Shoulder disorders are very common in clinical practice. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process with different/possible patterns of migration. In this paper, we have illustrated how and where these calcium depositions can migrate from the rotator cuff tendons to the peri-articular soft tissues. We have also tried to discuss the issue from the clinical side, i.e., how these particular conditions might impact the specific diagnosis, appropriate rehabilitation plan or interventional approach for optimal functional recovery.

Department of Physical and Rehabilitation Medicine Hacettepe University Medical School 06100 Ankara Turkey

Department of Physical Medicine and Rehabilitation National Taiwan University Hospital Bei Hu Branch Taipei 10845 Taiwan

Department of Rehabilitation Medicine 1st Faculty of Medicine and General University Hospital Charles University 12800 Prague Czech Republic

Physical and Rehabilitation Medicine Unit Luigi Sacco University Hospital ASST Fatebenefratelli Sacco 20157 Milan Italy

See more in PubMed

Özçakar L., Çarl A.B., Tok F., Tekin L., Akkaya N., Kara M. The utility of musculoskeletal ultrasound in rehabilitation settings. Am. J. Phys. Med. Rehabil. 2013;92:805–817. doi: 10.1097/PHM.0b013e3182971269. PubMed DOI

Bianchi S., Becciolini M. Ultrasound appearance of the migration of tendon calcifications. J. Ultrasound Med. 2019;38:2493–2506. doi: 10.1002/jum.14933. PubMed DOI

Ricci V., Özçakar L. Life after ultrasound: Are we speaking the same (or a new) language in physical and rehabilitation medicine? J. Rehabil. Med. 2019;51:234–235. doi: 10.2340/16501977-2527. PubMed DOI

Uhthoff H., Sarkar K. Calcifying tendinitis. Baillieres Clin. Rheumatol. 1989;3:567–581. doi: 10.1016/S0950-3579(89)80009-3. PubMed DOI

Uhthoff H.K., Loehr J.W. Calcific tendinopathy of the rotator cuff: Pathogenesis, diagnosis, and management. J. Am. Acad. Orthop. Surg. 1997;5:183–191. doi: 10.5435/00124635-199707000-00001. PubMed DOI

Cocco G., Ricci V., Boccatonda A., Iannetti G., Schiavone C. Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: Ultrasound image and treatment. J. Ultrasound. 2018;21:351–354. doi: 10.1007/s40477-018-0336-z. PubMed DOI PMC

Merolla G., Bhat M.G., Paladini P., Porcellini G. Complications of calcific tendinitis of the shoulder: A concise review. J. Orthop. Traumatol. 2015;16:175–183. doi: 10.1007/s10195-015-0339-x. PubMed DOI PMC

Guillin R., Marchand A.J., Roux A., Niederberger E., Duvauferrier R. Imaging of snapping phenomena. Br. J. Radiol. 2012;85:1343–1353. doi: 10.1259/bjr/52009417. PubMed DOI PMC

Akkaya N., Akkaya S., Gungor H.R., Yaşar G., Atalay N.S., Sahin F. Effects of weighted and un-weighted pendulum exercises on ultrasonographic acromiohumeral distance in patients with subacromial impingement syndrome. J. Back Musculoskelet. Rehabil. 2017;30:221–228. doi: 10.3233/BMR-160737. PubMed DOI

Tate A.R., McClure P.W., Young I.A., Salvatori R., Michener L.A. Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: A case series. J. Orthop. Sports Phys. Ther. 2010;40:474–493. doi: 10.2519/jospt.2010.3223. PubMed DOI

Mira R.M., Molinari Tosatti L., Sacco M., Scano A. Detailed characterization of physiological EMG activations and directional tuning of upper-limb and trunk muscles in point-to-point reaching movements. Curr. Res. Physiol. 2021;4:60–72. doi: 10.1016/j.crphys.2021.02.005. PubMed DOI PMC

Ricci V., Galletti S., Chang K., Özçakar L. Ultrasound imaging and guidance in the management of adhesive bursopathy of the shoulder: A video demonstration. J. Ultrasound Med. 2020;39:633–635. doi: 10.1002/jum.15117. PubMed DOI

Ricci V., Mezian K., Naňka O., Özçakar L. Assessing/imaging the subcoracoid space: From anatomy to dynamic sonography. J. Ultrasound Med. 2022;41:2149–2155. doi: 10.1002/jum.15898. PubMed DOI

Klontzas M.E., Vassalou E.E., Zibis A.H., Karantanas A.H. The effect of injection volume on long-term outcomes of US-guided subacromial bursa injections. Eur. J. Radiol. 2020;129:109113. doi: 10.1016/j.ejrad.2020.109113. PubMed DOI

Machida A., Sugamoto K., Miyamoto T., Inui H., Watanabe T., Yoshikawa H. Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tearsPressure measurements in 18 patients. Acta Orthop. Scand. 2004;75:109–113. doi: 10.1080/00016470410001708220. PubMed DOI

