56-year-old female patient with shoulder pain and radiating arm pain. The arm symptoms are provoked by neck movements, suggesting a possible cervical component. Ultrasound examination was performed to assess the rotator cuff, subacromial-subdeltoid bursa, and dynamic subacromial mechanics.
Ultrasound examination of the shoulder demonstrates findings consistent with subacromial pain syndrome.
There is a mild articular-sided partial tear of the anterior supraspinatus tendon at its insertion on the greater tubercle. The supraspinatus tendon also shows mild tendinopathic changes.
The combined supraspinatus tendon and subacromial-subdeltoid bursal complex is mildly thickened, measuring approximately 7.5 mm, compared with a stated reference range of approximately 5–7 mm. This is compatible with mild supraspinatus tendinopathy and reactive involvement of the SASD bursa.
There are no ultrasound signs of a full-thickness rotator cuff tear.
Dynamic ultrasound examination during active abduction demonstrates primary subacromial impingement of the supraspinatus tendon and SASD bursa against the acromion.
Clinically, the patient also reports radiating pain into the arm, which is provoked by neck movements. This raises the possibility of a cervical pain component. Ultrasound is not suitable for assessing cervical spine pathology, and the clinical relevance of the shoulder findings should therefore be correlated with physical examination.
1. Final diagnosis
Findings are consistent with subacromial pain syndrome, with a mild articular-sided partial insertional tear of the anterior supraspinatus tendon, mild supraspinatus tendinopathy, mild reactive thickening of the supraspinatus/SASD bursal complex, and dynamic subacromial impingement. No full-thickness rotator cuff tear is present.
2. Differential diagnosis
The primary diagnosis is subacromial pain syndrome related to mild supraspinatus tendon pathology and dynamic impingement. A cervical referred pain component or cervical radicular irritation should also be considered, given the radiating arm pain and provocation with neck movements. The mild ultrasound shoulder abnormalities may be clinically relevant, but they could also be incidental or not the dominant pain generator. Additional differential considerations include glenohumeral intra-articular pathology, AC joint pathology, and myofascial pain, depending on the clinical examination.
3. Teaching points
Dynamic ultrasound can help demonstrate subacromial impingement by showing mechanical conflict between the supraspinatus tendon, SASD bursa, and acromion during active abduction. Mild articular-sided partial supraspinatus tears and mild SASD bursal thickening should always be interpreted in relation to the patient’s recognizable pain. When arm pain is provoked by neck movement, cervical referred pain or radicular irritation should be assessed clinically, as ultrasound cannot evaluate the cervical spine.
4. Injury/disease information
Subacromial pain syndrome is a clinical and imaging pattern involving pain related to the rotator cuff, SASD bursa, and subacromial space. It may be associated with supraspinatus tendinopathy, partial-thickness cuff tears, bursal irritation, and dynamic impingement. Conservative treatment often focuses on education, load modification, rotator cuff and scapular control exercises, and gradual return to shoulder loading. If a clearly clinically relevant subacromial pain component persists despite adequate conservative management, an ultrasound-guided SASD bursal injection may be considered. Persistent neck-provoked arm pain, neurological symptoms, progressive radiation, weakness, or sensory disturbance should prompt clinical evaluation for a cervical component.
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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