56-year-old patient presenting with shoulder pain during active elevation and overhead movements. Symptoms are likely activity-related and consistent with subacromial impingement.
Ultrasound examination of the shoulder demonstrates findings consistent with subacromial pain syndrome (SAPS).
There is moderate filling of the subacromial-subdeltoid (SASD) bursa without evidence of neovascularization, in keeping with non-hyperemic bursitis.
The supraspinatus tendon shows moderate tendinopathy in the dysrepair phase, characterized by tendon thickening, reduced echogenicity, and loss of the normal fibrillar pattern.
A small articular-sided partial thickness tear is present, seen as a focal hypoechoic defect at the deep (articular) surface of the tendon.
The combined swelling of the supraspinatus tendon and SASD bursa results in narrowing of the subacromial space. During dynamic ultrasound assessment with active movement, there is clear impingement of the supraspinatus tendon and bursa against the coracoacromial ligament and acromion
1. Final diagnosis
Subacromial pain syndrome due to moderate supraspinatus tendinopathy with a small articular-sided partial thickness tear and associated SASD bursitis, resulting in dynamic subacromial impingement.
2. Differential diagnosis
Consider isolated bursitis, bursal-sided partial tear, or early full-thickness tear if visualization is limited. Internal impingement or additional intra-articular pathology may coexist and require further imaging if clinically suspected.
3. Teaching points
Articular-sided supraspinatus tears are common and may be subtle on ultrasound. Tendon and bursal thickening contribute to reduced subacromial space and impingement. Dynamic assessment is essential to confirm functional impingement. Absence of Doppler signal in the bursa suggests a less active inflammatory state.
4. Injury/disease information
Subacromial pain syndrome is a multifactorial condition involving rotator cuff degeneration, bursitis, and mechanical impingement. Articular-sided tears often occur due to increased tensile stress and may represent an early stage in rotator cuff disease progression.
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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