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Duke University Medical Center Durham, NC 27710
We would like to respond to the article written by Grainger et al. [1], which discusses the association of the presence of a subcoracoid bursa and the findings of a rotator cuff or rotator interval lesion. An article written by my colleagues and I [2] is referenced throughout their article, but our findings were misinterpreted. My collegues and I did not discuss the subcoracoid bursa as an incidental finding, and, in fact, made the point that this can be a source of pain. Additionally, we had several patients with rotator cuff tears and subcoracoid bursa. In only one patient did we conclude that the bursa may have been an incidental finding because no other findings were present on MR imaging to explain her shoulder pain other than a distended subcoracoid bursa. It is possible that the bursitis was the reason for her shoulder pain. The point of our report was not that this bursa may be noted incidentally, but it was to be aware of the potential pitfall in interpretation because of the communication with the subacromial-subdeltoid bursa. A careful evaluation of the rotator cuff should be performed, but a tear may not be present.
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The Freeman Hospital Newcastle upon Tyne, NE7 70N, United Kingdom
I thank Dr. Major for her comments relating to our article [1] discussing the association of a subcoracoid bursa effusion with the findings of a rotator cuff or interval tear. My coauthors and I would agree absolutely that a subcoracoid bursa effusion may be an isolated source of pain. Clearly in the absence of any other finding to account for the patient's pain and in the presence of a subcoracoid effusion, it may be that the effusion is the source of the symptoms. Whether the findings are incidental would be difficult to determine. To evaluate this further, it would be necessary to ascertain the prevalence and size of subcoracoid effusions in a healthy population. Clearly an important issue is how much fluid in the subcoracoid bursa constitutes an abnormal finding, and we concur with the statement in the original article by Schraner and Major [2] that further investigation may allow determination of the amount of fluid that is clinically relevant in this bursa.
Our report [1] emphasizes that we found subcoracoid effusions to be more commonly associated with rotator cuff and interval tears than not. As Major notes in her letter, their study also identified MR imaging findings of a rotator cuff tear in several patients. In all but one of these cases, the tear was associated with large bursae, of a size similar to those in our study. In their article [1], in addition to the one case mentioned in her letter, Schraner and Major report two further patients with small subcoracoid bursae and normal MR imaging and arthroscopy findings.
Our other observations concerning the subcoracoid bursa, including its potential for confusion with the subscapular recess, and the potential for a pitfall in interpretation in cases in which there is communication with the subacromial—subdeltoid bursa, concur with those of Schraner and Major. Although the emphasis of the two articles was slightly different, the concluding messages are similar.
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