Schulterinfo.ch - Tendons - Calcific tendinitis
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Abstract
Also called peritendinitis calcarea or periarthropathia calcificans, calcific tendinitis is a painful condition of the shoulder with calcific deposits in tendons of the rotator cuff and or the subdeltoid/subacromial bursa
The exact formation process of calcific deposits is not completely understood yet. However, several factors such as local ischemia, improper stem cell differentiation or overuse of the shoulder were claimed to have an impact on the accumulation of calcific crystals.
Most commonly, the infraspinatus and the supraspinatus tendon are affected (respectively in the layers and fascia in between), leading to impingement like symptoms. Chronic pain during motion with asymptomatic intervals as well as night pain in the shoulder are very characteristic for calcific tendinitis.
Clinical suspicion is confirmed by x-ray and ultrasound imaging, where calcific deposits impress as radiopaque or hyperechoic structures respectively.
Different therapy approaches can be evaluated individually. These consist of: Local or systemic NSAIDs, physical therapy, extracorporeal shock wave therapy, high-dose magnesium intake, slicing/needling or surgical removal.
Tendinosis calcarea is a painful shoulder pathology associated with single or multiple calcific deposits in the tendons of the rotator-cuff or subacromial bursa.
To this day, the exact mechanisms involved in the pathogenesis remain unclear. Several studies claim that an overuse of the shoulder or local ischemia leads to degenerative changes which progress into dystrophic calcification [1, 2], whereas more recent research postulates a more complex process including incorrect differentiation of tendon derived stem cells [1]. The later theory, established by Uhthoff et al., is regarded as the most plausible, where a metaplasia of tenocytes into chondrocytes is the root of calcification in the tendons. Factors causing metaplasia are unknown as of yet.
Moreover, several risk factors such as genetic mutations and endocrine disorders have been identified, which in combination could increase the chances of suffering from calcific tendinitis [3].
Based on the theory of Uhthoff et al. calcific tendinitis of the shoulder can be divided into three different stages [1-5]:
- Precalcific stage
- Fibrocartilaginous metaplasia occurs in the tendons of the rotator cuff (usually no symptoms)
- Calcific stage
- The calcific stage can be further divided into three different stages of calcification:
- Formative stage: calcium crystal deposition into the tendon, mediated by chondrocytes (no symptoms or reoccurring impingement-like pain)
- Resting stage: dormant stage of disease, lack of inflammation or vascular infiltration (no symptoms or reoccurring impingement-like pain)
- Resorptive stage: calcific deposits are absorbed by cell-mediated phagocytosis (acute onset of intense pain)
- The calcific stage can be further divided into three different stages of calcification:
- Postcalcific stage
- Tendon tissue remodelling by fibroblasts, occurs simultaneously with resorptive phase of calcific stage, is completed by full healing of the tendon (no symptoms or less intense pain)
- Precalcific stage
Tendinosis calcarea is a comparably common disorder, which usually affects people around 30-60 years of age and occurs in women more commonly [3]. It has been found that around 3% of population have asymptomatic calcific deposits [5]. The right shoulder is generally affected more often [1] and 10-20% of patients suffer from bilateral calcific deposits [2]. The supra- and infraspinatus tendon are most affected, combining for 90% of the cases [2].
Generally, clinical presentation correlates with the different histopathological stages. Patients usually present in the resorptive phase as absorption of calcific deposits is associated with sudden onset of severe pain [4]. They commonly visit the emergency room due to acute onset and intensity of the symptoms. Pain during the formative stage is typically inexistent or less severe and felt during shoulder flexion [1, 4].
Avoiding sleeping on the affected shoulder, posture of internal rotation and limited active range of motion are additional signs that the examiner should look out for [4].
Patients might report pain, when elevating the arm. Typically, symptoms often come in intervals with completely pain-free episodes and more intense pain during night-time, not rarely leading to sleeping-problems. At some point the pain suddenly intensifies (resorptive stage), especially when the subacromial bursa is affected as well [1].
Calcific tendinitis can be diagnosed by history and examination alone. Some findings might be:
- Tenderness on palpation of the rotator cuff
- Positive impingement tests (e.g., Neer, Hawkins-sign)
- Limited ROM, especially elevation and rotational movements
- Scapular dyskinesia as a result of relieving posture
Since the crystals are radiopaque, a variety of imaging-methods can be used to further investigate unclear cases or to determine the location of calcific deposits:
- X-ray
- Conventional anterior-posterior radiography in neutral and externally rotated position allows the depiction of calcium-rich deposits. Also, one can make a rough estimate of the different stages, since deposits in the formative and resting stage tend to have clearer margins when compared to the resorptive stage [3, 4]. However, several attempts at classifying radiological findings have not been successful so far, as they do not correlate well with symptomatology of the patient [3].