Chou W.-Y., Wang C.-J., Wu K.-T., Yang Y.-J., Ko J.-Y., Siu K.-K. Prognostic factors for the outcome of extracorporeal shockwave therapy for calcific tendinitis of the shoulder. Bone Jt. J. 2017;99-B:1643–1650. doi: 10.1302/0301-620X.99B12.BJJ-2016-1178.R1. PubMed DOI

Chiou H.-J., Chou Y.-H., Wu J.-J., Huang T.-F., Ma H.-L., Hsu C.-C., Chang C.-Y. The role of high-resolution ultrasonography in management of calcific tendonitis of the rotator cuff. Ultrasound Med. Biol. 2001;27:735–743. doi: 10.1016/S0301-5629(01)00353-2. PubMed DOI

Chiou H.-J., Chou Y.-H., Wu J.-J., Hsu C.-C., Huang D.-Y., Chang C.-Y. Evaluation of calcific tendonitis of the rotator cuff: Role of color Doppler ultrasonography. J. Ultrasound Med. 2002;21:289–295. doi: 10.7863/jum.2002.21.3.289. PubMed DOI

Uhthoff H.K., Sarkar K., Maynard J.A. Calcifying tendinitis: A new concept of its pathogenesis. Clin. Orthop. Relat. Res. 1976;118:164–168. doi: 10.1097/00003086-197607000-00030. PubMed DOI

Draghi F., Scudeller L., Draghi A.G., Bortolotto C. Prevalence of subacromial-subdeltoid bursitis in shoulder pain: An ultrasonographic study. J. Ultrasound. 2015;18:151–158. doi: 10.1007/s40477-015-0167-0. PubMed DOI PMC

Darrieutort-Laffite C., Blanchard F., Le Goff B. Calcific tendonitis of the rotator cuff: From formation to resorption. Jt. Bone Spine. 2018;85:687–692. doi: 10.1016/j.jbspin.2017.10.004. PubMed DOI

Greenberg D.L. Evaluation and treatment of shoulder pain. Med. Clin. N. Am. 2014;98:487–504. doi: 10.1016/j.mcna.2014.01.016. PubMed DOI

Ricci V., Chang K.-V., Güvener O., Mezian K., Kara M., Leblebicioğlu G., Stecco C., Pirri C., Ata A.M., Dughbaj M., et al. EURO-MUSCULUS/USPRM dynamic ultrasound protocols for shoulder. Am. J. Phys. Med. Rehabil. 2021;101:e29–e36. doi: 10.1097/PHM.0000000000001833. PubMed DOI

de Witte P.B., Kolk A., Overes F., Nelissen R.G., Reijnierse M. Rotator cuff calcific tendinitis: Ultrasound-guided needling and lavage versus subacromial corticosteroids: Five-year outcomes of a randomized controlled trial. Am. J. Sports Med. 2017;45:3305–3314. doi: 10.1177/0363546517721686. PubMed DOI

Messina C., Sconfienza L.M. Ultrasound-guided percutaneous irrigation of calcific tendinopathy. Semin. Musculoskelet. Radiol. 2016;20:409–413. doi: 10.1055/s-0036-1594285. PubMed DOI

Messina C., Banfi G., Orlandi D., Lacelli F., Serafini G., Mauri G., Secchi F., Silvestri E., Sconfienza L.M. Ultrasound-guided interventional procedures around the shoulder. Br. J. Radiol. 2016;89:20150372. doi: 10.1259/bjr.20150372. PubMed DOI PMC

Orlandi D., Mauri G., Lacelli F., Corazza A., Messina C., Silvestri E., Serafini G., Sconfienza L.M. Rotator cuff calcific tendinopathy: Randomized comparison of US-guided percutaneous treatments by using one or two needles. Radiology. 2017;285:518–527. doi: 10.1148/radiol.2017162888. PubMed DOI

Mitchell M.J., Causey G., Berthoty D.P., Sartoris D.J., Resnick D. Peribursal fat plane of the shoulder: Anatomic study and clinical experience. Radiology. 1988;168:699–704. doi: 10.1148/radiology.168.3.3406399. PubMed DOI

Järvinen M., Józsa L., Kannus P., Järvinen T.L.N., Kvist M., Leadbetter W. Histopathological findings in chronic tendon disorders. Scand. J. Med. Sci. Sports. 1997;7:86–95. doi: 10.1111/j.1600-0838.1997.tb00124.x. PubMed DOI

Moseley H.F. The natural history and clinical syndromes produced by calcified deposits in the rotator cuff. Surg. Clin. N. Am. 1963;43:1489–1493. doi: 10.1016/S0039-6109(16)37133-X. PubMed DOI

Merolla G., Singh S., Paladini P., Porcellini G. Calcific tendinitis of the rotator cuff: State of the art in diagnosis and treatment. J. Orthop. Traumatol. 2016;17:7–14. doi: 10.1007/s10195-015-0367-6. PubMed DOI PMC

Stella S.M., Gualtierotti R., Ciampi B., Trentanni C., Sconfienza L.M., Del Chiaro A., Pacini P., Miccoli M., Galletti S. Ultrasound features of adhesive capsulitis. Rheumatol. Ther. 2022;9:481–495. doi: 10.1007/s40744-021-00413-w. PubMed DOI PMC

