Calcific tendinitis: Difference between revisions

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==Background==
==Background==
*Self-limiting disorder of calcium deposition within one or more tendons of the rotator cuff
*Self-limiting disorder of calcium hydroxyapatite deposition within one or more tendons of the rotator cuff
**Usually spontaneous, not necessarily caused by trauma or overuse
**With time, the calcium undergoes painful resorption with subsequent tendon healing
**With time, the calcium undergoes painful resorption with subsequent tendon healing
*Middle-aged patients are most commonly affected (rarely seen in patients >70yrs)
*Middle-aged patients 30-50 years are most commonly affected (rarely seen in patients >70yrs), and women are moreso affected<ref>Merolla G, Singh S, Paladini P, Porcellini G. Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment. J Orthop Traumatol. 2016 Mar;17(1):7-14. doi: 10.1007/s10195-015-0367-6. Epub 2015 Jul 12. PMID: 26163832; PMCID: PMC4805635.</ref>
*[[Adhesive capsulitis]] is most common complication
*[[Adhesive capsulitis]] is most common complication
*Inflammatory reaction may exhibit warmth, swelling, or erythema that may mimic septic arthritis


==Clinical Features==
==Clinical Features==
===Precalcific phase===
===Precalcific phase===
*Fibrocartilaginous metaplasia of the tendon
*Fibrocartilaginous metaplasia of the tendon, leading to chondrocyte formation
*Pain-free
*Pain-free


===Calcification phase===
===Calcification phase===
*Formative phase
*Formative phase
**characterized by cell-mediated calcific deposits
**Characterized by cell-mediated calcific deposits
**+/- Shoulder pain
**+/- Shoulder pain
*Resting phase
*Resting phase
**lacks inflammation or vascular infiltration
**Lacks inflammation or vascular infiltration
**+/- pain
**+/- pain
*Resorptive phase (1-2 wks)
*Resorptive phase (1-2 wks)
**characterized by phagocytic resorption and vascular infiltration
**Characterized by phagocytic resorption and vascular infiltration
**most painful phase
**Most painful phase; due to inflammation in the resorptive process, increase in intratendinous pressure, or subacromial impingement
**Sudden onset of severe pain, usually at rest, worse at night
***Pain may be similar to rotator cuff tendinopathy; usually at rest, worse at night and with laying on affected side
**Any shoulder motion reproduces significant pain
***Leakage of calcium crystals onto the bursa may lead to sudden dramatic pain
**TTP over proximal humerus near tendinous insertion of rotator cuff
***Any shoulder motion reproduces significant pain; shoulder impingement tests are usually positive
***TTP over proximal humerus near tendinous insertion of rotator cuff; may also be near AC joint or deltoid


===Post-calcific phase===
===Post-calcific phase===
*Calcific deposits have been resorbed; tendon returns to normal
*Variable levels of pain and shoulder dysfunction
*Variable levels of pain and shoulder dysfunction


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*Imaging
*Imaging
**Plain films will show calcification in the tendon(s) of the rotator cuff
**Plain films will show calcification in the tendon(s) of the rotator cuff
**Note: calcification is not specific for calcific tendinitis (may occur in asymptomatic patients)
***Usually in the supraspinatus tendon, proximal to its insertion site on the greater tuberosity<ref>Kim MS, Kim IW, Lee S, Shin SJ. Diagnosis and treatment of calcific tendinitis of the shoulder. Clin Shoulder Elb. 2020 Nov 27;23(4):210-216. doi: 10.5397/cise.2020.00318. PMID: 33330261; PMCID: PMC7726362.</ref>
***Amount of calcification may not correlate with severity of symptoms<ref>Catapano, Michael, Robinson, David M., Schowalter, Sean and McInnis, Kelly C.. "Clinical evaluation and management of calcific tendinopathy: an evidence-based review" Journal of Osteopathic Medicine, vol. 122, no. 3, 2022, pp. 141-151. https://doi.org/10.1515/jom-2021-0213</ref>
***Note: calcification is not specific for calcific tendinitis (may occur in asymptomatic patients)
**Ultrasound is sensitive for detecting calcifications
***May show hyperechoic areas and posterior acoustic shadowing
***Can simultaneously detect rotator cuff tears or bursitis


