Calcific tendinitis

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Calcific tendinitis
Other namescalcific/calcifying/calcified/calcareous tendinitis/tendonitis/tendinopathy, tendinosis calcarea, hydroxyapatite deposition disease (HADD), calcific periarthritis
Calcific tendinitis marked.jpg
A plain X ray of the shoulder showing calcific tendinitis
Specialty Rheumatology   OOjs UI icon edit-ltr-progressive.svg
SymptomsPain of the shoulder exacerbated by overhead activities
Duration Self-limiting, typically resolves in 6-9 months
Risk factors Diabetes, hypothyroidism
Diagnostic method X-ray
Treatment Physiotherapy, sub-acromial injection with steroids, extracorporeal shockwave therapy, surgical excision
Medication NSAIDs, analgesics

Calcific tendinitis is a form of tendinitis, a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body, but most commonly in the tendons of the rotator cuff (shoulder), causing pain and inflammation. The condition is related to and may cause adhesive capsulitis ("frozen shoulder").

Contents

Calcific tendinitis most often occurs in females aged 30 to 60 years and occurs in 3–10% of the general population. [1] [2] Calcifications are usually located within the supraspinatus tendon (80% of cases), followed by the infraspinatus (15% of cases) and subscapularis (5% of cases) tendons, but can be present in any tendon, [3] and they are present in 5% or more of asymptomatic shoulders in healthy adults. [4]

Signs and symptoms

Around 50% of individuals with calcific tendinitis have symptoms. Symptoms include pain or weakness in the shoulder and often leads to decreased active range of motion. If the condition is chronic, muscle atrophy and scapular dyskinesia can occur. [5]

Pain is often aggravated by elevation of the arm above shoulder level or by lying on the shoulder. Pain may awaken the patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder.

Cause

Three main theories have emerged in an attempt to explain the mechanisms involved in tendon calcification. [6] The first theory is the theory of reactive calcification and involves an active cell-mediated process, usually followed by spontaneous resorption by phagocytosing multinucleated cells showing a typical osteoclast phenotype. The second theory suggests that calcium deposits are formed by a process resembling endochondral ossification. The mechanism involves regional hypoxia, which transforms tenocytes into chondrocytes. The third theory involves ectopic bone formation from metaplasia of mesenchymal stem cells normally present in tendon tissue into osteogenic cells. As no single theory is satisfactory to explain all cases, calcific tendinopathy is currently believed to be multifactorial. [6]

Risk factors that increase the chance of developing calcific tendinitis include; hormonal disorders, like diabetes and hypothyroidism, autoimmune disorders, like rheumatoid arthritis, and metabolic disorders that also cause kidney stones, gallstones, and gout. Occupations that consist of repetitive overhead lifting, such as athletes or construction workers, do not seem to significantly increase the likelihood of developing calcific tendinitis. [5]

Diagnosis

An x-ray showing calcific deposits in the area of the tendons of the rotator cuff muscles CalcificTendonitisMark.png
An x-ray showing calcific deposits in the area of the tendons of the rotator cuff muscles

The calcific deposits are visible on X-ray as discrete lumps or cloudy areas. The deposits look cloudy on X-ray if they are in the process of reabsorption, and this is also when they cause the most pain. The deposits are crystalline when in their resting phase and like toothpaste in the reabsorptive phase. However, poor correlation exists between the appearance of a calcific deposit on plain X-rays and its consistency on needling. Ultrasound is also useful to depict calcific deposits and closely correlates with the stage of disease. [6]

Treatment

When treating calcific tendinitis, the focus is initially upon symptom relief including the use of oral anti-inflammatories, analgesics, glucocorticoid injections, and physical therapy. Aspiration can be implemented [7] to decrease the amount of calcium deposits in the tissue, as well as to reduce the pain and improve function. [8] Usually it improves without specific treatment. [9] Treatments of calcific tendinitis may include physiotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroid injections. [9] If these do not work, extracorporeal shockwave therapy or surgery may be considered. [9]

Research has found conservative treatment consisting of Physical Therapy, NSAIDS, and steroid injections to be successful in managing 60-80% of cases, such that symptoms did not continue after 6 months. However, it is possible the high success rate is due to the natural progression of the disease. [5]

Medications

Analgesics and NSAIDs are useful to a limited extent. They can be used to relieve pain for 7-14 days, but can cause gastrointestinal, cardiovascular, and renal complications if NSAIDS are used long term. [5] Corticosteroid injections may be useful when the shoulder is acutely inflamed but otherwise are not generally useful except for the temporary relief of pain.