- Ultrasound
- US is of high significance in diagnosing calcific tendinitis as high-resolution ultrasound can not only be used to show the presence of deposits and the respective stage, but also to depict collateral rotator-cuff tears and bursitis. If used correctly, US has higher sensitivity and is therefore superior to x-ray [3].
- MRI
- Generally, MRI is rarely used in diagnosing tendinosis calcarea, although there is great value, if previous imaging is inconclusive or there is reason to believe that collateral rotator-cuff tears might be present [3].
Images of cases can be found on Radiopaedia.
- Frozen shoulder
- Subacromial impingement
- Arthritis
- Primary rotator-cuff tear
- Parsonage-Turner-Syndrome
Note: Since there is a comparably high asymptomatic population, other diseases should be ruled out first!
First-line therapy consists of a conservative approach, where patients are treated with local or systemic NSAIDs and take part in a physical therapy program [3]. Administration of a single high dose of magnesium was shown to be helpful in individual cases and should be tried with all patients. Since tendency of spontaneous remission is very high, these measures should always be the building stone of treatment. If symptoms persist, extracorporeal shock wave therapy or the use of ultrasound-guided needling (UGN) can be assessed. Both techniques are similar in outcome. However, studies have shown that ESWT is more effective in the chronic stages of the disease and for hard calcifications, whereas the effectiveness of UGN plays a bigger role in the acute phase and for soft calcifications [3, 4].
Patients, who do not respond to conservative treatment after a period of 6 months should be evaluated for surgery [4]. A study has shown that surgical removal of calcific deposits was especially effective in patients with prolonged course of disease and chronic shoulder pain [4].
Prognosis and progressive course of disease
As alluded to before, prognosis of tendinosis calcarea is very favourable. A study has found that about 72% of patients that underwent physical therapy and were treated with NSAID had good to excellent outcomes [1, 3]. Another research has found that approximately 10% of patients were eventually treated surgically due to failure of conservative treatment [4].
Despite having a generally great outcome, complications have been reported in some cases [6]:
- Adhesive capsulitis
- Very difficult to differentiate especially in acute stages of the disease
- Rotator cuff tears
- Studies have shown a 28% chance of concomitant rotator cuff tears in patients with calcific tendinitis [6]
- Greater tuberosity osteolysis (rare)
- Deposits near the insertion of the tendon may cause cortical lesions in the humeral head
- Ossifying tendinitis (rare)
- Only few cases after surgical removal of calcific deposits
- Suzuki, Kentaro, Aaron Potts, Oke Anakwenze, and Anshu Singh. 2014. "Calcific Tendinitis Of The Rotator Cuff: Management Options". Journal Of The American Academy Of Orthopaedic Surgeons 22 (11): 707-717. doi:10.5435/jaaos-22-11-707.
- Chianca, Vito, Domenico Albano, and Carmelo Messina. 2018. "Rotator Cuff Calcific Tendinopathy: From Diagnosis To Treatment". Acta Biomedica 89: 186-196. doi:10.23750/abm.v89i1-S.7022.
- Merolla, Giovanni, Sanjay Singh, Paolo Paladini, and Giuseppe Porcellini. 2016. "Calcific Tendinitis Of The Rotator Cuff: State Of The Art In Diagnosis And Treatment". Journal Of Orthopaedics And Traumatology 17 (1): 7-14. doi:10.1007/s10195-015-0367-6.
- Kim, Min-Su, In-Woo Kim, Sanghyeon Lee, and Sang-Jin Shin. 2020. "Diagnosis And Treatment Of Calcific Tendinitis Of The Shoulder". Clinics In Shoulder And Elbow 23 (4): 210-216. doi:10.5397/cise.2020.00318.
- Darrieutort-Laffite, Christelle, Frédéric Blanchard, and Benoit Le Goff. 2018. "Calcific Tendonitis Of The Rotator Cuff: From Formation To Resorption". Joint Bone Spine 85 (6): 687-692. doi:10.1016/j.jbspin.2017.10.004.
- Merolla, Giovanni, Mahendar G. Bhat, Paolo Paladini, and Giuseppe Porcellini. 2015. "Complications Of Calcific Tendinitis Of The Shoulder: A Concise Review". Journal Of Orthopaedics And Traumatology 16 (3): 175-183. doi:10.1007/s10195-015-0339-x.
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