70-year-old patient with shoulder pain clinically compatible with subacromial pain syndrome. Ultrasound examination was performed to assess the rotator cuff, subacromial-subdeltoid bursa, rotator interval, coracoacromial ligament region, and dynamic subacromial mechanics.
Ultrasound examination of the shoulder demonstrates findings consistent with subacromial pain syndrome.
There is moderate bursitis of the subacromial-subdeltoid bursa. The bursal involvement is visible at the level of the rotator interval and coracoacromial ligament, and to a lesser extent adjacent to the supraspinatus tendon.
The supraspinatus tendon shows degenerative tendinopathic changes. The combined supraspinatus tendon and subacromial-subdeltoid bursal complex is markedly thickened, measuring approximately 8.4 mm, compared with a stated reference range of approximately 5–7 mm.
Dynamic ultrasound examination during active abduction demonstrates primary subacromial impingement of the supraspinatus tendon and SASD bursa against the acromion.
No full-thickness rotator cuff tear is described.
1. Final diagnosis
Findings are consistent with subacromial pain syndrome caused by degenerative supraspinatus tendinopathy, moderate SASD bursitis, and marked thickening of the supraspinatus/SASD bursal complex. Dynamic assessment demonstrates subacromial impingement of the supraspinatus tendon and SASD bursa beneath the acromion.
2. Differential diagnosis
The primary diagnosis is subacromial pain syndrome with both tendinogenic and bursogenic components. Depending on the clinical examination, differential considerations include partial supraspinatus tear, AC joint pathology, glenohumeral intra-articular pathology, adhesive capsulitis, and cervical referred pain.
3. Teaching points
Subacromial pain syndrome is best interpreted as a clinical-imaging correlation rather than an isolated ultrasound diagnosis. Dynamic ultrasound can demonstrate impingement of the supraspinatus tendon and SASD bursa during active abduction. Marked thickening of the supraspinatus/SASD bursal complex supports reduced subacromial space and may explain pain during elevation, especially when it reproduces the patient’s recognizable symptoms.
4. Injury/disease information
Degenerative supraspinatus tendinopathy and SASD bursitis are common contributors to subacromial pain. Symptoms often include pain during arm elevation, painful arc, reduced loading tolerance, and difficulty with overhead or repetitive shoulder activity. Initial management is usually conservative, with education, modification of provocative loading, pain-guided exercise therapy, and gradual strengthening of the rotator cuff and scapular stabilizers. If clearly subacromial pain persists despite adequate conservative care, an ultrasound-guided SASD bursal injection may be considered; ultrasound guidance is preferred over landmark-based injection.
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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