Physical therapy

Physical therapy combines stretching and strengthening of the area to reduce pain and work on range of motion and function. Physical therapy can further work to reduce symptoms with iontophoresis, deep transverse friction massage, laser therapy, or hyperthermia. [5]

Electroanalgesia, ice therapy, and heat offer symptomatic relief. The benefit of ultrasound in calcific tendinitis is debated; most studies are negative but a study by Ebenbichler et al. (1999) [10] showed resolution of deposits and clinical improvement. Improving the biomechanics of the shoulder will reduce the tension on the fault muscles allowing a decrease in symptoms. Improved biomechanics are thought to reduce the amount of calcification that occurs especially in the case of the supraspinatus where it can be caused from repetitive compression against the acromion.

Ultrasound guided percutaneous irrigation

Ultrasound guided percutaneous irrigation (US-PICT) uses sonographic guidance to aspirate and remove calcium deposits while also increasing the vascular supply by causing microtrauma in the area. The technique is followed by a steroid injection to control pain and inflammation. US-PICT removes much of the calcium deposit, and the newly increased vasculature helps to reabsorb whatever calcium is left over. For both short term and long term management, US-PICT has been shown to be 90% successful one year post treatment, and has shown to reduce pain by around 55%. Complications are rare, but most common is bursitis. [5]

Extracorporeal shock wave therapy

In those with calcific tendinitis of the shoulder, high energy extracorporeal shockwave therapy may be useful; [11] it is not useful in other types of tendinitis. [12]

Extracorporeal shockwave therapy (ESWT) can reduce the calcium deposits significantly, thus contributing to decreased pain and increased function. There are different kinds of ESWT. High-energy focused extracorporeal shockwave therapy has been shown to yield the most results when compared with other forms of electrotherapy. Low-energy extracorporeal shockwave therapy, ultrasound and transcutaneous electrical nerve stimulation (TENS) are less likely to break apart the calcium deposits. However, ESWT requires multiple sessions to treat calcific tendinitis and may be quite costly in some countries. [13]

Surgery

Surgery is only recommended once 6 months of conservative, non-operative treatment has failed to reduce symptoms. Surgery is arthroscopic and involves calcification removal with or without acromioplasty of the shoulder. [14] Additionally, debate remains over whether a complete removal of the deposits is necessary, or if equal pain relief can be obtained from a partial removal of calcium deposits. [5]

Removing the deposits either with open shoulder surgery or arthroscopic surgery are both difficult operations, but with high success rates (around 90%). About 10% require re-operation. If the deposit is large, then frequently the patient will require a rotator cuff repair to fix the defect left in the tendon when the deposit is removed or to reattach the tendon to the bone if the deposit was at the tendon insertion into the bone.

Other

In studies, acetic acid iontophoresis combined with ultrasound provided no better clinical results or shrinkage of the calcific deposits than did no treatment. Platelet-rich plasma (PRP) is blood plasma that has been enriched with platelets. It has not been well studied in calcific tendinitis. [9]

Under local anesthetic, the calcific deposits can be mechanically broken up by puncturing them repeatedly with a needle and then aspirating the calcific material with the help of a sluice of saline. Ultrasound can be used to help localize the deposit and to visualize the needle entering the deposit in real time. Available evidence does not suggest a benefit over usual treatments. [15]

Related Research Articles

Rotator cuff Group of muscles

In anatomy, the rotator cuff is a group of muscles and their tendons that act to stabilize the shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are the supraspinatus muscle, the infraspinatus muscle, teres minor muscle, and the subscapularis muscle.

Tendinopathy

Tendinopathy, also known as tendinitis or tendonitis, is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

Trigger finger

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger. Pain may occur in the palm of the hand or knuckles. The name is due to the popping sound made by the affected finger when moved. Most commonly the ring finger or thumb is affected.

Shoulder problem

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

Achilles tendon Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

Plantar fasciitis Connective tissue disorder of the heel

Plantar fasciitis is a disorder of the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

Tennis elbow Condition in which the outer part of the elbow becomes sore and tender

Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm and grip strength may be weak. Onset of symptoms is generally gradual. Golfer's elbow is a similar condition that affects the inside of the elbow.

