This patient in their early 30s, attended clinic six weeks after she fell off her bike and she was complaining of left shoulder pain. She landed directly onto her left shoulder without a fall on an outstretched hand. She had been to A&E where x-rays indicated no fracture. Her pain had continued hence her referral. On examination she presented with reduced range to approx 90 degrees abduction and flexion limited by pain, limited lateral rotation. Horizontal adduction slightly uncomfortable end of range. Resisted tests all sore, as per usual, with no distinct weakness.

On ultrasound, there was an effusion present in the long head of biceps, which is a well recognised sign for intra-articular pathology/RC pathology. In light of the patients age and the history of trauma, this initially created suspicions. I then further assessed and encountered the images below on a longitudinal view of the Supraspinatus tendon. The key finding being the disruption of the echogenic line of the cortex (Figure 1).

I subsequently referred the patient for a repeat x-ray , stating my suspicions of a greater tuberosity fracture due to the cortical irregularity. The x-ray report concluded ‘A comminuted fracture of the greater tuberosity with minimal displacement of the fragments’.

Access to diagnostic ultrasound alongside the clinical examination in this case altered this patients management and understanding of their condition. This patient continued to be managed conservatively with Physiotherapy but a definitive diagnosis enabled realistic time frames for recovery .