. Labral injury (e.g., Bankart lesion) is likely but cannot be visualized with ultrasound.
3. Teaching points
Bursal-sided tears are often associated with impingement. Hill-Sachs lesions are indicative of prior anterior shoulder instability and should prompt consideration of associated labral injury. In overhead athletes, even small structural abnormalities may have significant functional impact.
4. Injury/disease information
Shoulder instability can lead to structural damage such as Hill-Sachs lesions and labral tears. These changes alter joint biomechanics and increase the risk of recurrent instability, especially in overhead sports. Coexisting rotator cuff pathology may further impair function and stability.
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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