54-year-old patient with shoulder pain. Ultrasound examination was performed to assess the rotator cuff tendons, tendon insertions, cortical surface, and possible associated cuff pathology.
Ultrasound examination of the shoulder demonstrates multiple calcifications at the insertions of several rotator cuff tendons. The subscapularis, supraspinatus, and infraspinatus tendons are involved. The largest calcific deposit is located at the insertion of the subscapularis tendon.
The calcifications are predominantly soft in appearance and are compatible with type 3 calcifications. There is no clear posterior acoustic shadowing. This appearance may correspond to a resorptive or migrating phase of calcific tendinopathy.
Mild cortical irregularity is visible at the sites of the calcific deposits. These cortical changes are most likely reactive and may be related to migration or resorption of the calcifications.
The supraspinatus tendon shows mild tendinopathic change, compatible with a dysrepair phase. A small articular-sided partial tear of the supraspinatus tendon at its insertion on the greater tubercle cannot be excluded with certainty on ultrasound.
1. Final diagnosis
Findings are consistent with multifocal calcific tendinopathy of the rotator cuff insertions, most pronounced in the subscapularis tendon. The predominantly soft calcific appearance without clear acoustic shadowing may fit a resorptive or migrating phase. There is associated mild supraspinatus tendinopathy, and a small articular-sided partial insertional tear of the supraspinatus tendon cannot be excluded.
2. Differential diagnosis
The primary diagnosis is calcific tendinopathy of the rotator cuff, especially involving the subscapularis tendon. Reactive cortical irregularity may be related to calcific migration or resorption. Additional considerations include mild degenerative supraspinatus tendon pathology with possible small articular-sided partial tear, hydroxyapatite deposition with acute inflammatory reaction, enthesopathic degenerative calcifications, or less likely crystal arthropathy, depending on the clinical presentation.
3. Teaching points
Calcific tendinopathy may involve more than one rotator cuff tendon and is not limited to the supraspinatus. Soft calcifications without clear acoustic shadowing may suggest a resorptive or migrating phase and can be clinically painful. The dominant symptomatic deposit should be identified by correlating imaging findings with tendon-specific provocation tests, particularly for the subscapularis and supraspinatus.
4. Injury/disease information
Rotator cuff calcific tendinopathy is characterized by calcium deposition within or near the tendon insertion. It may be asymptomatic or cause pain, restricted motion, and functional limitation, particularly during inflammatory or resorptive phases. Treatment depends on clinical severity and functional impact. Conservative management may include education, load modification, pain-guided exercise therapy, and maintaining shoulder mobility. In persistent or disabling cases, shockwave therapy or ultrasound-guided intervention, such as lavage or barbotage of the dominant symptomatic calcification with possible SASD bursal injection, may be considered. MRI may be useful when there is relevant weakness, traumatic onset, persistent loss of function, or uncertainty about an articular-sided cuff tear.
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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