==Management==
==Management==
*Nonoperative management is successful in most cases
*Nonoperative management is successful in most cases
**[[NSAIDs]]
**[[NSAIDs]], oral and topical
**Physical therapy
**Physical therapy for rotator/glenohumeral strength and ROM
**Stretch and strengthening
**Stretch and strengthening
***''Avoid'' immobilization
***''Avoid'' immobilization
****Rest shoulder in abduction on back of a chair as soon as tolerable
****Rest shoulder in abduction on back of a chair as soon as tolerable
****Sleep with pillow beneath axilla
****Sleep with pillow beneath axilla
**[[Corticosteroid]] injections
**Subacromial [[corticosteroid]] injection


==Disposition==
==Disposition==
*Primary care referral within 1wk
*Primary care referral within 1wk
*If chronic, may consider ortho referral for operative management
*If chronic, may consider ortho referral for extracorporeal shock wave therapy, ultrasound-guided lavage, or operative management


==See Also==
==See Also==

Revision as of 15:21, 14 February 2024

Background

  • Self-limiting disorder of calcium hydroxyapatite deposition within one or more tendons of the rotator cuff
    • Usually spontaneous, not necessarily caused by trauma or overuse
    • With time, the calcium undergoes painful resorption with subsequent tendon healing
  • Middle-aged patients 30-50 years are most commonly affected (rarely seen in patients >70yrs), and women are moreso affected[1]
  • Adhesive capsulitis is most common complication
  • Inflammatory reaction may exhibit warmth, swelling, or erythema that may mimic septic arthritis

Clinical Features

Precalcific phase

  • Fibrocartilaginous metaplasia of the tendon, leading to chondrocyte formation
  • Pain-free

Calcification phase

  • Formative phase
    • Characterized by cell-mediated calcific deposits
    • +/- Shoulder pain
  • Resting phase
    • Lacks inflammation or vascular infiltration
    • +/- pain
  • Resorptive phase (1-2 wks)
    • Characterized by phagocytic resorption and vascular infiltration
    • Most painful phase; due to inflammation in the resorptive process, increase in intratendinous pressure, or subacromial impingement
      • Pain may be similar to rotator cuff tendinopathy; usually at rest, worse at night and with laying on affected side
      • Leakage of calcium crystals onto the bursa may lead to sudden dramatic pain
      • Any shoulder motion reproduces significant pain; shoulder impingement tests are usually positive
      • TTP over proximal humerus near tendinous insertion of rotator cuff; may also be near AC joint or deltoid

Post-calcific phase

  • Calcific deposits have been resorbed; tendon returns to normal
  • Variable levels of pain and shoulder dysfunction

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Calcific tendinitis
  • Imaging
    • Plain films will show calcification in the tendon(s) of the rotator cuff
      • Usually in the supraspinatus tendon, proximal to its insertion site on the greater tuberosity[2]
      • Amount of calcification may not correlate with severity of symptoms[3]
      • Note: calcification is not specific for calcific tendinitis (may occur in asymptomatic patients)
    • Ultrasound is sensitive for detecting calcifications
      • May show hyperechoic areas and posterior acoustic shadowing
      • Can simultaneously detect rotator cuff tears or bursitis

Management

  • Nonoperative management is successful in most cases
    • NSAIDs, oral and topical
    • Physical therapy for rotator/glenohumeral strength and ROM
    • Stretch and strengthening
      • Avoid immobilization
        • Rest shoulder in abduction on back of a chair as soon as tolerable
        • Sleep with pillow beneath axilla
    • Subacromial corticosteroid injection

Disposition

  • Primary care referral within 1wk
  • If chronic, may consider ortho referral for extracorporeal shock wave therapy, ultrasound-guided lavage, or operative management

See Also

References

  1. ↑ Merolla G, Singh S, Paladini P, Porcellini G. Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment. J Orthop Traumatol. 2016 Mar;17(1):7-14. doi: 10.1007/s10195-015-0367-6. Epub 2015 Jul 12. PMID: 26163832; PMCID: PMC4805635.
  2. ↑ Kim MS, Kim IW, Lee S, Shin SJ. Diagnosis and treatment of calcific tendinitis of the shoulder. Clin Shoulder Elb. 2020 Nov 27;23(4):210-216. doi: 10.5397/cise.2020.00318. PMID: 33330261; PMCID: PMC7726362.
  3. ↑ Catapano, Michael, Robinson, David M., Schowalter, Sean and McInnis, Kelly C.. "Clinical evaluation and management of calcific tendinopathy: an evidence-based review" Journal of Osteopathic Medicine, vol. 122, no. 3, 2022, pp. 141-151. https://doi.org/10.1515/jom-2021-0213
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