45-year-old patient presenting with left shoulder pain, likely aggravated by elevation, overhead use, and daily activities. Symptoms may include stiffness and night pain
Ultrasound examination of the left shoulder was performed according to the ESSR shoulder protocol, including additional assessment of the rotator interval structures such as the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL).
There is mild fluid increase within the sheath of the long head of the biceps tendon, likely reactive to intra-articular and/or capsular irritation. The biceps tendon itself and its sheath otherwise demonstrate a normal sonographic appearance.
There is mild to moderate subacromial-subdeltoid (SASD) bursitis, visible at the rotator interval and extending along the supraspinatus and subscapularis tendons.
Marked thickening of the coracohumeral ligament is present at the rotator interval.
The supraspinatus tendon demonstrates moderate to severe calcific tendinopathy, with diffuse soft type 3 calcification throughout the tendon.
The combined supraspinatus tendon and SASD bursal complex is thickened to approximately 9.4 mm (reference approximately 5–7 mm).
Dynamic ultrasound during active abduction demonstrates primary subacromial impingement of the supraspinatus tendon and SASD bursa against the acromion and coracoacromial ligament.
A small partial intratendinous tear is present in the mid-portion of the supraspinatus tendon.
1. Final diagnosis
Subacromial pain syndrome caused by combined SASD bursitis, calcific supraspinatus tendinopathy, structural subacromial thickening, and dynamic impingement, with an associated small partial supraspinatus tear.
2. Differential diagnosis
Consider concomitant adhesive capsulitis, particularly given the marked coracohumeral ligament thickening and reactive biceps sheath fluid. Clinical range-of-motion assessment is recommended.
3. Teaching points
Subacromial pain is often multifactorial. Tendon thickening, bursitis, and calcification may collectively reduce subacromial space and provoke impingement. Coracohumeral ligament thickening is a recognized indirect imaging feature associated with frozen shoulder.
4. Injury/disease information
Calcific tendinopathy can trigger pain through inflammatory resorption and mechanical crowding. Repeated impingement may perpetuate bursitis and tendon overload. Small intratendinous tears may coexist and are not always the primary pain source.
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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