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Calcific Tendinitis of the Rotator Cuff

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Other Names

  • Calcific Tendinopathy
  • Calcific Tendonitis
  • Calcific Tendinitis of the Shoulder
  • Calcific Tendonosis
  • Calcific Perarthritis

Background

  • Defined as calcium deposits occurring within the tendons of the Rotator Cuff

Epidemiology

  • Most common site of calcific tendinopathy by far
  • Most often in 50s-60s[1]
  • 50% occur in Supraspinatous tendon
  • Females > Males
  • See in 7.5% of asymptomatic adults and 20% of painful shoulders[2]

Pathophysiology

  • There are two forms of calcium deposits
  • Calcific Tendinitis
    • Calcific tendinitis is calcification within a viable and well vascularized rotator cuff[3]
    • It occurs within the midsubstance of the cuff, 1 to 2 cm proximal to its insertion.
    • Classically resolves spontaneously without evidence of degeneration
  • Dystrophic calcification
    • Occurs within non-viable and poorly vascularized rotator cuff
    • Typically occurs at insertion site or edges of a cuff tear
    • Worsens over time, commonly associated with other degenerative changes

Pathogenesis

  • Controversial
  • Burkhead: "Degenerative process that involves necrotic changes of tendon fibers that progress into dystrophic calcification"[4]
  • Mclaughlin:"proceeded from focal hyalinization of the fibers that become fibrillated and detached from the tendon, thus wounding up into rice-like bodies that later undergo calcification"[5]
  • Uhthoff: Calcific tendinitis "occurred in viable and well vascularized tissues and thus could not be a degenerative process, instead they suggested that it was a reparative process progressing through a predictable disease cycle"[6]
  • 3 Phase model: precalcific, calcific, postcalcific
  • 4 Phase model: precalcific, formative, resorptive, healing[7]

Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • Frequently insidious onset
    • Shoulder pain with decreased range of motion, painful activities
  • Physical Exam: Physical Exam Shoulder
    • Similar to findings of subacromial impingement
  • Special Tests

Evaluation

AP Radiograph of the shoulder demonstrating calcific tendinitis

Radiographs

  • Standard Radiographs Shoulder
  • Findings
    • External rotation: may see deposits in subscapularis
    • Internal rotation: may see deposits in infraspinatous, teres minor
    • “Skullcap appearance” indicate rupture of the deposits within the bursa[8]

Ultrasound

  • Calcium deposits[9]
    • Appear hyperechoic with large fragmented deposits
    • Positive power Doppler signal
    • Widening of the subacromial bursal space
  • One study showed US to have high sensitivity for crystal deposits[10]
    • Its role in diagnosing calcific tendinitis of the rotator cuff is unclear

CT

  • Better localization of deposits than radiographs

MRI

  • Helpful for evaluation of other coexisting pathology[11]

Classification

Gartner and Heyer Classification of Calcific Tendinitis

  • Type I: Well circumscribed, dense calcification, formative[12]
  • Type II: Soft contour/dense or sharp/transparent
  • Type III: Translucent and cloudy appearance without clear circumscription, resorptive

Mole Classification of Calcific Tendinitis

  • Type A: Dense, homogeneous, sharp contours and well defined edges (20%)[13]
  • Type B: Dense, heterogenous, sharp contours (45%)
  • Type C: Heterogeneous, soft contours, ill defined deges (30%)
  • Type D: Dystrophic calcifications at the insertion of the rotator cuff tendon

Management

Non-operative

  • Overall
    • Cho (2010): 72% of patients improved (excellent or good results) with NSAIDS and range of motion exercises only[14]
  • Medications
  • Physical Therapy
    • Aimed at avoiding loss of range of motion and Adhesive Capsulitis
    • Little evidence that calcific tendinitis causes capsular contracture[15]
  • Corticosteroid Injection
    • Controversial, some studies report positive, none or negative effects[16]
    • Although patients do respond to corticosteroid injection alone, it is inferior to barbotage at 1 year follow up[17]
  • Iontophoresis
    • Leduc (2003): Although there was a trend towards improvement of pain scores, acetic acid iontophoresis and physical therapy was not superior to physical therapy alone[18]
  • Therapeutic Ultrasound
    • No relevant publications to recommend or refute the use of this modality.
  • Extracorporeal Shock Wave Therapy
    • Has been used to treat patients with radiologic evidence of calcific tendinitis[19]
    • Compared to arthroscopy, there was no difference in recurrent calcific deposits or UCLA shoulder scale for pain[20]
    • A systematic review found high-energy ESWT was effective for improving shoulder pain and function. They found two sessions to be most effective[21]
    • Krasny et al: ESWT combined with barbotage was superior to ESWT for elimating deposits, reducing pain and need for arthroscopic surgery[22]
    • High energy ESWT appears to work better than low energy ESWT[23]
    • Complications include bone marrow edema, humeral head necrosis[24]
  • Ultrasound Guided Needle Lavage
    • Sometimes referred to as Barbotage
    • A systematic review of barbotage found that it was safe with high success and low risk of complications[25] The authors noted that there were no comparison to other major treatment modalities
    • Some authors recommend using a two needle technique which allows a continuous inflow and outflow of saline solution, although this method has not been compared head-to-head to a single needle technique.[26]
    • Injection of corticosteroids after the procedure is recommended by some authors, which is supported by a 2016 meta-analysis[27]
  • Platelet Rich Plasma
    • Sejas (2012): Case report documents resolution of symptoms up to 1 year after two injections[28]

