57-year-old patient with [right/left] shoulder pain, particularly during abduction and overhead activity.
Ultrasound examination of the right shoulder demonstrates a large sharply defined calcification in the region of the supraspinatus tendon. The calcification has a hard appearance, consistent with a type 1 calcific deposit, and measures 11.1 mm in width and 11.8 mm in length.
The calcification is located at the supraspinatus insertion on the greater tuberosity, partly within or immediately adjacent to the supraspinatus tendon. The supraspinatus tendon itself shows features of moderate tendinopathy, with mild thickening up to 7.8 mm compared with an expected reference range of approximately 5–7 mm.
No ultrasound signs of a partial-thickness or full-thickness rotator cuff tear are described.
During active abduction, the calcification appears to make mechanical contact with the acromion. This dynamic finding is compatible with secondary subacromial impingement caused by the prominent calcific deposit.
The acromioclavicular joint shows capsular swelling. However, this finding is symmetrical compared with the asymptomatic contralateral side and is therefore most likely an incidental, clinically non-relevant finding.
1. Final diagnosis
Large calcific supraspinatus tendinopathy with a hard type 1 calcification measuring 11.1 x 11.8 mm at the supraspinatus insertion on the greater tuberosity. Associated moderate supraspinatus tendinopathy is present, with mild tendon thickening.
2. Differential diagnosis
The primary diagnosis is calcific tendinopathy of the supraspinatus tendon. The main differential consideration is mechanical subacromial pain syndrome secondary to the prominent calcification. There are no described ultrasound findings suggesting a rotator cuff tear.
3. Teaching points
Hard type 1 calcifications are typically sharply demarcated and may produce acoustic shadowing. Large calcific deposits at the supraspinatus insertion can cause symptoms not only through tendon irritation, but also through mechanical conflict beneath the acromion during shoulder abduction. Dynamic ultrasound is useful to demonstrate this mechanism.
4. Injury/disease information
Calcific tendinopathy of the rotator cuff is most frequently seen in the supraspinatus tendon. The condition may be asymptomatic or may cause shoulder pain, restricted movement, and painful abduction. Large or prominent deposits can contribute to secondary subacromial impingement, especially when they project toward the subacromial space.
To complete the case, the most useful missing details are: patient age, affected side, duration of symptoms, pain location, aggravating movements, occupation or sports activity, and whether there was prior treatment such as physiotherapy, injection, barbotage, or shockwave therapy.
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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