68-year-old patient presenting with shoulder pain, likely during elevation and overhead activities. Symptoms may be more pronounced on the left side.
Ultrasound examination of the shoulder demonstrates mild fluid distension of the biceps tendon sheath. The fluid likely originates from the glenohumeral joint, as the long head of the biceps tendon itself appears normal with preserved fibrillar architecture.
There is mild distension of the posterior recess of the glenohumeral joint, more pronounced on the left compared to the contralateral side, indicating intra-articular effusion.
The acromioclavicular (AC) joint capsule appears thickened, consistent with synovitis. Compared to the right side, the left AC joint shows clear swelling. No neovascularization is observed on Doppler imaging.
The supraspinatus tendon demonstrates tendinopathy, with thickening and altered echotexture. During dynamic ultrasound with guided active abduction, the thickened tendon contributes to subacromial impingement beneath the acromion.
1. Final diagnosis
Supraspinatus tendinopathy with dynamic subacromial impingement, associated with mild glenohumeral joint effusion and reactive biceps sheath fluid, and AC joint synovitis without Doppler activity.
2. Differential diagnosis
Consider early rotator cuff tear not clearly visualized, or primary AC joint degeneration. Inflammatory arthropathy is less likely given absence of neovascularization.
3. Teaching points
Fluid in the biceps sheath often reflects intra-articular pathology rather than primary tendon disease. Comparison with the contralateral side is valuable in detecting subtle asymmetry. AC joint synovitis may occur without Doppler signal. Dynamic ultrasound is essential to demonstrate functional impingement.
4. Injury/disease information
Shoulder pain is often multifactorial, involving rotator cuff tendinopathy, joint effusion, and AC joint pathology. Subacromial impingement occurs when tendon thickening reduces the available space during movement. Early recognition helps guide conservative management and prevent progression.
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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