45-year-old male patient with shoulder pain for approximately 5 months. Symptoms correlate with pain and reduced strength, especially during abduction movements, including physical work and sports activities. Ultrasound examination was performed in the context of suspected subacromial pain syndrome.
Ultrasound examination of the shoulder demonstrates marked calcific tendinopathy of the supraspinatus tendon. Multiple calcifications are present, including type 2 and type 3 calcific deposits.
The calcifications appear clinically relevant. During dynamic ultrasound examination with active abduction, the patient’s pain is reproduced when the supraspinatus tendon containing the calcific deposits moves into the subacromial space. Crepitus is also observed during this movement.
There is thickening of the supraspinatus/subacromial-subdeltoid bursal complex, measuring approximately 8.8 mm. This exceeds the stated reference range of 5–7 mm and is likely related to a combination of tendon swelling, calcific deposits, and reactive bursal involvement.
Dynamic assessment demonstrates findings consistent with subacromial impingement. The imaging findings correlate well with the clinical presentation of pain and reduced strength during abduction, particularly during physical labor and sports-related shoulder loading.
In the given clinical context, barbotage of the calcific deposits combined with an ultrasound-guided subacromial-subdeltoid bursal injection may be considered according to local guideline-based practice, especially given the persistence of symptoms for approximately 5 months.
1. Final diagnosis
Findings are consistent with marked calcific tendinopathy of the supraspinatus tendon, associated with thickening of the subacromial compartment and dynamic subacromial impingement. The calcifications are clinically relevant, as pain is reproduced during active abduction when the calcific supraspinatus tendon enters the subacromial space.
2. Differential diagnosis
The differential diagnosis includes subacromial pain syndrome due to calcific supraspinatus tendinopathy, reactive subacromial-subdeltoid bursopathy, rotator cuff tendinopathy without calcification, and mechanical subacromial impingement. The dynamic pain reproduction and visible calcific deposits make calcific supraspinatus tendinopathy the leading diagnosis.
3. Teaching points
Calcific deposits in the supraspinatus tendon are not always symptomatic; dynamic ultrasound is useful to assess whether the deposits mechanically contribute to subacromial pain. Pain reproduction during active abduction, especially when the calcific portion of the tendon enters the subacromial space, supports clinical relevance. Thickening of the SASD bursal complex may reflect reactive bursopathy, tendon swelling, or increased subacromial compartment volume caused by calcifications.
4. Injury/disease information
Calcific tendinopathy of the rotator cuff is characterized by calcium deposition within the tendon, most commonly involving the supraspinatus tendon. It may cause pain, reduced range of motion, weakness, and subacromial irritation. In symptomatic cases with persistent complaints, ultrasound-guided barbotage and/or SASD bursal injection may be considered to reduce pain and help the patient progress through the symptomatic phase.
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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