Shoulder

Sonographic evaluation of the association between calcific tendinopathy and rotator cuff tear: a case-controlled comparison

OBJECTIVES

To compare the incidence of rotator cuff (RC) tears on shoulder ultrasounds of patients with RC calcific tendinopathy (CaT) to that of a control group without CaT.

METHOD

In this retrospective case-control study, 50 shoulder ultrasounds of patients with CaT were compared independently by 2 musculoskeletal radiologists to 50 patients from a control group without CaT to catalog the number and type of RC tears. RC tears in the CaT group were further characterized based on location, into tears in the specific tendon(s) containing calcium versus all tendon tears.

RESULTS

RC tears were diagnosed in 38% (19/50) of the control group (16 full-thickness) as compared to 22% (11/50) with CaT (6 full-thickness). The fewer full-thickness tears in the CaT group (12%, 6 of 50) compared to that in the control group (32%, 16 of 50) was statistically significant (P = 0.016, odds ratio 0.29). Only 7 of the 11 tears in the CaT group were in a calcium-containing tendon (3 full-thickness). The fewer calcium-containing tendon tears compared to tears in the control group was also statistically significant (P = 0.006, odds ratio 0.27). Furthermore, the fewer full-thickness calcium-containing tendon tears (6%, 3/50) compared to full-thickness tears in the control group (32%, 16/50) were yet more statistically significant (P = 0.001, odds ratio 0.14).

CONCLUSIONS

In patients with shoulder pain and CaT, we observed a decreased number of RC tears and especially calcium-containing tendon tears, as compared to similar demographic patients with shoulder pain but without CaT. Key Points • Patients with rotator cuff calcific tendinopathy have few rotator cuff tears, especially full-thickness tears, compared to a control group without calcific tendinopathy. • The tendons containing the calcium hydroxyapatite deposition were the least likely to have a rotator cuff tear. • Future studies could evaluate if calcium hydroxyapatite deposition provides a protective mechanism against rotator cuff tears. • Musculoskeletal ultrasound is more sensitive than MRI in the evaluation of rotator cuff calcific tendinopathy.

Ultrasound Appearance of the Migration of Tendon Calcifications

Calcific tendinopathy (CTe) is a frequent disorder related to the deposition of calcium hydroxyapatite crystals within tendons. Ultrasound has been shown to be an excellent imaging modality for the evaluation of CTe. During the resorptive phase of CTe, calcium deposits may migrate inside the tendons or in neighboring tissues and lead to local inflammation and severe pain. In this pictorial essay, we describe the ultrasound appearance of a spectrum of CTe migrations. Knowledge of the different migration patterns can help sonologists in their detection and in establishing the correct diagnosis.

Case report - calcification of the medial collateral ligament of the knee with simultaneous calcifying tendinitis of the rotator cuff

BACKGROUND

Calcification of the medial collateral ligament (MCL) of the knee is a very rare disease. We report on a case of a patient with a calcifying lesion within the MCL and simultaneous calcifying tendinitis of the rotator cuff in both shoulders.

CASE PRESENTATION

Calcification of the MCL was diagnosed both via x-ray and magnetic resonance imaging (MRI) and was successfully treated surgically. Calcifying tendinitis of the rotator cuff was successfully treated applying conservative methods.

CONCLUSION

This is the first case report of a patient suffering from both a calcifying lesion within the medial collateral ligament and calcifying tendinitis of the rotator cuff in both shoulders. Clinical symptoms, radio-morphological characteristics and macroscopic features were very similar and therefore it can be postulated that the underlying pathophysiology is the same in both diseases. Our experience suggests that magnetic resonance imaging and x-ray are invaluable tools for the diagnosis of this inflammatory calcifying disease of the ligament, and that surgical repair provides a good outcome if conservative treatment fails. It seems that calcification of the MCL is more likely to require surgery than calcifying tendinitis of the rotator cuff. However, the exact reason for this remains unclear to date.

Ultrasound imaging-guided percutaneous treatment of rotator cuff calcific tendinitis: success in short-term outcome

OBJECTIVE

Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month.

METHODS

A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month.

RESULTS

In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis.

CONCLUSION

The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults.

ADVANCES IN KNOWLEDGE

Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).

Exploring the Use of Sonographic Evaluation of the Glenohumeral Labrum

Glenohumeral (GH) dislocations of the shoulder are prevalent in young male subjects and appear to be increasing in incidence. The classic diagnostic evaluation of labral injuries such as this involves the use of clinical testing as well as imaging modalities such as computed tomography, magnetic resonance imaging, and radiography, none of which provides a dynamic evaluation. This study was done to replicate sonographic evaluation of the glenoid labrum in a preclinical model and use the axillary scanning approach to specifically assess the integrity of the anterior inferior labrum. Using sonographic guidance, minimal amounts of differently colored dyes were injected into regions of the glenoid labrum. This replication was able to image only the posterior superior, posterior inferior, and anterior inferior aspects of the GH labrum. Bankart lesions were identified in two shoulders, confirmed on dissection. The presence of dyes in the target areas within and around the labrum was visually confirmed. These findings suggest that the concept of using an axillary scanning approach for detecting labral tears and Bankart lesions in patients with acute and chronic shoulder dislocation may be worthwhile to incorporate into a shoulder-scanning protocol.

Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial

PURPOSE

To compare short- and long-term outcomes of patients with rotator cuff calcific tendonitis who did and did not undergo ultrasonographically (US)-guided percutaneous treatment.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were obtained. Of patients referred for US-guided treatment of rotator cuff calcific tendonitis, 219 (86 men, 133 women; mean age, 40.3 years +/- 10.9 [standard deviation]) were treated; 68 (31 men, 37 women; mean age, 40.2 years +/- 11.3) patients refused treatment and served as control subjects. After local anesthesia was induced, two 16-gauge needles were inserted into the calcific deposit. Saline solution was injected through one needle, and the dissolved calcium was extracted through the other needle. Shoulder joint function was assessed by using Constant scores, and pain was assessed by using visual analogue scale (VAS) scores. Mann-Whitney U and chi(2) tests were performed.

RESULTS

At baseline, no significant difference in age or sex distribution, Constant score, or VAS score was detected between treated and nontreated (control) patients. Compared with control subjects, treated patients reported a significant decrease in symptoms at 1 month (mean Constant score, 73.2 +/- 6.2 vs 57.5 +/- 3.9; mean VAS score, 4.8 +/- 0.6 vs 9.1 +/- 0.5), 3 months (mean Constant score, 90.2 +/- 2.6 vs 62.6 +/- 7.2; mean VAS score, 3.3 +/- 0.4 vs 7.3 +/- 1.8), and 1 year (mean Constant score, 91.7 +/- 3.1 vs 78.4 +/- 9.5; mean VAS score, 2.7 +/- 0.5 vs 4.5 +/- 0.9) (P < .001). Symptom scores were not significantly different between the groups at 5 years (mean Constant score, 90.9 +/- 3.6 vs 90.5 +/- 4.8; mean VAS score, 2.6 +/- 0.5 vs 2.8 +/- 0.7) (P >or= .795) and 10 years (mean Constant score, 91.8 +/- 5.0 vs 91.3 +/- 9.6; mean VAS score, 2.5 +/- 0.6 vs 2.7 +/- 0.6) (P >or= .413).

CONCLUSION

US-guided percutaneous treatment facilitated prompt shoulder function recovery and pain relief. Treated patients had better outcomes than did nontreated patients at 1 year. However, 5 and 10 years after the procedure, the nontreated group reported outcomes similar to those of the treated group.