CASE 1585 Published on 11.11.2002

Calcific tendonitis: diagnosis and therapeutic intervention

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

Petrovska T, Chartampilas E, Kirimlidis I, Felix T Monga , Vougiouklis N.

Patient

34 years, female

Categories

No Area of Interest ; Imaging Technique Ultrasound, Ultrasound, Ultrasound, Ultrasound

No Procedure ; No Special Focus ;

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Clinical History

The patient was referred with severe shoulder pain of 1 month's duration.

Imaging Findings

The patient was referred with severe shoulder pain of 1 month's duration.

Discussion

Calcifying tendonitis of the rotator cuff (RC) of the shoulder is a clinical entity characterized by calcifications situated in the tendons of the supraspinatus, infraspinatus, subscapularis muscles tendons and the long bicepts tendon. Calcifying tendonitis is also observed in other anatomic areas such as the triangular tendon insertion of the Achilles and the tricepts tendons. The main reason of the deposits of calcium is probably poor blood supply, microtrauma or inflammation. The disease presents with dense calcification (stage I) which in the next stage liquefies (stage II) and later evolutes to adhesive periarthritis (stage III). Intratendinous calcification can penetrate into subacromio-subdeltoid bursa through a RC tear after small trauma or effort and then cause chemical bursitis which is very painful. However calcifying tendonitis may be asymptomatic in 1/3 of cases while this disorder is rarely combined with RC tears. Sonographic appearance of calcifying tendonitis varies from nearly normal (when calcifications are not so dense), to markedly echogenic (when the concentration of calcium has solidified). In the later condition presents as round or curvilinear high level echoes with posterior acustic shadowing. Inhomogeneity is another presentation, when the milk of calcium “peppers “the tendon. The soft form of calcification has the appearance of fibrofaty tissue which is created after tendon tear. In this case correlation with x-ray is needed. This is a significant problem since RC tear is a common entity and may be asymptomatic. In a study performed by Milgrom et al the percentage of asymptomatic tears between age 50-59 and 50-69 was 33% and 55% respectively. The orthopedic’s surgeon preferred treatment is arthroscopic removal of the calcified material. Under ultrasonographic guidance the puncture of the calcifications, although it is painful, is easily achieved and when their aspiration is feasible (slurry calcifications) many patients experience immediate relief of the pain. In other cases lavage or crushing with needles may alleviate the symptoms.

Differential Diagnosis List

Calcific tendonitis

Final Diagnosis

Calcific tendonitis

References

[1] Milgrom C, Schaffler M, Gilbert S, Van Holsbeeck. MT Rotator cuff changes in asymptomatic adults: Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender.
J Bone Joint Surg Br. 1995;77(2):296-8. (PMID: 7706351)

[2] Farin PU, Rasanen H, Jaroma H, Harju A .Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage.
Skeletal Radiol. 1996; 25(6):551-4. (PMID: 8865489)

[3] J.Antonio Bouffard, Sung-Moon Lee and Jag Dhanju: Ultrasonography of the shoulder
Semin Ultrasound CT MR. 2000; 21(3):164-91. (PMID: 10994687)

[4] Welfling J,Kahn MF,Desroy M,Paolaggi JB,de Sege S.Calcifications of the shoulder. II. The disease of multiple tendinous calcifications.
Rev Rhum Mal Osteoartic. 1965; 32(6):325-34. (PMID: 5843171)

Case information

URL:	https://www.eurorad.org/case/1585
DOI:	10.1594/EURORAD/CASE.1585
ISSN:	1563-4086

Figure 1

X-ray of shoulder with internal rotation, demonstrating calcification

X-ray of the shoulder with internal rotation, demonstrating calcification(arrow) projecting over the humerus head in the area of the rotator cuff.

Figure 2

Tranverse section of the subspinatus tendon

Transverse view taken with the patient´s arm in full internal rotation. The calcification (C) with prominent acoustic shadow is depicted in the lateral segment of the RC, the infraspinatus tendon. The subdeltoid bursa is the subtle hypoechoic line between the echogenic fat (arrow). D:deltoid, H:humerus

Figure 3

Sagittal section of the subspinatus tendon

Longitudinal section of the infraspinatus with the patient´s arm in full internal rotation. The calcification (arrow) is situated underneath the fat surrounding the subdeltoid bursa (stars). The highly reflective structure impedes the visualization of the proximal critical area of the tendon(t).

Figure 4

external rotation, demonstrating the evolution of the calcification