Calcific tendinopathy of the shoulder with intraosseous extension: outcomes of ultrasound-guided percutaneous irrigation

Arthroscopic treatment of chronic calcific tendinitis with intraosseous migration: a case report

We present a case of calcific tendinitis in the shoulder, where calcifications were observed within both the tendon and the adjacent bone. At the time of acute onset, radiographs (including a plain radiograph) and magnetic resonance imaging revealed calcific tendinitis with intraosseous migration. The patient's symptoms did not improve after 5 months of conservative treatment. The patient underwent arthroscopic debridement of the calcific deposits, and the defect was repaired using the double-row repair technique. The patient's symptoms improved 3 months after arthroscopic treatment. We share our unusual experience with arthroscopic debridement in the treatment of chronic calcific tendinitis with intraosseous migration.

Interobserver reliability of classifying shoulder calcific tendinopathy on plain radiography and ultrasound

INTRODUCTION

Shoulder calcific tendinopathy is a frequent cause of shoulder pain. Diagnosis is usually based on ultrasound (US) and/or X-ray. US is considered an inherently operator-dependent imaging modality and, interobserver variability has previously been described by experts in the musculoskeletal US. The main objective of this study is to assess the interobserver agreement for shoulder calcific tendinopathy attending to the size, type, and location of calcium analyzed in plain film and ultrasound among trained musculoskeletal radiologists.

MATERIAL AND METHODS

From June 2018 to May 2019, we conducted a prospective study. Patients diagnosed with shoulder pain related to calcific tendinopathy were included. Two different experienced musculoskeletal radiologists evaluated independently the plain film and the US.

RESULTS

Forty patients, with a mean age of 54.6 years, were included. Cohen's kappa coefficient of 0.721 and 0.761 was obtained for the type of calcium encountered in plain film and the US, respectively. The location of calcification obtained a coefficient of 0.927 and 0.760 in plain film and US, respectively. The size of the calcification presented an intraclass correlation coefficient (ICC) of 0.891 and 0.86 in plain film and US respectively. No statistically significant differences were found in either measurement.

CONCLUSION

This study shows very good interobserver reliability of type and size measurement (plain film and US) of shoulder calcifying tendinopathy in experienced musculoskeletal radiologists.

Intraosseous extension of supraspinatus calcific tendonitis in a young patient with severe shoulder pain: a rare case report

Calcific tendinopathy is one of the causes of shoulder pain and limited range of motion when it affects the rotator cuff tendons. Complications of such a condition are rare and include intraosseous and intramuscular migration. Calcific tendonitis can be classified as acute, subacute or chronic based on the onset of symptoms. The incidence of calcific tendonitis affects females more than males, with the median age of onset being between 40 and 60 years old. Diagnostic modalities include radiographs and computed tomography (CT); however, these are suboptimal when compared to the sensitivity of magnetic resonance imaging. Ninety percent of these cases are treated non-surgically. We present a rare case of a young female patient with right shoulder pain and limited range of motion secondary to the intraosseous migration of calcific tendonitis. The patient's symptoms were resolved after a CT-guided percutaneous bone biopsy of the lesion. Clinical correlation with the aid of imaging and histopathology is a multimodal approach to help diagnose and treat such conditions.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores

PURPOSE

To evaluate the surgical outcomes of arthroscopic removal of intraosseous deposits in patients with intraosseous calcific tendinitis of the rotator cuff.

METHODS

This study involved a retrospective review of 96 patients operated on from 2004 to 2019. Patients were divided into two groups according to the location of calcific deposits. Group I had pure tendinous involvement (n = 71), and Group II had tendinous and intraosseous involvement (n = 25). The mean follow-up time was 6.4 ± 3.9 years. There were 71 patients (46 women, 25 men) in Group I, and the mean age was 49.3 ± 8.2 years (range 30-65 years). In group II, there were 25 patients (18 women, 7 men); the mean age was 47.3 ± 11.2 years (range 28-70 years).

RESULTS

The mean preoperative VAS pain score was 8.8 ± 1.4 in Group I compared to 9.5 ± 0.5 in group II (p = 0.017). The median preoperative Constant and Oxford scores were 42 (20-65) and 22 (8-34) in Group I and 25.5 (22-46) and 10 (8-16) in group II, respectively (p < 0.001). There was no difference in postoperative pain scores (Group I: 0.7 ± 1.6 and group II: 0.5 ± 0.6, p = 0.926), Constant scores [Group I: 100 (80-100) and group II: 100 (90-100), (n.s).] and Oxford scores [Group I: 48 (28-48) and group II: 46.5 (4-48), (n.s.)] between the two groups. The number of preoperative injections was higher in Group II (p = 0.05). There was no correlation between the size of the soft tissue calcific deposit and the preoperative pain, Constant, and Oxford scores (n.s.).

