Calcific_Tendinitis_FINAL

Calcific Tendonitis of the Shoulder 10/12/2011: 

Calcific Tendonitis of the Shoulder 10/12/2011 Elaine Coetzee Julie Frymyer Jason Schoonover

General Description:: 

General Description: Described as a cell-mediated process which results in deposited calcium hydroxyapatite crystals within the tendons. (1) Calcium has a consistency of toothpaste. (2) Deposition of calcium can be rapid or slow. (2) Relatively common. Exact pathology remains unclear; however current literature describes 4 separate phases of the process: formative, calcific, resorptive, and reparative. (3) Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.) Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg 1997;5:183-91.

4 Phases of Calcific Tendinitis:(1): 

4 Phases of Calcific Tendinitis: (1) Formative: Part of the tendon undergoes a fibrocartilaginous transformation possibly due to vascular or mechanical involvement. In this phase, calcification begins to occur. Calcific: A relative rest period where patients may experience pain in the involved shoulder if the deposit is large. Resorptive: An inflammatory reaction (usually painful) begins in this stage. Vascular tissue then begins to form around the outside of the calcific formation and the absorption of the deposit begins. Reparative: Fibroblasts begin to replace a normal pattern of tendon collagen. 1. Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

Incidence:: 

Incidence: Men > Women. (1) Shoulder is the most common joint affected . (2) Accounts for ~7% of shoulder pain. (3) However , calcific deposits can also be found in 3-20% of asymptomatic shoulders . (4) Supraspinatus M. is most frequently involved followed by the infraspinatus M., teres minor M., and subscapularis M . (4) Deposit typically located ~1-2cm proximal to the tendonous insertion into the greater tuberosity . (6) Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.) Speed CA, Hazleman BL. Calcific tendinitis of the shoulder. N Engl J Med 1999;340:1582-4. Re LP Jr, Karzel RP. Management of rotator cuff calcifications. Orthop Clin North Am . Jan 1993;24(1):125-32. Uhthoff HK. Calcifying tendinitis. Ann Chir Gynaecol 1996;85:111-5. Woodward AH. Calcifying Tendonitis. WebMD Page. http://emedicine.medscape.com/article/1267908-overview#showall. Updated: Aug 12, 2011. Accessed October 10, 2011.

Signs and Symptoms:: 

Signs and Symptoms: The patient tends to hold the involved UE into the loose pack position (slight abducted and flexed). (1) No specific sign or symptom that would indicate calcific tendonitis by itself. Examining focuses on finding damage to the tendon and the tendonosis ( partial/complete tear). (1) In the acute phase, the pain may be so high that only slight movement is allowed/tolerated with severe tenderness. (2) In the chronic or subacute stage of condition, symptoms may demonstrate decreased range of motion, a painful arc (70-110 °) of forward elevation, or impingement signs. Catching or crepitus may be noted. (2) Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Woodward AH. Calcifying Tendonitis. WebMD Page. http://emedicine.medscape.com/article/1267908-overview#showall. Updated: Aug 12, 2011. Accessed October 10, 2011.

Positive Exam Findings: (1): 

Positive Exam Findings : (1) Palpation for condition – warmth and swelling over the supraspinatus tendon. AROM – painful arc. PROM – painful in the opposite direction that the muscle contracts (IR and adduction). MSTT – strong and painful with ER and abduction. MLT – pain with lengthening of the supraspinatus. Palpation for tenderness – painful over the supraspinatus tendon. 1. Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010.

Diagnosing Calcific Tendonitis: 

Diagnosing Calcific Tendonitis Diagnostic imaging would be the best examination to confirm the calcific component of this dysfunction as a result of shared signs and symptoms with other conditions. (1) Standard Radiograph most practical. (2) - Cost Effective - Can determine the presence and extent of calcium deposits Lab studies not required. (3) Woodward AH. Calcifying Tendonitis. WebMD Page. http://emedicine.medscape.com/article/1267908-overview#showall. Updated: Aug 12, 2011. Accessed October 10, 2011. Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.) 3. Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010.

Differential Diagnosis:: 

Differential Diagnosis: Peak occurrence at earlier age compared to degeneration. Calcifying tendinitis may resolve with spontaneous healing as opposed to degenerative tendinopathy. Rarely associated with rotator cuff tears. Chemical makeup of calcium salts found in degenerate tendons is different. Calcific deposit found in calcifying tendinitis consists of poorly crystallized hydroxyapatite. Calcifying tendinitis tends to present in healthy, not-necrotic, tissue, while dystrophic calcification appears to occur in necrotic tissue.

Prognosis:: 

Prognosis: Very good: - According to del Cura et al, 91% of patients treated for calcific tendinitis have resolution of symptoms and 89% have resolution of calcifications on radiographs, 1 year after intervention. (1) 1. del Cura JL, Torre I, Zabala R, et al. Sonographically guided percutaneous needle lavage in calcific tendinitis of the shoulder: short- and long-term results. AJR Am J Roentgenol 2007;189:W128-34.

