Shoulder pain 1: remember the exceptions
Which findings explain the symptoms? The case of teres minor.
A 21-year-old woman presented with ongoing shoulder pain. She was a high-level competitive swimmer, and found her pain increased during sets, or was a constant, low-level ache. She experienced pain in the left anterior glenohumeral joint region, clinically aggravated by active resisted internal rotation. Ultrasound examination (Philips iU22, L12-5 MHz transducer) of the left shoulder was performed, with the right shoulder also examined for the purpose of comparison.
The examination indicated: Subdeltoid/subacromial bursal fluid may indicate bursitis. Teres minor muscle atrophy. Supraspinatus and subscapularis tendons bilateral mild tendinopathy, likely within the normal range for a competitive swimmer.
Key findings (Figures A-F) included:
“The subdeltoid bursa is prominent and contains a mild amount of fluid in the inferior dependent part. The subacromial bursa has a small pocket of fluid. Comparison with the right side shows similar prominent subdeltoid bursa. No fluid is seen.
The teres minor muscle is reduced size and has diffuse moderate increased echogenicity. Comparison with the right side shows a significant difference (Lt = 181 mm² & Rt = 367 mm² cross sectional area). The tendon is intact.
The supraspinatus and subscapularis tendons are mildly reduced echogenic and have microcystic change. Comparison with the right side shows a similar appearance. The infraspinatus, and the long head biceps tendons are intact and are normal in appearance. The AC joint is normal.”
Figure A: the left sub deltoid bursa, thickened with fluid.
Figure B: the right sub deltoid bursa comparison, also thickened, no fluid.
Figure C: the left supraspinatus tendon, mildly reduced echogenic with microcystic change.
Figure D: the right suprspinatus comparison, mildly reduced echogenic with microcystic change.
Figure E: the left teres minor muscle, reduced size and increased moderate increased echogenicity.
Figure F: the right teres minor muscle comparison, no evidence of change.
Without the benefit of time with the patient and a thorough knowledge of the presentation it is harder to apply these findings in a person-centric way. We’ve given our opinion away in the case title, but with this in mind, how do you think the findings should be ordered to best explain the symptoms as they are presented here?