48-year-old female with persistent left shoulder pain following a fall three months previously, during which the shoulder was forced into anteflexion. Symptoms are load-dependent, with an NRS pain score of approximately 6 during activity. The patient is pain-free at rest.
Ultrasound examination of the left shoulder was performed according to the ESSR shoulder protocol. Additional assessment included the rotator interval with evaluation of the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL), as well as the rotator cuff, scapular musculature, and humeral musculature.
There is a considerable amount of fluid surrounding the long head of the biceps tendon within the tendon sheath. The biceps tendon itself demonstrates preserved continuity and no convincing structural abnormality. There are no clear sonographic features of primary biceps tenosynovial pathology.
Given the normal appearance of the biceps tendon and the amount of surrounding fluid, the fluid likely represents extension of glenohumeral joint fluid into the biceps tendon sheath. This may reflect glenohumeral effusion or reactive intra-articular irritation following trauma.
The supraspinatus tendon is markedly thickened and demonstrates pronounced tendinopathic changes.
At the transition between the supraspinatus and infraspinatus tendons, there is a full-thickness, partial-width rotator cuff tear.
During active abduction, the locally thickened supraspinatus region demonstrates clear dynamic mechanical compression within the subacromial space, compatible with secondary subacromial impingement.
Ultrasound is limited for further assessment of intra-articular glenohumeral structures.
1. Final diagnosis
Full-thickness, partial-width tear of the supraspinatus tendon at the transition toward the infraspinatus, occurring within a markedly thickened and tendinopathic tendon. Associated dynamic subacromial impingement is demonstrated during active abduction.
There is also a substantial amount of fluid within the long biceps tendon sheath without convincing primary biceps tendon pathology. This most likely represents extension of glenohumeral joint fluid into the tendon sheath and may reflect post-traumatic intra-articular irritation or effusion.
2. Differential diagnosis
For the glenohumeral fluid-related finding, post-traumatic reactive synovial or intra-articular irritation is the most likely explanation. A more specific intra-articular source, including labral or other capsulolabral pathology, cannot be reliably assessed with ultrasound.
If progressive restriction of shoulder motion develops, particularly loss of passive external rotation, evolving adhesive capsulitis should also be considered clinically.
3. Teaching points
Fluid within the long biceps tendon sheath does not necessarily indicate primary biceps tenosynovitis. Because the sheath communicates with the glenohumeral joint, substantial fluid around an otherwise normal biceps tendon may represent extension of a glenohumeral joint effusion.
A rotator cuff tear should be characterised not only by tendon thickness involvement but also by its width. A full-thickness, partial-width tear indicates complete disruption through the tendon depth over only part of its transverse extent.
Dynamic ultrasound can additionally demonstrate secondary mechanical subacromial compression during active elevation. Marked tendon thickening may contribute to reduced available subacromial space and symptomatic impingement.
4. Injury/disease information
Traumatic full-thickness rotator cuff tears may cause persistent pain, weakness, and functional limitation. Initial management may include progressive exercise therapy aimed at restoring shoulder mobility, rotator cuff capacity, and scapular function, with loading adjusted according to symptoms and functional response.
For the subacromial pain component, rehabilitation remains important. If pain substantially prevents adequate exercise therapy, an ultrasound-guided subacromial-subdeltoid corticosteroid injection may be considered for temporary symptom reduction to facilitate rehabilitation. Such an injection does not repair the structural tendon tear.
The glenohumeral range of motion should be monitored during follow-up. Progressive loss of passive motion, particularly external rotation, should prompt clinical reassessment for possible adhesive capsulitis.
Given the traumatic mechanism and the sonographically demonstrated full-thickness cuff tear, persistent functional limitation, objective weakness, or insufficient improvement during rehabilitation may warrant assessment by an orthopaedic shoulder specialist. MRI may provide additional information about tear dimensions, tendon retraction, muscle quality, and associated intra-articular abnormalities when these findings would influence treatment. MR arthrography may be considered when a specific labral or capsulolabral question remains clinically relevant.
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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