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James Wilson Upper Limb Fellow Teaching

30/09/2014

Calcific Tendonitis

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• Calcific tendonitis / calcific perarthritis • Predominantly in the shoulder • Can be manifest throughout the body

• (Longus coli)

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• Due to deposition of poorly calcified Hydroxyapatite

Ca10(PO4)6(OH)2

Definition

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• Exact pathogenesis unclear. • ? association with endocrine disorders (Harvie) • ? matrix vesicles (Gohr) • ? due to tendon degeneration and necrosis

• Peak age earlier • Calcific tendinitis may resolve • Dystrophic calcification occurs in necrotic tissue • Different chemical composition

Aetiology

Harvie P, Pollard TC, Carr AJ. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg 2007; 16:169–173 Gohr CM. Fahey M. Rosenthal AK. Calcific tendonitis: a model. Connect Tissue Res 2007:48:286-91.

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• Formative • Calcific • Resorptive • Reparative !

• Natural History

Cell Mediated Process

Uhthoff HK. Loehr JW, Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg 1997:5:183-91.

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• Age of onset typically 30-60 yrs • Slight female preponderance

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• Location • supraspinatus - 80% • infraspinatus - 15% • subscapularis - 5% • periarticular soft tissues - ligaments, capsule, bursae

Clinical Presentation

Speed CA. Hazleman BL. Calcific tendinitis of the shoulder, N Engl J Med 1999:340:1582-4.

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• X-ray • Most practical • Diagnosis • Extent • Density !

• Gartner and Heyer • I, II, III

• Molé et al. • A,B,C,D

Investigations

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• Diagnostic and Therapeutic

• Hyperechoic focus • Posterior acoustic

shadowing may be present • Can’t classify phase

Ultrasound

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• Often incidental • Best for assessing bony erosion

(humeral head) • Best for assessing consistency

• Soft or semi-liquid heterogeneous

• Hard / solid more homogeneous and higher density

CT

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MRI

• T1 - ◦ hypo intense homogeneous signal ◦ adjacent tendon may be thickened ◦ some enhancement surrounding deposit may be seen • T2 - ◦ hypo intense calcium deposits ◦ hyper intense signal may be present peripherally (oedema) ◦ hyper intense subacromial-subdeltoid bursal fluid • T2* - calcifications may bloom

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• Rest • NSAIDs • Physiotherapy • Subacromial steroid injection • Radial or traditional ESWT • Needling / Barbotage (better if not solid) • Surgical release

Treatment

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• ‘High’ or ‘low’ energy • Measured by Energy Flux Density (EFD) • 10-30 mins +/- local anaesthetic

ESWT

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ESWT• High energy ESWT effective

for pain and function • High energy > 0.28 mJ/mm2 • No useful comparisons with

surgery • (? equivalence for non-homogenious

deposits)

• No benefit in treating non-calcific tendinitis

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• Case series - n=35 • Combined with Subacromial

steroid injection • 71% improved within 6 months • Constant scores 54 - 88 • 6 failed and had Surgery • (mean Constant - 92)

U/S guided Needling

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• Increased vascularity may be evident when viewing from GHJt side (resorbtive phase)

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• Large residual defects can be repaired

Surgical Debridement

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• Case-control study • 50 patients, 25 in each arm • 2 surgeons with different

techniques • data collected over 10 yrs • Outcome measures - return to

full activity • Found no difference in long

term outcome but sooner return to full activity.

Surgical debridement