56-year-old patient presenting with shoulder pain, likely aggravated by rotational movements and overhead activity.
Ultrasound examination of the shoulder demonstrates a large type 3 (soft) calcification within the subscapularis tendon at its insertion on the tuberculum minus, measuring approximately 12.5 × 7.3 mm.
During dynamic assessment in internal rotation, there appears to be mild subcoracoid friction, likely due to a reduced coracohumeral distance and increased tendon volume from the calcification.
The supraspinatus tendon shows moderate tendinopathy, with thickening and altered echotexture.
Additionally, a small articular-sided partial-thickness tear is present at the level of the anatomical neck (collum anatomicum). This finding correlates with a focal cortical irregularity at the insertion site.
The acromioclavicular (AC) joint demonstrates joint space narrowing and cortical irregularity, consistent with degenerative changes.
1. Final diagnosis
Calcific subscapularis tendinopathy (type 3) with dynamic subcoracoid impingement, associated with supraspinatus tendinopathy and a small articular-sided partial tear, and AC joint osteoarthritis.
2. Differential diagnosis
Consider isolated calcific tendinopathy versus combined rotator cuff pathology. Subcoracoid impingement may also be influenced by anatomical variation.
3. Teaching points
Calcifications in the subscapularis tendon can contribute to subcoracoid impingement, particularly during internal rotation. Articular-sided supraspinatus tears often correlate with cortical irregularities at the insertion. Multistructural involvement is common in degenerative shoulder conditions.
4. Injury/disease information
Calcific tendinopathy involves deposition of calcium within the tendon, often leading to pain and mechanical irritation. When located in the subscapularis, it may reduce the subcoracoid space and cause impingement. Rotator cuff degeneration and AC joint osteoarthritis frequently coexist and contribute to overall shoulder dysfunction.
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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