 Now that we're done with cuff test, let's move on to calcific tendinosis, which is also quite common This is most often a diagnosis made on radiographs However ultrasound helps in identifying the soft calcium, which is not seen on radiographs And there are no rules which tendons are commonly involved or not any tendon can get involved. All right So you need not remember what type of calcification this is But then if you know it's going to really help you in and making certain Decisions when you have to do some interventions. So type one is typically hyperaquic foci With have which have distal shadowing type 2. They are hyperaquic foci with faint shedding So this is typically slurry cuts calcification and Sometimes you might have hyperaquic foci without distal shadowing. So these type 3 calcifications are Commonly missed out on radiographs. So that's where ultrasound is extremely helpful Ultrasound will help you tell which area of the cuff is Involved is it the supraspinatus infraspinatus? Is it only the bicep tendon? And you can tell the surgeon which how far is the calcification from the bicep tendon? And if there's migration of the calcification sometimes the Calcium which is there along the bursal surface of the fibers It can just rupture into the subacromial subdeltoid bursa or in the bicep tendon sheath and it can cause intense pain And of course, you know, it will also Tell you which calc which types of calcium which you can needle or which you can aspirate For instance, it's a type one calcium. These are the calcium which you really cannot aspirate But the type 3 calcium is you can actually just put in a needle and you would be able to aspirate them easily Apart from nearly the most common therapeutic intervention that a radiologist can do is just injection into the subacromial subdeltoid bursa So over here what we see is that, you know, we put in a needle and we infiltrate the subacromial subdeltoid bursa That's all that the patient needs you need to know that it's not the calcium which gives rise to pain But it is the other inflammatory substances which are released by the calcium Which gives to so much of inflammation and pain quite often you might see that you know after an intervention the pain The calcium is still there, but the pain has significantly reduced Another thing as a radiologist what you can do is either ultrasound guided needling or you can do a barbotage So if you look over here on the left, this was intra tenderness soft calcification What we do is we go to the center of the calcium we infiltrate it with saline try to break it up and we can aspirate sometimes Some calcifications can be hard and all that you can do is just do a little bit of needling infiltrate the break the calcium Followed by you can just infiltrate the subacromial subdeltoid bursa and that's it. You're done. Your job is done So this was the patient what on day zero This was a nice thick subscapularis calcification All we did was just needling and we infiltrated into the bursa and on day six the calcium has significantly resolved So the big home points are Ultrasound is awesome for evaluation of pathologies Knowledge of anatomy is a key. You should know all the layers You should know where the supraspinitis ends where the infaspinitis begins. It's really helpful Have a systematic approach in evaluation of the shoulder because this is the only joint which actually requires a systematic approach you should try and get the specific information that the surgeon wants which was going to help him in Decision-making for surgery and of course you should know what kind of US guided interventions that you can do But you should first consult the surgeon and then plan your procedure. Thank you