61-year-old patient with right shoulder pain after a hard fall onto the shoulder while in the forest. The patient has an active lifestyle and physically demanding work in the cleaning sector. Ultrasound examination was performed according to the full ESSR shoulder protocol, with additional assessment of the rotator interval, including the superior glenohumeral ligament and coracohumeral ligament.
Ultrasound examination of the right shoulder demonstrates swelling and structural alteration of the supraspinatus tendon, compatible with tendinopathy in the dysrepair phase.
During dynamic ultrasound assessment with active abduction, subacromial impingement is visible. The supraspinatus tendon and subacromial-subdeltoid bursal complex impinge beneath the acromion during movement.
There is mild bursitis of the subacromial-subdeltoid bursa. In addition, a small amount of fluid or synovial swelling is visible in the glenohumeral joint, particularly in the posterior glenohumeral recess. This indicates a mild intra-articular reaction after trauma.
No full-thickness rotator cuff tear is described.
Because the symptoms started after a hard fall and there is glenohumeral joint swelling, underlying intra-articular traumatic pathology cannot be excluded by ultrasound. Ultrasound has limitations for assessing the labrum, cartilage, bone contusion, occult osseous injury, and deeper capsuloligamentous structures. Clinical follow-up is therefore important, with further imaging if recovery does not progress as expected.
1. Final diagnosis
Findings are consistent with post-traumatically provoked subacromial pain syndrome of the right shoulder, with supraspinatus tendinopathy in the dysrepair phase, dynamic subacromial impingement, and mild SASD bursitis. Mild glenohumeral joint swelling suggests an associated intra-articular post-traumatic reaction.
2. Differential diagnosis
The primary diagnosis is supraspinatus tendinopathy with secondary dynamic subacromial impingement and mild reactive bursitis. Given the traumatic onset and visible glenohumeral joint swelling, additional intra-articular post-traumatic pathology should be considered, including labral injury, chondral injury, bone contusion, capsular irritation, capsuloligamentous injury, or occult osseous injury.
3. Teaching points
Dynamic ultrasound is useful for demonstrating subacromial impingement during active abduction and for correlating tendon and bursal movement with pain. In a post-traumatic shoulder, even mild glenohumeral joint swelling is an important sign of intra-articular reaction. A normal or non-ruptured rotator cuff on ultrasound does not exclude labral, chondral, bone marrow, or deeper capsuloligamentous injury.
4. Injury/disease information
Subacromial pain syndrome may be provoked or aggravated by trauma, especially when tendon swelling and reactive bursitis reduce the available subacromial space. Physically demanding work with repetitive or loaded shoulder use can maintain symptoms during recovery. Conservative management usually includes relative load modification, avoidance of repeated overhead or heavy work in the painful phase, pain-guided exercise therapy, and gradual rebuilding of rotator cuff and scapular control. If pain, functional limitation, weakness, night pain, or recovery delay persists over the following weeks, additional imaging of the shoulder may be useful to assess intra-articular and osseous traumatic pathology.
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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