Case Presentation: 64 year old female with right shoulder pain
Alicia M. Yochum RN, DC, DACBR
Published: September 2016
Journal of the Academy of Chiropractic Orthopedists
September 2016, Volume 13, Issue 1
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: https://ianmmedicine.org. © 2015 Yochum and the Academy of Chiropractic Orthopedists.
A 64 year old female presented for chiropractic care with anterior right shoulder pain. She is retired but continues to participate in shot put, javelin, and the hammer throw which exacerbates her pain. She had decreased range of motion with pain in abduction, internal rotation, and flexion. Orthopedic testing revealed pain with supraspinatus press test. Neurological and physical examination was negative.
Fig 1: Normal diagnostic ultrasonography of the rotator cuff. A- Longitudinal view which compares to the coronal magnetic resonance imaging (MRI) perspective. B- Transverse view which compares to the sagittal MRI perspective.
Fig 2: A- Coronal T2 fat saturated MRI depicting a full thickness tear of the supraspinatus (arrows). There is also evidence of a joint effusion (arrowhead). B- Longitudinal diagnostic ultrasound in the same patient showing the focal tear of the supraspinatus.
Fig 3: A- Sagittal T2 fat saturated MRI demonstrating a full thickness tear of the supraspinatus tendon with partial thickness tearing as well. B- Transverse diagnostic ultrasound in the same patient showing the focal tearing of the supraspinatus.
Legend: Arrows all point to the area of tearing in the supraspinatus tendon
* – Biceps tendon (long head)
GT- Greater tuberosity
SST- Supraspinatus tendon
IST- Infraspinatus tendon
The shoulder is the most movable joint in the body and prone to dysfunction and injury. Rotator cuff tears are the most common cause of shoulder pain and dysfunction in adults. They are commonly related to overuse and degeneration within the tendon. In patients over 66 years old who present with a symptomatic rotator cuff tear, 50% of those patients will have an asymptomatic tear on the contralateral side as well.
Rotator cuff tears can be categorized into partial or complete (full thickness). A complete tear extends through the entire thickness of the tendon and creates a communication between the subacromial space and the glenohumeral joint. This will allow fluid to be visualized superficial to the cuff tendons at the greater tuberosity and can be helpful when determining if a tear is partial or full thickness. A complete tear may allow retraction of the tendon and could create a wavy appearance to the tendon called the “cuff wave sign.” If this is present, it is associated with easier reattachment of the tissue on surgical repair .
Partial thickness tears are divided into articular sided, bursal sided or intrasubstance. They are twice as common as complete tears. Articular sided are adjacent to the humeral cartilage while bursal sides are adjacent to the subacromial bursa. Intrasubstance tears are within the center of the tendon. Bursal sided and intrasubstance tears may be hidden during arthroscopic examination therefore imaging evaluation is important for accurate diagnosis .
In this case presentation, the coronal MRI depicts fluid (high/white signal) filling the region of the anterior rotator cuff where tendon should be visualized (Fig 2a- arrow). The corresponding longitudinal ultrasound image depicts the fluid within the rotator cuff as black region known as hypoechogenicity (Fig 2b-arrow). The normal appearance of the rotator cuff is demonstrated in figure 1a without focal areas of hypoechogenicity to indicate tearing.
The sagittal MRI demonstrates fluid communicating between the glenohumeral joint and the subacromial space through a focal fluid filled rotator cuff tear within the supraspinatus tendon (Fig 3a). Note the proximity to the biceps tendon (*). The correlating transverse ultrasound image depicts the focal fluid collection as the focal hypoechogenicity within the tendon also near the biceps tendon (Fig 3b). A normal transverse ultrasound image is provided for comparison (Fig 1b).
The sensitivity of diagnostic ultrasound for full thickness rotator cuff tears is equal to MRI (>90%). The sensitivity of MRI and ultrasound for partial thickness tears is equivalent (67-68%) but an MRI arthrogram where contrast is injected into the joint is the most sensitive (83%). The specificity of MRI and ultrasound for full thickness and partial thickness tears is >93%. Musculoskeletal ultrasound allows the examiner to perform dynamic maneuvers such as orthopedic tests while imaging the anatomy which is very beneficial to help localize abnormalities .
Diagnostic musculoskeletal ultrasonography is a growing diagnostic tool that is cost effective and noninvasive. It is user dependent and requires significant training but can be very useful as an imaging modality when utilized appropriately.
Case courtesy of Logan University
- Stoller, D.:Rotator cuff Tears, Microinstability, Rotator Interval/Biceps Pulley, and the Throwing Shoulder. In Stoller’s Orthopaedics and Sports Medicine: The Shoulder. Wolters Kluwer. Philadelphia, PA; 2015: 237-471
- Roy J-S, et al.: Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterization of rotator cuff disorders: a systematic review and meta-analysis. British Journal of Sports Medicine. 2015, 49:1316-1328