Functional Impact: 

Functional Impact Depending on the patient’s stage of condition and/or which phase of the cell-mediated process they are in, the functional impact could : - No loss of function : secondary to the possibility of the patient being asymptomatic. - Varied loss of function : (1) - Pain that radiates from the apex of the shoulder down towards the deltoid tubercle is often induced by elevation of the arm above 90°or by lying down on/sleeping on the shoulder. - Patient may be awaken by pain. - May complain of stiffness, snapping, catching, or generalized weakness of the shoulder during ADL’s. Woodward AH. Calcifying Tendonitis. WebMD Page. http://emedicine.medscape.com/article/1267908-overview#showall. Updated: Aug 12, 2011. Accessed October 10, 2011.

Management: 

Management Conservative (1,2) Physical Therapy Iontophoresis Deep friction massage Ultrasound NSAIDs Mouzopoulos G, Stamatakos M, Mouaopoulos D, Tzurbakis M. Extracoporpereal Shock Wave Treatment for Shoulder Calcific Tendonitis: A Systemic Review. Skeletal Radiol: 2007 (36): 803-811. Ebenbichler GR et al. Ultrasound Therapy for Calcific Tendonitis of the Shoulder. The England Journal of Medicine. 1999: 340 (20) 1533--1538.

Management: 

Management Minimally Invasive (1,2) Extracorporeal shockwave lithorpsy-effective expensive, painful, not widely available Ultrsound or fluodorosopicallly guided needle aspiration of calcium deposit Subacromial bursal steroid injection Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.) Mouzopoulos G, Stamatakos M, Mouzopoulos D, Tzurbakis M. Extracoporeal Shock Wave Treatment for Shoulder Calcific Tendonitis: A Systemic Review. 2007: (36) 803-811.

Management : 

Management Invasive 1,2 Surgery Arthoscopic Debridement of calcium deposit Subacromial decompression Mouzopoulos G, Stamatakos M, Mouaopoulos D, Tzurbakis M. Extracoporpereal Shock Wave Treatment for Shoulder Calcific Tendonitis: A Systemic Review. Skeletal Radiol: 2007 (36): 803-811. Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

Imaging Evaluation: 

Imaging Evaluation Standard Radiograph A/P (neutral and internally rotated) Supraspinatus outlet view Lateral view (Cross table view) CT MRI T1/T2 US

Imaging Evaluation-Radiograph: 

Imaging Evaluation-Radiograph Radiographs (1) Primary imaging for evaluation Assesses extent, delineation, and density Typically small ranging from a few mm to cms Well defined homogenous contour is formative phase Hazy, ill defined contour is indicative of resorptive phase Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

Radiographs: 

Radiographs Mass superior and lateral to the greater tubercle in supraspinatus tendon Dip in contour of bone at greater tubercle Increased radio opaqueness at the greater tubercle on head of humerus Appears to be decreased space between the arcomian and head of the humerus Otherwise normal radiograph according to ABCs Patel, M. Calcific Tendinosis of Supraspinatus Tendon. Radiopaedia page. http://radiopaedia.org/images/907771. Updated May 7 , 2011. Accessed October 10 2011. Aguston, H. . Imaging for Physical and Occupational Therapists. PHT 6403E. University of St. Augustine. Fall 2011. McKinnis, L.(2005). Fundamentals of Musculoskeletal Imaging. Philadelphia: F.A. Davis Company

Possible Biomechanical and Physical Findings from Radiograph (1,2,3):: 

Possible Biomechanical and Physical Findings from Radiograph (1,2,3) : Well defined calcific mass Indicates formative phase Very painful and symptomatic phase May present with shoulder in loose pack position in efforts to decrease pain May present with painful arc of motion May present with crepitus during ROM May present with altered joint mobility testing Possible hypomobile inferior glide or hyerpmobility Increased radio opaqueness at greater tubercle Could be indicative of tendon pulling on bone Possible cause: decreased length of supraspinatus May present with decreased MLT of supraspinatus May present with other muscular imbalance in the shoulder complex Decreased muscle length, decreased strength

Possible Biomechanical and Physical Findings from Radiograph (1,2,3):: 

Possible Biomechanical and Physical Findings from Radiograph (1,2,3) : Decreased space between acromian and head of humerus May present with forward, rounded shoulders May present with forward head May present with kyphotic posture Cannot seat humeral head during elevation due to stretch weakness Baldwin, T., Patla, C.E., Verala, T. Musculoskelatal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Chase L, Schooley M. Therapuetic Exercise. PHT5234. University of St. Augustine. Summer 2010. Woodward AH. Calcifying Tendonitis. WebMD Page. http://emedicine.medscape.com/article/1267908-overview#showall. Updated: Aug 12, 2011. Accessed October 10, 2011.