CONCLUSION

Arthroscopic debridement of calcific tendinitis with intraosseous involvement is a safe and effective treatment method similar to that of pure tendinous involvement.

LEVEL OF EVIDENCE

III.

Predicting long-term outcomes of ultrasound-guided percutaneous irrigation of calcific tendinopathy with the use of machine learning

OBJECTIVE

To evaluate the performance of two machine learning models in predicting the long-term complete pain resolution in patients undergoing ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT).

MATERIALS AND METHODS

Within a 3-year period, 100 consecutive patients who underwent US-PICT for rotator cuff disease were prospectively enrolled. The location, maximum diameter, and type of each calcification were recorded. The degree of calcium retrieval was graded as complete or incomplete. Shoulder pain was assessed with the visual analogue scale (VAS) at baseline, 1-week, 1-month, and 1-year post-treatment. Measurements related to procedural details, patient, and calcification characteristics were used to construct a machine learning model for the prediction of pain at 1-year post-US-PICT. Two distinct models were built, one including VAS data at 1 week and another additionally including pain data at 1-month post-treatment. Variable importance analysis was performed for the 1-week model. Model performance was evaluated by using receiver operating characteristics (ROC) curves and the respective areas under the curve (AUC).

RESULTS

The model exhibited an AUC of 69.2% for the prediction of complete pain resolution at 1 year. The addition of VAS scores at 1 month did not significantly alter the performance of the algorithm. Age and baseline VAS scores were the most important variables for classification performance.

CONCLUSION

The presented machine learning model exhibited an AUC of almost 70% in predicting complete pain resolution at 1 year. Pain data at 1 month do not appear to improve the performance of the algorithm.

Back to the roots of rheumatology - Imaging of regional pain syndromes

Musculoskeletal regional pain syndromes (RPS) often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can, in most cases, reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods, such as ultrasound (US) may support the clinical assessment. This paper reviews the underlying pathologies of some of the most frequently encountered RPS and the role of musculoskeletal US imaging for their diagnosis and treatment. If available, data on diagnostic accuracy and comparisons with gold standards are reported. The article stresses the importance of anatomical and sonoanatomical knowledge for the proper interpretation of the US images, points out the advantages and disadvantages of this imaging tool, and suggests the future research agenda.

Ultrasound-guided percutaneous irrigation of calcific tendinopathy: redefining predictors of treatment outcome

OBJECTIVES

To identify prognostic factors affecting the clinical outcome in patients treated with rotator cuff ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT), by evaluating the degree of calcium removal, the size and consistency of calcific deposits, and baseline level of shoulder pain and functionality.

METHODS

From January 2017 to December 2019, 79 patients (23 males, 56 females; mean age, 45.7 years) who underwent US-PICT were prospectively enrolled. The calcifications' location, consistency, and size were evaluated. For US-PICT, local anesthesia, lavage of calcific material, and intrabursal steroid injection were performed. The degree of calcium removal was graded as total/partial. Shoulder pain and functionality were assessed with the visual analogue scale (VAS) in all and Constant score (CS) in a subset of patients, respectively, at 4 time-points. Mann-Whitney U test, Fisher's test, and linear and binary logistic regression were utilized for analysis.

RESULTS

Pain improvement correlated with the presence of larger calcifications and lower baseline VAS score, at 1 week (p = 0.001, p < 0.001, respectively) and 1 year (p < 0.001, p = 0.002, respectively). Improved functionality correlated with total calcification retrieval, higher baseline CS, and fluid/soft calcific consistency at 1 week (p = 0.013, p = 0.003, p = 0.019, respectively). Increased calcification size, cystic appearance, and lower baseline VAS scores independently predicted complete pain resolution at 1 year.

CONCLUSION

Large calcifications and low-grade pain at baseline correlated with short- and long-term pain improvement. The degree of calcium removal did not impact pain or functional improvement beyond 1 week. Increased calcification size, cystic appearance, and low-grade baseline pain predicted complete pain recovery at 1 year.

KEY POINTS

• The presence of larger calcifications and lower-grade baseline pain appear to correlate with pain improvement at 1 week and 1 year after ultrasound-guided irrigation of rotator cuff calcific tendinopathy (US-PICT). • Total calcification retrieval, less affected baseline shoulder functionality, and presence of fluid/soft consistency of calcific deposits appear to correlate with improved shoulder functionality at 1 week post-treatment. • Baseline pain intensity and calcifications' morphologic characteristics, but not the degree of calcium retrieval, represent predictors of complete pain recovery at 1 year after US-PICT.

Calcific tendinopathy of the shoulder with intraosseous extension: experience with arthroscopic treatment and review of the literature

BACKGROUND AND AIM

Calcific tendinitis of the rotator cuff is a common cause of shoulder pain. The aim of the present study was to show a rare presentation of calcific tendinopathy of the shoulder, the intraosseous extension, which can be mistaken for a bone tumour or an infectious disease.

