69-year-old patient presenting with shoulder pain during abduction and overhead activity. Symptoms likely chronic with functional limitation. History notable for prior distal clavicle resection at the acromioclavicular joint.
Ultrasound examination of the shoulder demonstrates significant pathology of the supraspinatus tendon.
There is a suspected full-thickness tear involving part of the tendon width (partial-width), identified as a hypoechoic defect with disruption of the normal fibrillar structure. The remaining tendon shows moderate tendinopathy in the dysrepair phase, with thickening and heterogeneous echotexture.
There is associated moderate subacromial-subdeltoid (SASD) bursitis, with increased fluid and bursal thickening.
The combined thickening of the supraspinatus tendon remnant and SASD bursa results in a reduced subacromial space. Dynamic ultrasound during guided active abduction demonstrates clear primary impingement, with mechanical compression of the supraspinatus tendon and bursa beneath the acromion.
At the acromioclavicular (AC) joint, there are postoperative changes consistent with prior distal clavicle resection.
1. Final diagnosis
Subacromial pain syndrome due to a suspected partial-width full-thickness tear of the supraspinatus tendon, associated with moderate dysrepair-phase tendinopathy and SASD bursitis, resulting in dynamic primary impingement. Status post distal clavicle resection.
2. Differential diagnosis
Consider high-grade partial-thickness tear versus full-thickness tear if tendon continuity is difficult to assess. Additional considerations include isolated bursitis or postoperative biomechanical changes contributing to impingement.
3. Teaching points
A focal hypoechoic defect with fiber discontinuity suggests a full-thickness tear, even if limited in width. Coexisting tendinopathy and bursitis contribute to subacromial narrowing and impingement. Dynamic ultrasound is essential to demonstrate functional impingement. Prior distal clavicle resection may alter shoulder biomechanics and should be considered in interpretation.
4. Injury/disease information
Rotator cuff tears often develop on a background of chronic tendinopathy. Full-thickness tears may be partial in width and still significantly impact function. Subacromial pain syndrome is frequently multifactorial, involving tendon degeneration, bursitis, and mechanical impingement. Surgical history, such as distal clavicle resection, may influence load distribution and symptom persistence.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at the Laurentius Hospital in Roermond, the Netherlands.
More Cases from Marc Schmitz
