Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: Ultrasound image and treatment

Imaging of calcific tendinopathy: natural history, migration patterns, pitfalls, and management: a review

Calcific tendinopathy is characterized by the deposition of calcium hydroxyapatite crystals in various tendons of the body. Terms like calcium tendinitis, tendinosis, and tendinopathy are used interchangeably. Calcific tendinopathy is a common and well-documented ailment in the literature. Although common, the natural history, aetiology, and progression of calcific tendinitis are poorly understood. The treatment options include conservative and interventional measures. However, these measures cannot be applied as a blanket and are often tailored depending on the stage/phase of the disease. Out of the recognized stages of the disease, the resorptive stage causes the utmost symptoms when the calcium is rather soft and unstable. During this stage, the calcium may migrate beyond expected resorption and get deposited in the adjacent tissues contiguous with the calcium focus. The common destinations include bursal migration, intraosseous migration, muscular migration, and other less common migration sites. Such atypical presentations can lead to dilemmas in the diagnosis, prolongation of the diagnostic pathway, unwarranted apprehension, and treatment delay. Radiologists' role in this situation is to correctly recognize the imaging findings of atypical presentations of calcific tendinopathy and prevent unnecessary diagnostic and interventional studies. In this review article, we describe the pathogenic pathway and natural history of calcific tendinopathy from a radiologist's perspective and discuss different migratory patterns of calcium in calcific tendinopathy not only around the shoulder but also in other areas of the body on different imaging modalities. We also show a few examples of mimics and pitfalls on imaging. Finally, we discuss the appropriate management option of this condition.

Calcific Tendinopathy Atypically Located Outside the Rotator Cuff: A Systematic Review

BACKGROUND AND PURPOSE

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited. The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

METHODS

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

RESULTS

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

CONCLUSION

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

Ultrasound imaging of bone fractures

Ultrasound imaging is widely used to evaluate the neuromusculoskeletal system, and recently, a particular interest is mounting in assessing the bone tissue and fractures. Ultrasound can be considered a valuable diagnostic tool to perform a first-line evaluation of bone tissue, especially in particular settings without direct access to X-ray imaging and/or in emergency conditions. Moreover, different healing phases of bone fractures can be accurately assessed by combining the B-mode modality and (high-sensitive) color/power Doppler optimizing the management of patients-e.g., planning of progressive loads and rehabilitation procedures. In this review, we summarized the role of ultrasound imaging in the management of bone fractures and described the most common sonographic signs encountered in the daily practice by assessing different types of bone fractures and the progressive phases of the healing process.

Clinical/Sonographic Assessment and Management of Calcific Tendinopathy of the Shoulder: A Narrative Review

Shoulder disorders are very common in clinical practice. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process with different/possible patterns of migration. In this paper, we have illustrated how and where these calcium depositions can migrate from the rotator cuff tendons to the peri-articular soft tissues. We have also tried to discuss the issue from the clinical side, i.e., how these particular conditions might impact the specific diagnosis, appropriate rehabilitation plan or interventional approach for optimal functional recovery.

Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls

Rotator cuff calcific tendinopathy (RCCT) is a very common condition, characterized by calcium deposition over fibrocartilaginous metaplasia of tenocytes, mainly occurring in the supraspinatus tendon. RCCT has a typical imaging presentation: in most cases, calcific deposits appear as a dense opacity around the humeral head on conventional radiography, as hyperechoic foci with or without acoustic shadow at ultrasound and as a signal void at magnetic resonance imaging. However, radiologists have to keep in mind the possible unusual presentations of RCCT and the key imaging features to correctly differentiate RCCT from other RC conditions, such as calcific enthesopathy or RC tears. Other presentations of RCCT to be considered are intrabursal, intraosseous, and intramuscular migration of calcific deposits that may mimic infectious processes or malignancies. While intrabursal and intraosseous migration are quite common, intramuscular migration is an unusual evolution of RCCT. It is important also to know atypical regions affected by calcific tendinopathy as biceps brachii, pectoralis major, and deltoid tendons. Unusual presentations of RCCT may lead to diagnostic challenge and mistakes. The aim of this review is to illustrate the usual and unusual imaging findings of RCCT that radiologists should know to reach the correct diagnosis and to exclude other entities with the purpose of preventing further unnecessary imaging examinations or interventional procedures.

Diagnosing acetabular labral tears with hip traction sonography: a case series

PURPOSE

Three cases of acetabular labral tear (ALT) diagnosed with sonography (US) are reported. We aim to show utility for US with the addition of manual hip traction as an adjunctive modality to the current diagnostic imaging of choice, magnetic resonance arthrography (MRA), for diagnosing ALT.