Imaging Evaluation-CT: 

Imaging Evaluation-CT CT (1) Best when evaluating osseous involvement Helps to evaluate cortical changes and intramedullary extension Most accurate modality for predicting consistency of calcific deposits Soft calcifications appear heterogeneous and hard calcifications appear homogenous Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

CT: 

CT Low attenuation at greater tuberosity Extension into marrow Calcification at medial portion of lesion Flemming, D. Murphy D, Shekitka A, Temple HT, Jelinek J, Kransdorf M.  Osseous Involvement in calcific tendinitis: a respective review of 50 cases. American Journal of Roentgenology.  Oct 2003.  Vol. 181 (4)  965-972. Aguston, H. . Imaging for Physical and Occupational Therapists. PHT 6403E. University of St. Augustine. Fall 2011.

Possible Biomechanical and Physical Findings from CT:: 

Possible Biomechanical and Physical Findings from CT: Low attenuation at greater tuberosity Calcification at medial portion of lesion May present with painful arc of motion May present with increased pain above 90 degrees May present with crepitus during ROM May present with altered joint mobility testing Possible hypomobile inferior glide or hyerpmobility Baldwin, T., Patla, C.E., Verala, T. Musculoskeletal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Chase L, Schooley M. Therapuetic Exercise. PHT5234. University of St. Augustine. Summer 2010

Imaging Evaluaiton-MRI: 

Imaging Evaluaiton-MRI MRI Best when evaluating soft tissue abnormalities Characterize extent of abnormality Appear as low signal, typically at or near tendon insertion Small deposits difficult to see Comparison radiographs should be obtained in conjunction with MRI Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

MRI: 

MRI Dark signal superior lateral to greater tubercle (marked by green arrow) This is calcific mass in supraspinatus tendon Heterogeneous signal within the supraspinatus tendon Displacement of subdeltoid bursa due to calcific mass BMJ Publishing Group. Tendenopathy. Best Practice Webpage. http://bestpractice.bmj.com/best-practice/monograph/582/resources/images.html Accessed October 10 2011. Aguston, H. . Imaging for Physical and Occupational Therapists. PHT 6403E. University of St. Augustine. Fall 2011. McKinnis, L.(2005). Fundamentals of Musculoskeletal Imaging. Philadelphia: F.A. Davis Company

Possible Biomechanical and Physical Findings from MRI:: 

Possible Biomechanical and Physical Findings from MRI: Calcific Mass in supraspinatus tendon May present with rounded shoulder posture May present with painful arc of motion May present with crepitus during ROM May present with altered joint mobility testing Possible hypomobile inferior glide or hyerpmobility Displacement of subdeltoid bursa Patient may present with S/S of bursitis including inflammation and swelling at the subdelotid bursa May complain of pain even at rest Pain with lengthening of muscle over bursa in PROM Pain with any motion that compresses the bursa Baldwin, T., Patla, C.E., Verala, T. Musculoskeletal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Chase L, Schooley M. Therapuetic Exercise. PHT5234. University of St. Augustine. Summer 2010.

Imaging Evaluation-US: 

Imaging Evaluation-US US (1) Appears as hyperechoic focus Reliable in detection and location Unable to classify pathophysiologic phase Should be combined with radiograph studies Useful for guiding percutaneous needle aspiration Siegal DS,  Wu JS , Newman JS, del Cura JL, Hochman MG.  Calcific Tendinitis: A Pictorial Review. Canadian Association of Radiologists Journal.  Montreal:Dec 2009.  Vol. 60,  Iss. 5,  p. 263-72 (10 pp.)

Ultrasound: 

Ultrasound Echogenic mass in the supraspinatus tendon Disrupted parallel fiber pattern in the supraspinatus tendon Humeral head contour is not smooth and rounded Widening of bursa and increase less hypoechoic Thickening of the cartilage Cullinane, B.Supraspinatus Tendon. Radiopaedia Webpage. http://radiopaedia.org/images/634504 Updated February 6 2011 . Accessed October 10 2011. Aguston, H. . Imaging for Physical and Occupational Therapists. PHT 6403E. University of St. Augustine. Fall 2011. Normal Calcific Tendonitis

Possible Biomechanical and Physical Findings from US:: 

Possible Biomechanical and Physical Findings from US: Echogenic mass in the supraspinatus tendon and disrupted parallel fiber pattern May present with painful arc of motion May present with increased pain above 90 degrees May present with crepitus during ROM May present with altered joint mobility testing Possible hypomobile inferior glide or hyerpmobility Altered humeral head contour and thickening of cartilage May present with rounded shoulder posture May present with altered joint mobility testing Widening of bursa Patient may present with S/S of bursitis including inflammation and swelling at the subdelotid bursa May complain of pain even at rest Pain with lengthening of muscle over bursa in PROM Pain with any motion that compresses the bursa Baldwin, T., Patla, C.E., Verala, T. Musculoskeletal I: Orthopeadics. PHT 5132C. University of St. Augustine. Summer 2010. Chase L, Schooley M. Therapuetic Exercise. PHT5234. University of St. Augustine. Summer 2010

Questions: 

Questions How/why would a patients treatment differ during each phase (formative, calcific, resorptive, and reparative) of calcific tendonitis? Since imaging is required to diagnose calcific tendonitis, what are some differential diagnosis without imaging based on signs, symptoms, and impairments during a PT evaluation?