Operative

  • Indications
    • Failure of conservative measures
    • Predictors of failure[29]
      • Bilateral or large calcifications
      • Deposits underlying the anterior third of the acromion
      • Extension of the calcific deposits medial to the acromion
    • Patients respond well to arthroscopic removal[30]
  • Technique
    • Open (rarely used anymore)
    • Arthroscopic

Return to Play

  • No clear guidelines

Complications

  • Chronic pain
  • Loss of function

See Also


References

  1. 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;24:1588–1593.
  2. Sconfienza, Luca Maria, et al. "Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks." Skeletal radiology 42.1 (2013): 19-24.
  3. ElShewy, Mohamed Taha. "Calcific tendinitis of the rotator cuff." World journal of orthopedics 7.1 (2016): 55.
  4. Burkhead WZ. A history of the rotator cuff before Codman. J Shoulder Elbow Surg. 2011;20:358–362.
  5. Mclaughlin HL. The selection of calcium deposits for operation; the technique and results of operation. Surg Clin North Am. 1963;43:1501–1504.
  6. Uhthoff HK, Loehr JW. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997;5:183–191.
  7. Gosens T, Hofstee D-J. Calcifying tendinitis of the shoulder: advances in imaging and management. Curr Rheum Reports 2009; 11:129–134.
  8. Izadpanah K, Jaeger M, Maier D, Südkamp NP, Ogon P. Preoperative planning of calcium deposit removal in calcifying tendinitis of the rotator cuff - possible contribution of computed tomography, ultrasound and conventional X-Ray. BMC Musculoskelet Disord. 2014;15:385.
  9. Le Goff B, Berthelot JM, Guillot P, Glémarec J, Maugars Y: Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine 2010;77(3):258–263.
  10. Filippucci, Emilio, et al. "Ultrasound imaging for the rheumatologist XLVII. Ultrasound of the shoulder in patients with gout and calcium pyrophosphate deposition disease." (2013): 659-664.
  11. Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. J Shoulder Elbow Surg. 1996;5:314–319
  12. https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis
  13. Molé D, Kempf JF, Gleyze P, Rio B, Bonnomet F, Walch G. [Results of endoscopic treatment of non-broken tendinopathies of the rotator cuff. 2. Calcifications of the rotator cuff] Rev Chir Orthop Reparatrice Appar Mot. 1993;79:532–541.
  14. Cho NS, Lee BG, Rhee YG: Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: Does the initial radiologic aspect affect the final results? J Shoulder Elbow Surg 2010;19(2):267–272.
  15. Matsen FA, Lippitt SB, Sidles JA, Harrymann D. Synthesis: practice guide lines. In: Practical evaluation in management of the shoulder, editor. Philadelphia: WB Saunders; 1994. pp. 221–230.
  16. Merolla, Giovanni, et al. "Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment." Journal of Orthopaedics and Traumatology 17.1 (2016): 7-14.
  17. de Witte, Pieter Bas, et al. "Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids." The American journal of sports medicine 41.7 (2013): 1665-1673.
  18. Leduc, Bernard E., et al. "Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial." Archives of physical medicine and rehabilitation 84.10 (2003): 1523-1527.
  19. Galasso O, Amelio E, Riccelli DA, Gasparini G. Short-term outcomes of extracorporeal shock wave therapy for the treatment of chronic non-calcific tendinopathy of the supraspinatus: a double-blind, randomized, placebo-controlled trial. BMC Musculoskelet Disord. 2012;13:86.
  20. Rebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. J Orthop Traumatol. 2008;9:179–185.
  21. Bannuru RR, Flavin NE, Vaysbrot E, Harvey W, McAlindon T. High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: a systematic review. Ann Intern Med. 2014;160:542–549.
  22. Krasny C, Enenkel M, Aigner N, Wlk M, Landsiedl F: Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. J Bone Joint Surg Br 2005;87(4):501–507
  23. Peters J, Luboldt W, Schwarz W, Jacobi V, Herzog C, Vogl TJ: Extracorporeal shock wave therapy in calcific tendinitis of the shoulder. Skeletal Radiol 2004;33(12):712–718
  24. Liu HM, Chao CM, Hsieh JY, Jiang CC. Humeral head osteonecrosis after extracorporeal shock-wave treatment for rotator cuff tendinopathy. A case report. J Bone Joint Surg Am. 2006;88:1353–1356.
  25. Gatt DL, Charalambous CP. Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients. Arthroscopy. 2014;30:1166–1172.
  26. Sconfienza, Luca Maria, et al. "Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks." Skeletal radiology 42.1 (2013): 19-24.
  27. Arirachakaran, Alisara, et al. "Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs." European Journal of Orthopaedic Surgery & Traumatology 27.3 (2017): 381-390.
  28. Seijas R, Ares O, Alvarez P, et al. Platelet-rich plasma for calcific tendinitis of the shoulder: a case report. J Orthop Surg 2012; 20:126–130
  29. Ogon P, Suedkamp NP, Jaeger M, Izadpanah K, Koestler W, Maier D: Prognostic factors in nonoperative therapy for chronic symptomatic calcific tendinitis of the shoulder. Arthritis Rheum 2009;60(10):2978–2984
  30. El Shewy MT. Arthroscopic removal of calcium deposits of the rotator cuff: a 7-year follow-up. Am J Sports Med. 2011;39:1302–1305
Created by:
John Kiel on 11 June 2019 01:49:27
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Last edited:
17 February 2021 00:39:45
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