69-year-old male with left shoulder pain. The clinical relevance of the calcification should be correlated with local tenderness and pain provocation during subacromial loading, abduction, or elevation.
Ultrasound examination of the shoulder demonstrates a large, soft type 3 calcification at the insertion of the supraspinatus tendon. The calcification measures approximately 2.0 × 2.2 cm and is located at the bursal side of the supraspinatus tendon.
The remainder of the ultrasound examination shows no clinically relevant abnormalities. The other scanned structures demonstrate normal anatomical appearance. There is no evidence of rotator cuff tear, long head of biceps tendon pathology, relevant bursitis, active hyperemia, or other structural damage in the examined tissues.
If the patient’s recognizable pain corresponds with local pressure pain or pain provocation during subacromial loading, abduction, or shoulder elevation, this calcification may be clinically relevant.
1. Final diagnosis
Large soft calcific tendinopathy of the supraspinatus tendon insertion, located at the bursal side of the tendon. The rotator cuff is intact, and no other clinically relevant sonographic abnormality is identified.
2. Differential diagnosis
The primary diagnosis is calcific tendinopathy of the supraspinatus tendon, most likely in a softer or resorptive phase given the type 3 appearance. Secondary subacromial irritation may be present if the bursal-sided calcification becomes mechanically compressed during arm elevation. Based on the current ultrasound examination, rotator cuff tear, biceps tendon pathology, relevant bursitis, and AC joint-related pathology are less likely as the primary explanation for the symptoms.
3. Teaching points
Soft type 3 calcifications may appear less sharply defined than dense calcifications and can be symptomatic when located at the bursal side of the supraspinatus tendon. Clinical correlation is essential, as calcifications may be incidental unless they reproduce the patient’s recognizable pain. A normal surrounding rotator cuff, biceps tendon, and bursa helps focus the interpretation on the calcific deposit as the most relevant structural finding.
4. Injury/disease information
Calcific rotator cuff tendinopathy is characterized by calcium deposition within or adjacent to the rotator cuff tendons, most commonly the supraspinatus tendon. Symptoms may arise from chemical irritation, local pressure, or mechanical compression during subacromial movement. When symptoms are functionally limiting and correlate with the calcification, ultrasound-guided barbotage or needling may be considered, particularly for a large soft deposit. If symptoms are mild or do not clearly correlate with the calcification, conservative management with pain-guided loading, avoidance of provocative overhead activity, and exercise therapy focused on scapular control and rotator cuff function may be appropriate.
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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