MATERIAL AND METHODS

Two clinical cases of calcific tendinopathy of the shoulder with intraosseous extension and a review of the literature are presented.

RESULTS

Cortical erosion, osteolytic lesion in the greater tuberosity and perilesional oedema were observed in both cases. Good results were achieved with shoulder arthroscopy including lesion debridement and reinsertion of the tendon in the greater tuberosity with an anchor.

CONCLUSIONS

In the presence of an osteolytic lesion with perilesional oedema in the greater tuberosity, the intraosseous expansion of a calcifying tendinopathy should be included in the differential diagnosis. In our cases the arthroscopic treatment was successful.

Changing appearance of intraosseous calcific tendinitis in the shoulder with time: A case report

We report a case of a 66-year-old woman who presented with acute shoulder pain. Initial radiographs revealed a sclerotic intraosseous lesion in the greater tuberosity with associated cortical erosions and subacromial calcification. The diagnosis of intraosseous calcific tendinitis was confirmed with additional magnetic resonance imaging and nuclear medicine imaging. Within 3 months of conservative measures, the patient's symptoms improved but the radiographic appearance had become more aggressive with a wider zone of transition. After 1 year, the imaging findings continued to change, with the development of subcortical cysts. Correct diagnosis of this uncommon manifestation of tendinitis requires knowledge of how its appearance changes with time.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Intraosseous migration of tendinous calcifications: two case reports

Calcific tendinopathy of the rotator cuff is a common cause of shoulder pain. Inflammation of the rotator cuff tendons may be complicated by adjacent bone erosion and subsequent migration of calcific deposits within the bone resulting in marrow inflammation. Bone marrow involvement is not readily visible using X-ray and ultrasound (US) and further testing is necessary. Magnetic resonance imaging (MRI) is a highly sensitive technique that can detect a focal bone T1 and T2-weighted hypointensity with bone marrow edema-like signal and cortical erosion. These findings can mislead the radiologist by suggesting an infectious or neoplastic lesion, often requiring further evaluation with computed tomography (CT) and biopsy. We report two cases of patients with shoulder pain in which different radiological approaches were used with pathological confirmation in one of them. In the first case, MRI revealed significant bone involvement in the head of the humerus and cortical erosion of the greater tuberosity. A CT examination and a biopsy was necessary for a final diagnosis of inflammatory bone reaction from intraosseous migration of tendinous calcifications. In the second case, similar MRI findings prompted re-evaluation of imaging to make a diagnosis of intraosseous migration of tendinous calcifications, obviating the need to perform CT and biopsy. We illustrate MRI signs of this complication that we think would allow to narrow the differential diagnosis potentially avoiding biopsy and additional CT examinations.

Rotator Cuff Calcific Tendinopathy: Randomized Comparison of US-guided Percutaneous Treatments by Using One or Two Needles

Purpose To determine whether the use of one or two needles influences procedure performance and patient outcomes for ultrasonography (US)-guided percutaneous irrigation of calcific tendinopathy. Materials and Methods Institutional review board approval and written informed patient consent were obtained. From February 2012 to December 2014, 211 patients (77 men and 134 women; mean age, 41.6 years ± 11.6; range, 24-69 years) with painful calcific tendinopathy diagnosed at US were prospectively enrolled and randomized. Operators subjectively graded calcifications as hard, soft, or fluid according to their appearance at US. US-guided percutaneous irrigation of calcific tendinopathy (local anesthesia, needle lavage, intrabursal steroid injection) was performed in 100 patients by using the single-needle procedure and in 111 patients by using the double-needle procedure. Calcium dissolution was subjectively scored (easy = 1; intermediate = 2; difficult = 3). Procedure duration was recorded. Clinical evaluation was performed by using the Constant score up to 1 year after the procedure. The occurrence of postprocedural bursitis was recorded. Mann-Whitney U, χ², and analysis of variance statistics were used. Results No difference in procedure duration was seen overall (P = .060). Procedure duration was shorter with the double-needle procedure in hard calcifications (P < .001) and with the single-needle procedure in fluid calcifications (P = .024). Ease of calcium dissolution was not different between single- and double-needle procedures, both overall and when considering calcification appearance (P > .089). No clinical differences were found (Constant scores for single-needle group: baseline, 55 ± 7; 1 month, 69 ± 7; 3 month, 90 ± 5; 1 year, 92 ± 4; double-needle group: 57 ± 6; 71 ± 9; 89 ± 7; 92 ± 4, respectively; P = .241). In the single-needle group, nine of 100 cases (9%) of postprocedural bursitis were seen, whereas four of 111 cases (3.6%) were seen in the double-needle group (P = .180). Conclusion The only difference between using the single- or double-needle procedure when performing US-guided percutaneous irrigation of calcific tendinopathy is procedure duration in hard and fluid calcifications. Clinical outcomes are similar up to 1 year. ^© RSNA, 2017.