55-year-old patient presenting with left shoulder pain and functional limitation, likely aggravated by elevation and overhead activity. Symptoms may interfere with rehabilitation progress.
Ultrasound examination of the left shoulder was performed according to the ESSR shoulder protocol, including additional assessment of the rotator interval (SGHL, CHL), anterior labrum, glenohumeral joint, and dynamic stability.
There is marked subacromial-subdeltoid (SASD) bursitis, most prominent in the anterior shoulder region near the long head of the biceps tendon and around the transition zone between the supraspinatus and infraspinatus tendons.
The supraspinatus tendon demonstrates severe tendinopathy with multiple moderate partial-thickness tears.
Dynamic ultrasound shows subacromial impingement between the supraspinatus tendon and the coracoacromial ligament, likely secondary to the combined effect of tendon thickening and bursal distension.
There is moderate tenosynovitis of the biceps tendon sheath.
The acromioclavicular (AC) joint capsule demonstrates mild synovitis.
Doppler imaging reveals multifocal neovascularization: mild at the AC joint, moderate within the supraspinatus tendon, and marked within the SASD bursa, indicating active inflammatory change.
Although the likelihood is considered low, the degree and distribution of vascular activity raise the possibility of an underlying inflammatory/rheumatologic component and should not be fully excluded.
1. Final diagnosis
Marked SASD bursitis with active inflammation, severe supraspinatus tendinopathy with multiple partial tears, dynamic subacromial impingement, biceps tenosynovitis, and mild AC joint synovitis.
2. Differential diagnosis
Primary degenerative rotator cuff disease with reactive bursitis versus inflammatory shoulder synovitis. A rheumatologic contribution is considered less likely but remains a differential consideration.
3. Teaching points
Extensive Doppler activity within the bursa often correlates with pain generation. In multifactorial shoulder pain, the SASD bursa can be a major nociceptive source. Widespread neovascularization should prompt consideration of both mechanical overload and inflammatory disease.
4. Injury/disease information
Subacromial bursitis commonly coexists with rotator cuff pathology and may significantly amplify pain and movement restriction. Partial cuff tears and tendon degeneration alter biomechanics, further perpetuating impingement and inflammation.
5. Clinical recommendation:
An ultrasound-guided injection into the SASD bursa may be a reasonable therapeutic option, particularly if bursitis is considered the primary pain generator. Reducing bursal inflammation may also facilitate progression of physiotherapy. Final decision-making should be based on the broader clinical picture and treating physician assessment.
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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