54-year-old female] with left right shoulder pain. Symptoms are likely provoked by abduction, elevation, overhead reaching, or lying on the affected side. Symptom duration, trauma history, dominant arm, and previous treatment are not provided.
Ultrasound examination of the shoulder demonstrates mild filling and swelling of the subacromial-subdeltoid bursa, most clearly visible around the rotator interval, supraspinatus tendon, and subscapularis tendon.
The supraspinatus tendon shows tendinopathic changes consistent with a dysrepair phase. The tendon is thickened and measures 8.8 mm, compared with 6.8 mm on the contralateral, non-affected side. The usual reference range is approximately 5–7 mm.
At the bursal side of the supraspinatus tendon, a small partial tear is visible. There is no evidence of a full-thickness supraspinatus tendon tear.
Due to swelling of the supraspinatus tendon and mild bursal distension, dynamic ultrasound demonstrates subacromial impingement between the acromion/coracoacromial ligament and the supraspinatus tendon/subacromial-subdeltoid bursa.
The overall appearance is consistent with subacromial pain syndrome, supraspinatus tendinopathy, mild bursal irritation, and a small bursal-sided partial supraspinatus tendon tear.
1. Final diagnosis
Subacromial pain syndrome with mild subacromial-subdeltoid bursal swelling, supraspinatus tendinopathy in the dysrepair phase, and a small bursal-sided partial tear of the supraspinatus tendon. Dynamic subacromial impingement is visible between the thickened supraspinatus tendon/bursa and the acromion/coracoacromial ligament. There is no evidence of a full-thickness rotator cuff tear.
2. Differential diagnosis
The primary diagnosis is rotator cuff-related shoulder pain or subacromial pain syndrome, related to supraspinatus tendinopathy, mild bursal irritation, and dynamic impingement. The small bursal-sided partial tear may contribute to pain during abduction, elevation, overhead reaching, and lying on the affected side. Differential diagnoses include additional subacromial bursitis, mechanical impingement due to tendon thickening, and functional scapulothoracic dyskinesia. If symptoms do not fully correlate with the ultrasound findings, intra-articular shoulder pathology or cervical referred pain should also be considered.
3. Teaching points
Dynamic ultrasound can demonstrate subacromial impingement during active movement and may help correlate structural findings with symptoms. Supraspinatus tendon thickening, especially when compared with the contralateral side, supports tendinopathy. A small bursal-sided partial tear should be distinguished from a full-thickness cuff tear, as tendon continuity remains preserved. Mild bursal swelling can be both a pain generator and a secondary response to rotator cuff overload.
4. Injury/disease information
Subacromial pain syndrome is part of the spectrum of rotator cuff-related shoulder pain. It may involve supraspinatus tendinopathy, bursal irritation, altered shoulder mechanics, and dynamic narrowing of the subacromial space. Management is usually conservative, with pain-guided loading, temporary reduction of provocative overhead activity, and exercise therapy focused on rotator cuff function, scapular control, posture, and gradual restoration of shoulder load tolerance. If pain prevents rehabilitation, an ultrasound-guided subacromial-subdeltoid corticosteroid injection may be considered, while avoiding intratendinous injection. Repeated corticosteroid injections should be used cautiously in the presence of tendinopathy and partial tendon tearing.
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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