67-year-old female with longstanding right shoulder pain radiating through the upper arm toward the elbow. Pain intensity is VAS 7. Abduction is the most provocative movement. Symptoms cause substantial limitations in activities of daily living, dancing, and occupational participation.
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 scapular musculature.
The supraspinatus tendon demonstrates sonographic features of tendinopathy. Within the posterior portion of the tendon, a type 2–3 calcific deposit is present.
During active shoulder abduction, dynamic ultrasound demonstrates mechanical contact between the calcific deposit and the acromion. At the precise moment of contact, the patient reports a characteristic sharp pain that reproduces the recognizable shoulder symptoms.
The acromioclavicular joint demonstrates degenerative changes. The joint capsule is thickened, with associated intra- and periarticular fluid. Based on the sonographic appearance alone, the clinical relevance of the AC-joint abnormalities cannot be determined with certainty.
1. Final diagnosis
Calcific tendinopathy of the posterior supraspinatus tendon with dynamically demonstrated subacromial mechanical impingement during active abduction. Reproduction of the patient’s characteristic pain at the exact moment of contact between the calcific deposit and the acromion provides strong clinical-sonographic correlation and makes this the most likely primary pain generator. Associated degenerative AC-joint changes with capsular thickening and fluid are present, although their symptomatic relevance remains uncertain.
2. Differential diagnosis
Symptomatic calcific supraspinatus tendinopathy with dynamic subacromial impingement is the primary consideration. Symptomatic AC-joint arthropathy may represent an additional pain source, but degenerative sonographic changes of the AC joint alone are insufficient to establish clinical significance.
3. Teaching points
Dynamic ultrasound can provide important functional information beyond static tendon morphology. Direct visualization of contact between a calcific deposit and the acromion, particularly when the patient’s characteristic pain is simultaneously reproduced, substantially strengthens the likelihood that the observed calcification is clinically relevant. In contrast, degenerative AC-joint changes are common and should not automatically be interpreted as symptomatic without appropriate clinical correlation or diagnostic testing.
4. Injury/disease information
Calcific tendinopathy of the rotator cuff is characterized by calcium deposition within a tendon, most commonly the supraspinatus. Symptoms may arise from local tendon irritation, associated subacromial inflammation, or mechanical conflict during shoulder elevation. Initial management generally consists of graded exercise therapy aimed at restoring rotator cuff and scapular function. If pain prevents effective rehabilitation, an ultrasound-guided subacromial corticosteroid and local anesthetic injection may be considered to facilitate active therapy. If uncertainty remains regarding the contribution of the AC joint, an ultrasound-guided diagnostic intra-articular local anesthetic injection may help determine whether it represents a relevant pain source. Persistent symptomatic calcific tendinopathy despite adequate conservative treatment may be considered for ultrasound-guided needling and lavage.
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.
More Cases from Marc Schmitz