Achilles tendinitis

Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon, found at the back of the ankle, becomes sore. Achilles tendinopathy is accompanied by alterations in the tendon’s structure and mechanical properties. The most common symptoms are pain and swelling around the affected tendon. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.

Rotator cuff tear

A rotator cuff tear is an injury where one or more of the tendons or muscles of the rotator cuff of the shoulder get torn. Symptoms may include shoulder pain, which is often worse with movement, or weakness. This may limit people’s ability to brush their hair or put on clothing. Clicking may also occur with movement of the arm.

Adhesive capsulitis of the shoulder Painful disease restricting movement

Adhesive capsulitis, also known as frozen shoulder, is a condition associated with shoulder pain and stiffness. There is a loss of the ability to move the shoulder, both voluntarily and by others, in multiple directions. The shoulder itself; however, does not generally hurt significantly when touched. Muscle loss around the shoulder may also occur. Onset is gradual over weeks to months. Complications can include fracture of the humerus or biceps tendon rupture.

Supraspinatus muscle Muscle of the upper back

The supraspinatus is a relatively small muscle of the upper back that runs from the supraspinous fossa superior portion of the scapula to the greater tubercle of the humerus. It is one of the four rotator cuff muscles and also abducts the arm at the shoulder. The spine of the scapula separates the supraspinatus muscle from the infraspinatus muscle, which originates below the spine.

Calcium pyrophosphate dihydrate crystal deposition disease

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, also known as pseudogout and pyrophosphate arthropathy, is a rheumatologic disease which is thought to be secondary to abnormal accumulation of calcium pyrophosphate dihydrate crystals within joint soft tissues. The knee joint is most commonly affected.

Patellar tendinitis Human disease

Patellar tendinitis, also known as jumper's knee, is an overuse injury of the tendon that straightens the knee. Symptoms include pain in the front of the knee. Typically the pain and tenderness is at the lower part of the kneecap, though the upper part may also be affected. Generally there is not pain when the person is at rest. Complications may include patellar tendon rupture.

Enthesopathy

An enthesopathy refers to a disorder involving the attachment of a tendon or ligament to a bone. This site of attachment is known as the enthesis . If the condition is known to be inflammatory, it can more precisely be called an enthesitis.

Subacromial bursitis

Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coraco-acromial ligament, acromion, and coracoid and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.

Extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is a treatment mostly used to treat kidney stones and in physical therapy and orthopedics.

Shoulder surgery is a means of treating injured shoulders. Many surgeries have been developed to repair the muscles, connective tissue, or damaged joints that can arise from traumatic or overuse injuries to the shoulder.

Shoulder impingement syndrome

Shoulder impingement syndrome is a syndrome involving tendonitis of the rotator cuff muscles as they pass through the subacromial space, the passage beneath the acromion. It is particularly associated with tendonitis of the supraspinatus muscle. This can result in pain, weakness, and loss of movement at the shoulder.

Platelet-rich plasma Concentrate of platelet-rich plasma protein derived from whole blood

Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of platelet-rich plasma protein derived from whole blood, centrifuged to remove red blood cells. Though promoted to treat an array of medical problems, evidence for benefit is mixed as of 2020, with some evidence for use in certain conditions and against use in other conditions. The cost per injection is generally US$500 to $2,000 as of 2019.

Calcific bursitis

Calcific bursitis refers to calcium deposits within the bursae. This most occurs in the shoulder area. The most common bursa for calcific bursitis to occur is the subacromial bursa. A bursa is a small, fluid-filled sac that reduces friction, and facilitates movements between its adjacent tissues. Inflammation of the bursae is called bursitis.

References

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  2. "Evaluation and Management of Calcific Tendinitis". Clinical Advisor. 20 December 2016. Retrieved 12 March 2018.
  3. Schneider D, Hirsch M. Acute calcific tendonitis of dorsal interosseous muscles of the hand: uncommon site of a frequent disease. https://doi.org/10.4081/reumatismo.2017.950
  4. Serafini, Giovanni; Sconfienza, Luca M.; Lacelli, Francesca; Silvestri, Enzo; Aliprandi, Alberto; Sardanelli, Francesco (July 2009). "Rotator Cuff Calcific Tendonitis: Short-term and 10-year Outcomes after Two-Needle US-guided Percutaneous Treatment— Nonrandomized Controlled Trial". Radiology. 252 (1): 157–164. doi:10.1148/radiol.2521081816. PMID   19561254.
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