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Calcific tendinitis

Calcific tendinopathy is a common painful condition characterized by formation of deposits of calcium in one or several rotator cuff tendons

 

One of the most frequent cause of non-traumatic shoulder pain Also known by other names as calcific periarthritis Reported prevalence between 2.7 % – 10.3 % More common in women Age group 30- 50 yrs ( rare in those > 70 ) It can be B/L in about 10 % – 20 % cases
○ some papers report that it is more common in the right shoulder
○ slight preponderance in the dominant shoulder Affected tendons
○ supraspinatus and infraspinatus- most commonly affected
○ rarely affects the teres minor and subscapularis Incidence is not higher in either individuals who do heavy duty work involving the upper limbs or in overhead athletes Association with metabolic disorder ( eg, diabetes ) and autoimmune conditions as rheumatoid arthritis has been noted but not fully elucidated Rotator cuff tear can also be present in about 25 % of those with CT Genetic predisposition.

 

calcific tendinitis can also affect other joints ( for e,g wrist ) / areas in the MSK system rotattor cuff – particularly the supraspinatus tendon is most commonly affected aetiology is unclear – several pathophysiological mechanisms have been proposed CT can be seen in association with shoulder impingement most commonly accepted ones are the degenerative ( similar to degenerative lesions of the RX ) and multiphasic theories ( describing a cell mediated process ) deposition of calcium around the shoulder joint can also be a finding in asymptomatic individuals many individuals with radiographic evidence of CT are asymptomatic

 

presence of calcium hydroxyapatite crystal deposits in RC tendons and in the subacromial bursa deposits can range from 2 – 5 mm and are linear in form more than one tendon can be involved three clinical stages ( may overlap ) have been proposed ( Uhthoff et al )

 

Pre-calcification – pt may be asymptomatic or complain of chronic pain that does not affect the shoulder function. Calcification – further divided into formative and reabsorption phases -severe disabling shoulder pain which may not respond to common analgesic may be seen in this phase formative phase my extend from 1-6 yrs and is usually asymptomatic acute resorptive phase – patient suffers with severe symptoms

Post calcification – Subacute symptoms can manifest as transient intensification of chronic symptoms.

 

Presentation – shoulder pain ( acute or chronic ) is the main presenting symptom range of presentation can include asymptomatic coincidental finding to pronounced pain with functional deficit severe acute pain can bother the patient in the resorptive phase pain happens spontaneously usually in the morning sudden onset with no h/o trauma , severe pain which is present at rest and increases with any shoulder movement some patients may experience stiffness – a frozen shoulder like clinical picture among patients with CT 2.7 % to 20 % are asymptomatic and 35 % to 40 % found to have calcium deposit on XR develop symptoms it is widely agreed that symptoms mostly occur when calcification’s were > 1.5 cm in diameter ( Bosworth ) pain and stiffness can lead to reduced ROM the pain is thought to happen due to factors as
○ calcium causing chemical irritation of tissues
○ tissue edema causing pressure
○ bursal thickening due to irritation or impingement
○ pain due to chronic stiffening of the GH jt.

 

Study by Louwerens et al has shown that women between 30-60 with SAPS and calcific deposit of > 1.5 cm in length have higher chance of suffering
 with CT.

 

Differentials – subdeltoid bursitis subacromial impingement RC tears frozen shoulder gout

Plain radiograph – standard 1st line modality to identify CT standard AP , outlet and axillary views calcifications typically appear as homogenous and amorphous densities with smooth ill defined margins various classifications systems have been proposed based on location / appearance of deposits skull cap appearance indicates rupture of deposits within the bursa

 

Ultrasound – accuracy approaches that of MRI high resolution US ( HRUS ) can identify and localise even small calcifications , integrity of the RC and the long head of biceps enabling a dynamic evaluation HRUS can be combined with Doppler for a more descriptive study / vascularity

 

CT provides a better charecterization of shoulder anatomy rarely needed in diagnosis of CT

 

MRI – has an important role in identifying and localising calcific deposits , surrounding edema , associated pathologies of the RC , subacromial bursitis reserved for doubtful cases

 

Management – Most cases resolve spontaneously within few weeks but some deposits could remain for many months or may be years some patients may suffer with recurring symptoms ( sometime for yrs ) while others may recover spontaneously after a single episode of pain 90 % if cases can be treated conservatively natural history of the condition is eventual resorption of the deposits and complete relief from pain patients may seek help in the painful resorptive phase & various interventions have been attempted conservative treatment options include

Extracorporeal shock wave therapy acoustic waves generated by pizoelectric electrohydraulic and electromagmnetic devices leading to mechanical disintegration of calcium deposits can be helpful in short term but reported complications include transient bone marrow edema and humeral head necrosis.

 

Surgical – when conservative methods fail ( about 10 % of patients ) as a last resort multiple hard and gritty deposits can be done by open surgery or arthroscopically.

 

pain rotator cuff tear phase of adhesive capsulitis which is always reversible osteroarthritis evolution of joint greater tuberosity osteolysis ossifying tendinitis.

REFERENCES

  1. Umamahesvaran, Balaji et al. “Calcifying Tendinitis of Shoulder: A Concise Review.” Journal of orthopaedics vol. 15,3 776-782. 20 May. 2018, doi:10.1016/j.jor.2018.05.040  Calcifying Tendinitis of Shoulder: A Concise Review (nih.gov)
  2. DE Carli, Angelo et al. “Calcific tendinitis of the shoulder.” Joints vol. 2,3 130-6. 1 Aug. 2014, doi:10.11138/jts/2014.2.3.130 Calcific tendinitis of the shoulder (nih.gov)
  3. ElShewy, Mohamed Taha. “Calcific tendinitis of the rotator cuff.” World journal of orthopedics vol. 7,1 55-60. 18 Jan. 2016, doi:10.5312/wjo.v7.i1.55 Calcific tendinitis of the rotator cuff (nih.gov)
  4. 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 Mar;17(1):7-14. doi: 10.1007/s10195-015-0367-6. Epub 2015 Jul 12. PMID: 26163832; PMCID: PMC4805635. Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment – PubMed (nih.gov)
  5. Louwerens JK, Sierevelt IN, van Hove RP, van den Bekerom MP, van Noort A. Prevalence of calcific deposits within the rotator cuff tendons in adults with and without subacromial pain syndrome: clinical and radiologic analysis of 1219 patients. J Shoulder Elbow Surg. 2015 Oct;24(10):1588-93. doi: 10.1016/j.jse.2015.02.024. Epub 2015 Apr 11. PMID: 25870115. ( Abstract )
  6. Loew, M., Schnetzke, M. & Lichtenberg, S. Current treatment concepts of calcifying tendinitis of the shoulder. Obere Extremität 16, 85–93 (2021). https://doi.org/10.1007/s11678-020-00620-

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