44-year-old patient presenting with shoulder pain during abduction and overhead activities. Symptoms likely progressive and activity-related.
Ultrasound examination of the shoulder demonstrates a large type 3 (soft) calcification within the supraspinatus tendon at its insertion on the greater tuberosity (tuberculum majus) and extending toward the anatomical neck. The calcification measures approximately 22.6 × 9.4 mm.
The supraspinatus tendon shows moderate tendinopathy, characterized by thickening, reduced echogenicity, and loss of the normal fibrillar architecture.
There is mild distension of the subacromial-subdeltoid (SASD) bursa, consistent with mild bursitis.
The combined effect of tendon thickening, calcification, and bursal swelling results in an increased thickness of the supraspinatus–bursa complex measuring approximately 8.7 mm (reference range 5–7 mm).
During dynamic ultrasound with guided active abduction, there is clear subacromial impingement, with mechanical compression of the supraspinatus tendon and SASD bursa against the acromion.
1. Final diagnosis
Subacromial pain syndrome due to calcific supraspinatus tendinopathy (type 3 calcification), with associated SASD bursitis and dynamic subacromial impingement.
2. Differential diagnosis
Consider non-calcific tendinopathy with secondary bursitis, or early rotator cuff tear if visualization is limited. However, the calcification is the dominant feature.
3. Teaching points
Type 3 (soft) calcifications are often symptomatic and may be associated with inflammatory changes and bursitis. Increased thickness of the supraspinatus–bursa complex contributes to mechanical impingement. Dynamic ultrasound is essential to demonstrate functional subacromial impingement.
4. Injury/disease information
Calcific tendinopathy is characterized by calcium deposition within the tendon, often in the supraspinatus. The resorptive (soft) phase is typically painful and may be associated with bursitis. Mechanical impingement can occur due to increased tendon volume, contributing to symptoms.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at the Laurentius Hospital in Roermond, the Netherlands.
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