56-year-old patient presenting with left shoulder pain, likely severe and aggravated by elevation, reaching, side-lying, or overhead activity. Symptoms may be heightened during the resorptive phase of calcific tendinopathy.
Ultrasound examination of the left shoulder was performed according to the ESSR shoulder protocol, including additional assessment of the rotator interval structures such as the superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL).
The supraspinatus tendon demonstrates severe degenerative tendinopathy. The tendon is thickened, hypoechoic, and shows marked loss of normal fibrillar architecture.
There is a type 3 (soft) calcification within the supraspinatus tendon. The calcific material appears to be migrating from the tendon into the subacromial-subdeltoid bursa and into adjacent bone. The deposit has a diffuse “veil-like” appearance through the tendon, compatible with the resorptive phase of calcific tendinopathy.
Mild to moderate neovascularization is identified within the supraspinatus tendon on Doppler imaging. Detection of Doppler signal within the rotator cuff is relatively uncommon due to technical underestimation caused by tendon tension and patient positioning. Therefore, visible intratendinous vascularity likely reflects clinically meaningful inflammatory activity.
Given the increased tendon volume caused by tendinopathy and calcific expansion, secondary subacromial impingement is considered present.
1. Final diagnosis
Severe supraspinatus degenerative tendinopathy with type 3 calcific tendinopathy in the resorptive phase, associated intratendinous hypervascularity, and secondary subacromial impingement.
2. Differential diagnosis
Consider acute calcific bursitis if pain is severe and bursal migration predominates. Partial-thickness cuff tearing may coexist but is not specifically described.
3. Teaching points
The resorptive phase of calcific tendinopathy is often the most painful stage. Type 3 soft calcifications may appear cloud-like or veil-like and can migrate into adjacent bursa. Visible Doppler flow in the rotator cuff tendon may underestimate the true inflammatory burden.
4. Injury/disease information
Calcific tendinopathy is caused by calcium deposition within a tendon, most commonly the supraspinatus. During the resorptive phase, the body attempts to break down the deposit, often triggering intense inflammation and pain. Tendon thickening and bursal irritation can reduce subacromial space and provoke impingement symptoms.
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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