47-year-old patient presenting with shoulder pain during abduction and overhead activities. Symptoms are consistent with subacromial impingement.
Ultrasound examination of the shoulder demonstrates findings consistent with subacromial pain syndrome (SAPS).
There is subacromial-subdeltoid (SASD) bursitis with mild neovascularization, indicating a mildly active inflammatory process.
The supraspinatus tendon shows moderate to severe tendinopathy, with significant thickening measuring approximately 8.6 mm (reference range 5–7 mm). The tendon appears hypoechoic with loss of the normal fibrillar architecture.
A small intrasubstance calcification (type 3) is present at the supraspinatus tendon insertion at the greater tuberosity (tuberculum majus). This finding is likely incidental and not clinically relevant.
During dynamic ultrasound with guided abduction, there is clear subacromial impingement, with mechanical compression of the supraspinatus tendon and SASD bursa against the acromial arch.
1. Final diagnosis
Subacromial pain syndrome due to moderate to severe supraspinatus tendinopathy with associated SASD bursitis and dynamic subacromial impingement. Incidental small intratendinous calcification.
2. Differential diagnosis
Consider early partial-thickness supraspinatus tear or isolated bursitis. Calcific tendinopathy is less likely as the calcification appears small and non-reactive.
3. Teaching points
Tendon thickening beyond normal reference values supports the diagnosis of tendinopathy. Small intratendinous calcifications are often incidental and not always symptomatic. Dynamic ultrasound is essential to confirm functional impingement. Mild neovascularization in the bursa suggests low-grade inflammatory activity.
4. Injury/disease information
Subacromial pain syndrome is a common cause of shoulder pain and is often multifactorial. Tendon degeneration and bursal inflammation reduce the subacromial space, leading to mechanical impingement. Not all structural abnormalities, such as small calcifications, are clinically relevant and should be interpreted in the context of symptoms.
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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