53-year-old female with approximately nine months of right shoulder pain, varying between VAS 4 and 8/10. Pain is predominantly provoked by abduction, overhead activity, and activities of daily living, with radiation into the upper arm. Exercise therapy is currently difficult to perform adequately because of pain. Associated neck symptoms are also reported.
A complete ultrasound examination of the right shoulder was performed according to the ESSR shoulder protocol. Additional assessment included the rotator interval, including the superior glenohumeral ligament and coracohumeral ligament, with specific attention to the regional musculature.
The supraspinatus tendon is thickened and structurally heterogeneous, consistent with tendinopathy. Within the anterior to middle portion of the supraspinatus tendon, a large type 2 calcific deposit is present.
The subacromial-subdeltoid bursa is thickened and contains an increased amount of fluid, consistent with reactive bursopathy.
During active shoulder abduction, dynamic examination demonstrates anterior mechanical conflict involving the thickened supraspinatus tendon and subacromial-subdeltoid bursa against the coracoacromial ligament.
A small partial-thickness articular-sided tear of the supraspinatus tendon is also present and is considered likely incidental in relation to the dominant clinical and sonographic findings.
The visualized muscles of the shoulder region demonstrate normal anatomical architecture. No sonographic evidence of a posterior shoulder muscle tear is identified.
1. Final diagnosis
Calcific tendinopathy of the supraspinatus tendon with a large type 2 calcific deposit, associated reactive subacromial-subdeltoid bursopathy, and dynamic anterior subacromial mechanical impingement during active abduction. These findings correlate well with the reported pain during abduction and overhead activities. A small partial-thickness articular-sided supraspinatus tear is considered a likely incidental associated finding.
2. Differential diagnosis
If symptoms persist despite appropriate treatment, an additional glenohumeral or other intra-articular pain source should be considered, as these structures are only partly assessable with ultrasound. A cervicogenic or referred pain component should also remain in the differential diagnosis given the reported neck symptoms, particularly if the clinical pain pattern does not fully correspond with the sonographic abnormalities.
3. Teaching points
Calcific supraspinatus tendinopathy may be associated with secondary subacromial-subdeltoid bursal inflammation and dynamic mechanical conflict during shoulder elevation. Dynamic ultrasound is useful because it can directly demonstrate the relationship between the symptomatic tendon, bursa, and coracoacromial arch during provocative movement. Small partial-thickness cuff defects should be interpreted in the context of the dominant imaging abnormality and clinical presentation rather than automatically regarded as the primary pain generator.
4. Injury/disease information
Calcific tendinopathy is characterized by deposition of calcium hydroxyapatite within a rotator cuff tendon, most commonly the supraspinatus. Symptoms may result from the calcific deposit itself, associated tendon inflammation, reactive bursopathy, or secondary mechanical impingement. Initial management is generally conservative and centered on activity modification and progressive exercise therapy. When pain substantially limits rehabilitation, an ultrasound-guided subacromial corticosteroid and local anesthetic injection may be considered to facilitate active rehabilitation. In persistent symptomatic cases with a large calcific deposit, ultrasound-guided needling and lavage may be discussed, taking into account the variable evidence for additional clinical benefit. Further specialist assessment may be appropriate when symptoms remain significant despite an adequate conservative treatment course.
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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