62-year-old patient presenting with shoulder pain, especially during elevation and overhead activities, with likely functional limitation and painful arc symptoms.
Ultrasound examination of the shoulder demonstrates a primary subacromial impingement mechanism.
The supraspinatus tendon shows moderate to severe tendinopathy with thickening and altered fibrillar architecture. At the tendon insertion, there is a type 3 (soft) calcification, further increasing tendon volume.
There is moderate to severe distension of the subacromial-subdeltoid (SASD) bursa, consistent with bursitis.
Together, the thickened supraspinatus tendon, intratendinous calcification, and swollen bursa create an enlarged tendinobursal complex, which demonstrates frictional contact with the acromion during movement, consistent with dynamic subacromial impingement.
Additionally, the supraspinatus tendon demonstrates a full-thickness tear involving part of the tendon width (partial-width rupture).
The acromioclavicular (AC) joint shows degenerative changes, including cortical irregularity, osteophyte formation, and joint space narrowing.
1. Final diagnosis
Subacromial pain syndrome due to dynamic impingement from supraspinatus tendinopathy, type 3 calcific tendinopathy, and SASD bursitis, with associated partial-width full-thickness supraspinatus tear and AC joint osteoarthritis.
2. Differential diagnosis
Consider primary rotator cuff degeneration with secondary impingement versus chronic calcific tendinopathy with reactive bursitis.
3. Teaching points
Subacromial impingement is often multifactorial. Combined tendon thickening, calcification, and bursitis can significantly reduce the subacromial space. Full-thickness tears may coexist even when pain is dominated by bursitis or impingement.
4. Injury/disease information
Rotator cuff degeneration may lead to tendon thickening, tearing, and calcification. Associated bursitis increases pain sensitivity and restricts motion. AC joint osteoarthritis frequently coexists and may contribute to superior shoulder pain and reduced mechanics.
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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