Ecalle A., Julien C., Chaouche S., Cungi P.-J., Anger F., Galland A., Gravier R., Airaudi S. Is routine gleno-humeral exploration a risk factor for adhesive capsulitis after arthroscopic removal of rotator cuff calcifications? A comparative retrospective study in 340 cases. Orthop. Traumatol. Surg. Res. 2021;107:102915. doi: 10.1016/j.otsr.2021.102915. PubMed DOI

Lee J.C., Sykes C., Saifuddin A., Connell D. Adhesive capsulitis: Sonographic changes in the rotator cuff interval with arthroscopic correlation. Skelet. Radiol. 2005;34:522–527. doi: 10.1007/s00256-005-0957-0. PubMed DOI

Tamborrini G., Möller I., Bong D., Miguel M., Marx C., Müller A.M., Müller-Gerbl M. The rotator interval—A link between anatomy and ultrasound. Ultrasound Int. Open. 2017;03:E107–E116. doi: 10.1055/s-0043-110473. PubMed DOI PMC

Carbone S., Napoli A., Gumina S. MRI of adhesive capsulitis of the shoulder: Distension of the bursa in the superior subscapularis recess is a suggestive sign of the pathology. Eur. J. Radiol. 2014;83:345–348. doi: 10.1016/j.ejrad.2013.10.017. PubMed DOI

Ricci V., Özçakar L. Looking into the joint when it is frozen: A report on dynamic shoulder ultrasound. J. Back Musculoskelet. Rehabil. 2019;32:663–665. doi: 10.3233/BMR-181448. PubMed DOI

Fields B.K.K., Skalski M.R., Patel D.B., White E.A., Tomasian A., Gross J.S., Matcuk G.R. Adhesive capsulitis: Review of imaging findings, pathophysiology, clinical presentation, and treatment options. Skelet. Radiol. 2019;48:1171–1184. doi: 10.1007/s00256-018-3139-6. PubMed DOI

Catapano M., Mittal N., Adamich J., Kumbhare D., Sangha H. Hydrodilatation with corticosteroid for the treatment of adhesive capsulitis: A systematic review. PM&R. 2018;10:623–635. doi: 10.1016/j.pmrj.2017.10.013. PubMed DOI

Wang J.-C., Tsai P.-Y., Hsu P.-C., Huang J.-R., Wang K.A., Chou C.-L., Chang K.-V. Ultrasound-guided hydrodilatation with triamcinolone acetonide for adhesive capsulitis: A randomized controlled trial comparing the posterior glenohumeral recess and the rotator cuff interval approaches. Front. Pharmacol. 2021;12:686139. doi: 10.3389/fphar.2021.686139. PubMed DOI PMC

Wang J.-C., Chang K.-V., Wu W.-T., Han D.-S., Özçakar L. Ultrasound-guided standard vs dual-target subacromial corticosteroid injections for shoulder impingement syndrome: A randomized controlled trial. Arch. Phys. Med. Rehabil. 2019;100:2119–2128. doi: 10.1016/j.apmr.2019.04.016. PubMed DOI

Ricci V., Chang K., Özçakar L. Ultrasound-guided hydrodilatation of the shoulder capsule at the rotator interval: Technical tips and tricks. Pain Pract. 2020;20:948–949. doi: 10.1111/papr.12920. PubMed DOI

Noten S., Meeus M., Stassijns G., Van Glabbeek F., Verborgt O., Struyf F. Efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: A systematic review. Arch. Phys. Med. Rehabil. 2016;97:815–825. doi: 10.1016/j.apmr.2015.07.025. PubMed DOI

Mertens M.G., Meert L., Struyf F., Schwank A., Meeus M. Exercise therapy is effective for improvement in range of motion, function, and pain in patients with frozen shoulder: A systematic review and meta-analysis. Arch. Phys. Med. Rehabil. 2022;103:998–1012.e14. doi: 10.1016/j.apmr.2021.07.806. PubMed DOI

Candela V., Giannicola G., Passaretti D., Venditto T., Gumina S. Adhesive capsulitis of the shoulder: Pain intensity and distribution. Musculoskelet. Surg. 2017;101((Suppl. S2)):153–158. doi: 10.1007/s12306-017-0488-6. PubMed DOI

Hsu P.-C., Chang K.-V., Mezian K., Naňka O., Wu W.-T., Yang Y.-C., Meng S., Ricci V., Özçakar L. Sonographic pearls for imaging the brachial plexus and its pathologies. Diagnostics. 2020;10:324. doi: 10.3390/diagnostics10050324. PubMed DOI PMC

Chang K.-V., Hung C.-Y., Wu W.-T., Han D.-S., Yang R.-S., Lin C.-P. Comparison of the effectiveness of suprascapular nerve block with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: A meta-analysis of randomized controlled trials. Arch. Phys. Med. Rehabil. 2016;97:1366–1380. doi: 10.1016/j.apmr.2015.11.009. PubMed DOI