METHODS

Three cases of young athletic patients with similar clinical presentations are reported. All received US examination of the hip with attention to the labrum that included a novel long-axis hip traction technique which assisted in diagnosing ALT.

RESULTS

In the first and second cases, MRA and orthopedic consult were obtained for confirmation of the diagnosis. Arthroscopy was performed to correct the ALT. The third patient declined an MRA. Conservative management consisted of McKenzie method active care, resulting in return to sport in the third case.

CONCLUSION

These three cases demonstrate the clinical and sonographic presentation of ALT. The dynamic long-axis hip traction protocol facilitated the use of US as an adjunctive modality for diagnosing ALT by increasing the visualization of the defect.

Not all abolished lung sliding are pneumothorax: the case of a particular lung atelectasis

INTRODUCTION

Lung ultrasound (LUS) is expanding from the field of emergency medicine, also to the pneumological specialist field, becoming part of the diagnostic procedure of lung consolidation.

CASE PRESENTATION

A 78-year-old male was admitted to our emergency department for exertional dyspnea. LUS was performed, thus showing at right hemitorax air interface, A lines pattern, pleural sliding abolished on the whole hemitorax, thus suggesting a pneumothorax, but no evidence of lung point. A scan of lower lung segment showed an absence of the diaphragmatic excursion, suggestive for hemiparalysis of the diaphragm muscle, then confirmed by a subcostal scan. Moreover, at the lower segment of right hemitorax there was mild pleural effusion allowing the visualization of a round-shaped parenchymal consolidation with the absence of air bronchograms.

CONCLUSIONS

LUS allowed the visualization of a particular and rare disease such as anthracosis-associated rounded atelectasis, thus leading to a more correct and faster patient management.

Rectus abdominis muscle tear diagnosed with sonography and its conservative management

PURPOSE

This is a rare case of a post-traumatic rectus abdominis muscle tear in an adolescent female diagnosed by ultrasonography (US). Conservative management is also described.

METHODS

A 14-year-old female presented to a chiropractic clinic with extreme pain and tenderness in the right lower quadrant (RLQ) after post-plyometric power kneel box jumps. Movement aggravated her pain and she demonstrated active abdominal guarding with RLQ palpation. Ultrasonography revealed a subacute Grade 2 right rectus abdominis muscle tear, without evidence of hyperemia or a hematoma. Following the diagnosis of a right rectus abdominis muscle tear, she was treated with spinal manipulation and a course of musculoskeletal rehabilitation directed at truncal stabilization.

RESULTS

After treatment, the patient was able to return to play 5 week post-injury without any pain or discomfort. A follow-up US at 3 months provided evidence of muscle healing without complications.

CONCLUSION

This case demonstrates the diagnosis of a rare rectus abdominis muscle tear managed conservatively. To our knowledge, less than a dozen cases are reported using US in the evaluation and diagnosis of a rectus abdominis tear.

Calcific tendinopathy of the direct head of rectus femoris: a rare cause of groin pain treated with ultrasound guided percutaneous irrigation

Groin pain can be caused by a myriad of pathologies. Abnormalities of the rectus femoris are a very rare cause of groin pain; calcific tendinopathy of the direct head is particularly so, with only two case reports in the literature. We report the first case of calcific tendinopathy of the direct head of the rectus femoris that was treated effectively with ultrasound-guided percutaneous irrigation of calcific tendinopathy (USPICT). The anatomy of the rectus femoris and the technique for US-PICT of the rectus femoris are also described.

Ultrasound features of painful intraosseous migration of pectoralis major tendinous calcifications with follow-up

Calcific tendinitis is a common disorder in adults. Although rare, humerus involvement associated with pectoralis major tendon calcification migration has previously been reported in studies that focus on its CT and MRI appearance. We present four cases of intraosseous migration of pectoralis major tendon calcification and their ultrasound features. Calcification migration into osseous structures is associated with cortical erosions, intraosseous calcifications, and bone marrow edema. These findings may be misleading on MRI, where the significant bone marrow and surrounding tissue inflammation may raise concerns regarding neoplasia and lead to unnecessary invasive biopsy. In these cases, echography can be less alarming, enabling the identification of the calcification, its location in the pectoralis major tendon enthesis, and the continuity between the calcification and the typical cortical erosion. Ultrasound features may be diagnostic and might help avoid additional costly imaging studies or invasive biopsy.