61-year-old male with chronic right shoulder pain and persistent functional limitation despite multiple previous therapies. Symptoms are provoked by shoulder elevation, active abduction, overhead activity, and possibly horizontal adduction or pressure over the AC joint.
Ultrasound examination of the shoulder demonstrates mild bursal distension in the subscapularis region, with thickening of the peribursal fat layers. At the bursal side of the subscapularis tendon, a partial tear is visible, measuring 8.5 × 5.6 mm.
The supraspinatus tendon shows marked tendinopathic change, with pronounced tendon thickening up to approximately 10–11 mm. During ultrasound-guided active abduction, dynamic impingement is visible between the supraspinatus tendon/subacromial-subdeltoid bursa and the coracoacromial ligament/acromion.
The acromioclavicular joint shows narrowing of the joint space with irregular cortical margins, consistent with degenerative AC joint osteoarthritis. The AC joint capsule is bulging and distended, compatible with capsular distension and synovial irritation.
The overall appearance is consistent with chronic rotator cuff-related shoulder pain, with dynamic subacromial impingement, severe supraspinatus tendinopathy, a partial subscapularis tendon tear, mild bursal irritation, and degenerative AC joint pathology.
1. Final diagnosis
Chronic rotator cuff-related shoulder pain with severe supraspinatus tendinopathy and dynamic subacromial impingement during active abduction. Additional findings include a partial bursal-sided subscapularis tendon tear measuring 8.5 × 5.6 mm, mild bursal distension with thickened peribursal fat layers, and degenerative AC joint osteoarthritis with capsular distension.
2. Differential diagnosis
The primary diagnosis is chronic subacromial pain syndrome related to severe supraspinatus tendinopathy, dynamic impingement, and bursal irritation. The partial subscapularis tear may contribute to anterior shoulder pain, weakness, or pain during internal rotation. The degenerative AC joint changes may contribute to superior shoulder pain, pain during horizontal adduction, night pain, or local pressure-related symptoms. Intra-articular glenohumeral pathology, such as labral or chondral disease, should also be considered when symptoms are not fully explained by the sonographic findings, although ultrasound is limited for assessing these structures.
3. Teaching points
Dynamic ultrasound during active abduction can demonstrate mechanical subacromial impingement in patients with rotator cuff-related shoulder pain. Severe supraspinatus tendinopathy may present with marked tendon thickening and altered tendon echotexture. A partial subscapularis tear should be actively assessed in patients with anterior shoulder pain or internal rotation symptoms. AC joint degeneration with capsular distension can be a separate pain generator and should be correlated with localized clinical tenderness and provocative testing.
4. Injury/disease information
Rotator cuff-related shoulder pain is a common chronic shoulder disorder involving the rotator cuff tendons, subacromial-subdeltoid bursa, scapulohumeral mechanics, and sometimes the AC joint. Ultrasound can evaluate tendon morphology, partial tendon tears, bursal distension, dynamic impingement, and accessible degenerative joint changes. In chronic therapy-resistant cases, correlation with clinical examination is important to determine whether symptoms arise mainly from the rotator cuff, bursa, AC joint, or an intra-articular pain source. Additional MRI may be useful when the extent of tendon tearing, tendon quality, or intra-articular pathology may influence further 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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