Case of the Month: October, 2011, Page 3

Answer: C. Calcific tendinitis.

Findings

  • MRI images demonstrate a 2 cm well circumscribed focus of decreased signal on both T1 and T2 weighted images within the supraspinatus tendon, corresponding to a focus of calcification.  There is marked surrounding edema within the supraspinatus tendon as well as reactive fluid within the subacromial/subdeltoid bursa. Findings are consistent with calcific tendinitis.

Discussion:

  • Calcific tendinitis is an acute or chronically painful condition associated with periarticular deposition of calcium hydroxyapatite within or about tendons.  The exact pathogenesis is unknown. The pain is thought to be due to several factors, including the calcium irritating the surrounding tissues chemically, pressure within the tissue from mass effect, and impingement-like pain from bursal thickening and irritation.
  • The most common site of calcium deposition is within the supraspinatus tendon, approximately 1.5-2 cm proximal to its insertion site on the greater tuberosity of the humerus.  Calcium deposition within shoulder tendons is seen in up to 10% of people over the age of 30, and is more common in women than men.  Most patients with calcium deposition are asymptomatic, and it is thought that pain only occurs when the calcium starts to be resorbed.
  • Two types of calcium deposition are seen on conventional radiographs.  Type I deposits demonstrate a fluffy appearance with ill-defined borders and are usually seen in patients with acute pain.  Type II deposits are well circumscribed and homogeneous in density, and are usually seen in patients with little or no pain.  On MRI, the calcifications appear as areas of decreased signal intensity on both T1 and T2 weighted images.  Areas of edema can be seen around these foci.

Management:

Several nonoperative and operative options are available for the management of acute calcific tendinitis:

  • Needle lavage:  Under ultrasound guidance, a needle is used to help break up the focus of calcification.  Lavage with a local anesthetic such as lidocaine mixed with normal saline and a steroid is also performed to help further break up and remove the calcified material.  This minimally invasive procedure is extremely effective, and is considered the first line of treatment in patients with severe pain from calcific tendinitis.
  • Oral analgesics and physical therapy:  This treatment can be considered if the patient can tolerate the pain with oral analgesics and physical therapy (to prevent “frozen shoulder” caused by the patient keeping their arm to the side due to the pain).
  • Extracorporeal shock wave therapy:  High energy shock wave therapy used predominantly in Europe.  Noninvasive, but lower short and long term success rates than needle lavage.
  • Surgery:  Surgery is indicated for patients that do not respond to non-operative therapy, have progression of their pain, and constant pain that interferes with activities of daily living.

References:

  • Hurt G, Baker CL.  Calcific tendinitis of the shoulder.  Orthop Clin N Am 2003: 34;567-575
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