Orthopedic Teaching Cases 2023, Jan, 18 | 12:00 am

Shoulder and Elbow cases calcific tendonitis

A 44-year-old, right-hand-dominant male with well-controlled diabetes and hypertension presents to clinic with left shoulder pain. The patient denies a history of trauma or injury. He localizes his pain over the superolateral aspect of the shoulder, and it radiates to the deltoid insertion. He has experienced pain over the past few months, but it has progressively become more severe over the past several days. He has difficulty sleeping and with range of motion because of severe pain. While examining the patient, he has a warm and tender left shoulder, and while performing a range of motion evaluation, the patient notes that he has a sensation of “catching.” He has a positive Hawkins sign, negative drop arm test, and pain with a cross body adduction test. A radiograph of the left shoulder is shown in Figure 2–77.

 

 

 

Figure 2–77

 

What is the most likely diagnosis?

  1. Rotator cuff arthropathy

  2. Septic arthritis

  3. Acromioclavicular (AC) joint osteoarthritis

  4. Calcifying tendinitis

  5. Glenohumeral (GH) joint osteoarthritis

 

Discussion

The correct answer is (D). Calcific tendonitis (CT) is a condition characterized by the buildup of calcium hydroxyapatite crystals within tendons. It typically occurs around synovial joints and has been reported in the hip, paraspinal muscles, hand, and foot. It most frequently occurs around the shoulder in patients who are 30 to 50 years old. No one over the age of 71 has been recorded having this condition. Degenerative calcification and reactive calcification have both been proposed as mechanisms for the deposition of calcium. Although the etiology is not understood, most believe that it is a reactive mechanism involving an active, cell-mediated process in a viable tendon. The cell-mediated process has been divided into three distinct phases: precalcific, calcific, and postcalcific. Depending on the stage, imaging, and physical examination characteristics can differ. The calcific stage can be further classified into three phases: formative, resting, and resorption. Rotator cuff arthropathy is seen in older patients with chronic, massive, rotator cuff tears and glenohumeral osteoarthritis. Septic arthritis can look similar to CT, but this patient has had a history of shoulder pain without fever or other risk factors for infection. Answers C and E are incorrect because there are no signs of osteoarthritis of the AC or GH joint on radiograph or physical examination.

What can be said about the phase of this patient’s shoulder pathology?

  1. The calcium is most likely being deposited

  2. The calcium deposit is mostly likely undergoing resorption

  3. The tenocytes are likely undergoing metaplasia

  4. The tenocytes are likely becoming ischemic and losing vascularity

  5. The musculotendinous junction is the area most likely causing the patient’s pain

 

Discussion

The correct answer is (B). In calcific tendonitis (CT), calcium must be deposited for it to be resorbed. Patients presenting during the resorptive phase of the calcific stage will have this type of acute, inflammatory shoulder syndrome that this patient most closely represents. This hyperalgic syndrome will typically last 2 weeks. This is

very different from the formative and resting phase, when calcium crystals are being deposited and isolated in the tendon. These phases can last for 2 to 3 years and may be associated with intermittent or constant symptoms. The resorptive and formative phases are important to distinguish for treatment purposes. It should be noted that whereas other musculoskeletal diseases progress from an acute to chronic phase, CT will progress from a chronic phase followed by an acute phase. Answer C is incorrect because this may be happening in the precalcific stage, which is not the patient’s current stage. Answer D is incorrect because this is one theory of how the calcific stage is prompted. Answer E is incorrect because calcification at the musculotendinous junction is considered degenerative or dystrophic calcification, which will typically occur in older patients.

Which structure is most likely to be affected on the basis of the information obtained thus far, including the radiograph Figure 2–77?

  1. Deltoid

  2. Infraspinatus

  3. Supraspinatus

  4. Teres minor

  5. Subscapularis

 

Discussion

The correct answer is (C). Calcific tendonitis (CT) is most often localized in the supraspinatus tendon. Radiographic views should include a true AP in internal and external rotation, axillary, and scapular-Y to evaluate for calcium deposits in the tendons of the rotator cuff. There are no reports of the deltoid muscle being involved in CT. Radiographs also help to distinguish resorptive and formative phases. Two radiographic types have been described: Type I (associated with the resorptive phase and acute pain) is a deposit that is fluffy or fleecy in appearance with a poorly defined periphery. Type II (associated with the formative phase and chronic pain) has discrete, homogeneous deposits that have a well-defined periphery.

How should this patient be initially managed?

  1. Therapeutic ultrasound

  2. Extracorporeal shock wave therapy (ESWT)

  3. Needle aspiration and lavage

  4. Arthroscopic calcium deposit decompression

  5. Combined needle aspiration followed by ESWT

 

Discussion

The correct answer is (C). When managing calcific tendonitis (CT), it is important to distinguish between the formative and resorptive phases for proper treatment. Conservative measures (i.e., physical therapy, moist heat, nonsteroidal anti-inflammatory drugs, sling) should be attempted in all cases if the symptoms are not severe. Needle aspiration with lavage is often successful during the acute, resorptive phase because the consistency of the calcification tends to be creamy or toothpastelike. Therapeutic ultrasound has been utilized by physical therapists, but no long-term benefit has been found. ESWT is being utilized with encouraging results, however, more investigation is needed to identify long-term outcomes and safety concerns. Arthroscopic or open surgical intervention is very rarely indicated in the resorptive phase. Surgery is typically only indicated after 6 to 12 months of failed conservative treatment, during the formative phase, and progressive symptoms that are negatively impacting daily activities.

What is the most likely outcome of this patient after being treated?

  1. Will require repeat needle aspiration and lavage

  2. Decreased pain and resolution of symptoms

  3. Will likely require arthroscopic surgery

  4. Decreased range of motion and increased pain

 

Discussion

The correct answer is (B). The most likely outcome for this patient is decreased pain and resolution of symptoms with supportive care provided. Most cases of calcific tendonitis (CT) are self-limiting, and the role of the clinician is to control pain and maintain function until recovery occurs. During the resorptive phase, natural mechanisms usually succeed in removing the deposit. Rarely will repeated needle aspiration be necessary. Surgery is very rarely indicated for the resorptive phase of CT, particularly after needle aspiration and lavage have been performed. The patient is likely to experience increased range of motion and less pain with continued supportive measures if necessary.

Objectives: Did you learn …?

 

 

Recognize and diagnose a patient with calcific tendonitis? Realize that the etiology of calcific tendonitis is not known?

 

Recognize that patients may present while in the resorptive phase or formative phase of calcific tendonitis and treatments will differ for each?

 

Recognize that the chronic phase of calcific tendonitis occurs prior to the acute phase?

 

Recognize the different conservative and operative treatment options available for calcific tendonitis and when to implement them?

 

Appreciate that the outcome of calcific tendonitis is typically favorable with conservative measures?