56-year-old male with right shoulder pain. The patient recently experienced radiating symptoms into the entire arm, which improved as compensatory muscle tension in the neck, cervical, and shoulder region decreased. Clinically, the shoulder feels stiff, especially in external rotation and abduction.
Ultrasound examination demonstrates a relatively large, soft type 3 calcification at the transition zone between the supraspinatus and infraspinatus tendons. The calcification appears clinically relevant, as it becomes compressed during ultrasound-guided active shoulder movement and reproduces the patient’s recognizable shoulder pain.
Clinically, there is passive restriction of shoulder motion, particularly in external rotation and abduction. The limitation is present but relatively mild for a pronounced frozen shoulder.
The patient recently reported radiating symptoms into the entire arm. Based on the clinical course, these symptoms are more likely secondary to compensatory muscle tension in the shoulder, neck, and cervical region than to a primary local arm abnormality visible on ultrasound. The patient showed an antalgic movement and posture pattern. As relaxation of the neck, cervical, and shoulder region improved over the following days, the radiating arm symptoms decreased.
The overall sonographic and clinical picture suggests multiple interacting components: symptomatic calcific rotator cuff tendinopathy, a mild or early capsular component compatible with adhesive capsulitis, and transient referred arm symptoms related to compensatory muscle tension and antalgic movement behavior.
1. Final diagnosis
Symptomatic calcific rotator cuff tendinopathy with a larger soft type 3 calcification at the supraspinatus-infraspinatus transition. Dynamic ultrasound reproduces the patient’s recognizable pain during active movement, supporting the clinical relevance of the calcification. There is also clinical suspicion of mild or early adhesive capsulitis, based on passive restriction of external rotation and abduction, although the limitation is relatively mild and the diagnosis cannot be made with full certainty.
2. Differential diagnosis
The primary differential diagnosis is symptomatic calcific rotator cuff tendinopathy with mechanical or chemical pain provocation during active shoulder movement. Mild or early adhesive capsulitis should also be considered because of the passive limitation in external rotation and abduction. A combination of both conditions is possible: calcific tendinopathy may cause pain and protective movement limitation, while capsular pathology typically causes passive restriction. The transient arm radiation may represent referred pain or increased muscle tension from the neck, cervical, and shoulder region. Primary peripheral nerve compression is currently less likely, given improvement after reduction of compensatory tension, but cervical radicular irritation or peripheral nerve involvement should be reconsidered if neurological symptoms recur or progress.
3. Teaching points
Dynamic ultrasound can help determine whether a calcification is clinically relevant by assessing pain reproduction during active movement and compression. Soft type 3 calcifications may be more amenable to ultrasound-guided needling or barbotage than dense calcifications, but treatment response is variable. Passive restriction of external rotation and abduction should raise suspicion for adhesive capsulitis, even when the limitation is mild. Radiating arm symptoms are not always caused by nerve compression; they may also occur secondary to antalgic posture, increased cervical or shoulder girdle muscle tension, and altered movement behavior.
4. Injury/disease information
Calcific rotator cuff tendinopathy is characterized by calcium deposition within or around the rotator cuff tendons and can cause acute or chronic shoulder pain, especially when the deposit is mechanically compressed or chemically irritating. Adhesive capsulitis, or frozen shoulder, is a capsular disorder causing painful passive restriction, typically most evident in external rotation. When both conditions may coexist, diagnostic uncertainty can be addressed with targeted ultrasound-guided intervention. An intra-articular glenohumeral injection may help confirm and treat a capsular pain component, while ultrasound-guided barbotage or needling may be considered when the calcification remains the dominant pain generator.
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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