Calcifying Tendinitis

The deposition of crystals of monosodium urate (gout), calcium pyrophosphate dehydrate (CPPD chondrocalcinosis, pseudogout) and calcium hydroxyapatite (HADD calcifying tendinitis) within synovium, articular cartilage, fibrocartilages and para-articular soft tissues may produce a spectrum of clinical conditions ranging from asymptomatic entities to severe rapidly destructive arthropathy (Steinbach 2004 Clement et al. 2005). The accumulation of crystals takes months to years to develop and leads to the establishment of a chronic synovitis with intermittent acute flares. 

The intra-articular involvement of calcium hydroxyapatite deposition disease—a condition more commonly referred to as calcifying tendinitis because of the involvement of tendons near to their osseous insertion—may produce an acute arthritis (chronic apatite arthropathy) possibly mimicking an infectious condition (see Chapter 6). 

Rotator cuff calcifications are a common finding (occurring in as many as 3% of adults with a prevalence in females in their fourth to sixth decades of life) when examining the shoulder with US. Generally speaking, calcifying tendinitis refers to deposition of calcium, predominantly hydroxyapatite, in the rotator cuff tendons the most commonly affected tendon... 

Fig. 6.103a,b. Calcifying tendinitis of the pectoralis major tendon, a Anteroposterior radiograph shows a juxtacortical calcification (arrow) adjacent to the anterior proximal humeral shaft cortex, b Corresponding transverse 12-5 MHz US image over the myotendinous junction of the long head of the biceps (B) demonstrates a well-defined type I deposit (arrow) within the distal pectoralis major tendon (arrowheads). Hs, humeral shaft... 

Carroll KW, Helms CA, Otte MT et al (2003) Enlarged spi-noglenoid notch veins causing suprascapular nerve compression. Skeletal Radiol 32 72-77 Chan R, Kim DH, Millett PJ, et al (2004) Calcifying tendinitis of the rotator cuff with cortical bone erosion. Skeletal Radiol 33 596-599... 

Uhthoff HK, Sarkar K (1989) Calcifying tendinitis. Baillieres Clin Rheumatol 3 567-581... 

Some general considerations merit attention. First, only painful calcifications must be treated finding calcification within a rotator cuff tendon does not automatically mean that shoulder pain is related to it. A typical mistake is to treat calcifying tendinitis in patients with shoulder pain derived from other causes, including cervical spine disease. Remember that most calcifications are asymptomatic. Second, the best results are achieved on large calcifications. Treatment of clusters of smaller calcifications is almost invariably unsuccessful. Third, the goal of the procedure is to disrupt the calcification and to remove some but not all calcific material (Fig. 18.14f). Too many needle insertions to remove as much as possible of the calcification should be avoided to prevent tendon tears. Once ruptured, calcification almost invariably evolves toward resorption, and shoulder pain and disability improve in most cases (Fig. 18.16). 

Fig. 18.14a-f. US-guided treatment of calcifying tendinitis aspiration irrigation technique. Schematic drawings illustrate the standard sequence of a two-needle procedure, a Under real-time US observation, lidocaine is injected within the subacromial bursa (asterisk) by the first 18 gauge needle. The needle path should point toward the rotator cuff (rc) calcification (star) to be treated, b The same needle is advanced (black arrows) until its tip penetrates the calcification, c A second 20 gauge needle is inserted (black arrows) within the calcification. With this needle, multiple passages within the calcification and rotational movements are performed, d Injection (open arrows) of saline and lidocaine by the second needle and aspiration by the first needle is then performed in an effort to remove as much calcified material as possible, e When a substantial amount of calcium has been washed out, steroids are injected (open arrow) into the subacromial bursa to treat inflammation secondary to diffusion of calcium into the bursa. Then the needles are withdrawn (black arrows), e At the end of the procedure, residual calcific deposits remain within the tendon... 

Fig. 18.16a-c. US-guided treatment of calcifying tendinitis radiographic results. Series of anteroposterior standard radiographs of the shoulder obtained a before, b soon after the procedure and c 2 months later in a patient with a painful calcification (arrow) in the supraspinatus tendon. Although partial removal of the calcification is observed initially, most of the calcification then dissolves with time. (Courtesy of Dr. Giovanni Serafini, Pietra Ligure, Italy)... 

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