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Page 1 of 24 Special forms of calcific tendonitis in the rotator cuff, with predominance of osseous involvement. Apropos of 6 cases Poster No.: C-1021 Congress: ECR 2013 Type: Scientific Exhibit Authors: A. Alcalá-Galiano Rubio , M. Baeva Trunina, M. J. Argüeso Chamorro; Madrid/ES Keywords: Extremities, Musculoskeletal bone, Musculoskeletal soft tissue, Conventional radiography, MR, CT DOI: 10.1594/ecr2013/C-1021 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third- party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org

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Page 1: Special forms of calcific tendonitis in the rotator …...Keywords: Extremities, Musculoskeletal bone, Musculoskeletal soft tissue, Conventional radiography, MR, CT DOI: 10.1594/ecr2013/C-1021

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Special forms of calcific tendonitis in the rotator cuff, withpredominance of osseous involvement. Apropos of 6 cases

Poster No.: C-1021

Congress: ECR 2013

Type: Scientific Exhibit

Authors: A. Alcalá-Galiano Rubio, M. Baeva Trunina, M. J. ArgüesoChamorro; Madrid/ES

Keywords: Extremities, Musculoskeletal bone, Musculoskeletal soft tissue,Conventional radiography, MR, CT

DOI: 10.1594/ecr2013/C-1021

Any information contained in this pdf file is automatically generated from digital materialsubmitted to EPOS by third parties in the form of scientific presentations. Referencesto any names, marks, products, or services of third parties or hypertext links to third-party sites or information are provided solely as a convenience to you and do not inany way constitute or imply ECR's endorsement, sponsorship or recommendation of thethird party, information, product or service. ECR is not responsible for the content ofthese pages and does not make any representations regarding the content or accuracyof material in this file.As per copyright regulations, any unauthorised use of the material or parts thereof aswell as commercial reproduction or multiple distribution by any traditional or electronicallybased reproduction/publication method ist strictly prohibited.You agree to defend, indemnify, and hold ECR harmless from and against any and allclaims, damages, costs, and expenses, including attorneys' fees, arising from or relatedto your use of these pages.Please note: Links to movies, ppt slideshows and any other multimedia files are notavailable in the pdf version of presentations.www.myESR.org

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Purpose

INTRODUCTION

Calcific tendonitis, caused by intratendinous deposits of calcium hydroxyapatite, is avery frequent entity, especially in the rotator cuff, where it most repeatedly affects thesupraspinatus tendon ( Fig. 1 on page 2 ) (1-6), representing up to 7% of the casesof painful shoulder (1, 6). It is not exclusive of this anatomic region, and may occur in othersites (1, 3-6). In rare occasions, calcium deposits may undergo intraosseous migration,in the case of the rotator cuff into the greater or lesses tuberosities (1, 2, 5).

The diagnosis is usually straightforward if there are soft tissue calcifications in the typicallocations (1, 3, 4). As in other frequent entities, atypical imaging manifestations mayrepresent a diagnostic challenge. in these cases, the imaging findings may be confusing,with cortical erosions and significant bone marrow edema, so that this entity may bemistaken by imaging and even by histopathology with more aggressive entities, such asneoplasms (1, 3, 4).

The majority of the references in the literature are restricted to case reports or smallseries of cases, since it is an unusual form of presentation (1, 3-5).

We must recognize this variant of calcific tendonitis to distinguish it from other entitiesand avoid unnecessary studies or aggressive surgery (1, 3, 4).

PURPOSE

1. To describe the spectrum of imaging findings of an infrequent form of calcifictendonitis of the rotator cuff.

2. To differentiate this entity from other lesions to avoid unnecessary studies oraggressive surgery.

3. Review of the literature.

Images for this section:

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Fig. 1: Calcific tendonitis of the left supraspinatus tendon.

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Methods and Materials

We retrospectively reviewed the cases of calcific tendonitis with atypical imaging findingswhich presented in a 2-year period (2009-2011).

We present 6 cases of calcific tendonitis with underlying osseous involvement.

The inclusion criteria were the following:

• Availability of imaging studies (radiography, MDCT, MRI)• Presence of soft tissue calcifications: rotator cuff tendons or

subacromiosubdeltoid (SASD) bursa• Evidence of underlying osseous involvement• Absence of coexisting disorders affecting calcium metabolism

The MDCT studies were performed in a 64-detector row CT (General Electric Lightspeed64). MRI studies were performed in a high-field unit (Philips Intera 1.5T), with a dedicatedsurface coil, using the standard shoulder protocol in our Center, which includes: axial PDwith fat saturation, oblique coronal PD and T2WI with fat saturation, and sagittal obliqueT1 and T2 with fat saturation.

The clinical data, the imaging findings and the therapeutic managagement in each caseare represented in Table 1.Fig. 14 on page 4

Images for this section:

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Fig. 14: Table 1

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Results

There were 4 female and 2 male patients. The mean age was 47, 5 years (range35-58 years). All patients presented with pain, with associated limitation in the rangeof movement in 2 cases. All the patients were initially studied with plain radiography,and even though in 3 of the cases these could not be evaluated, the radiological reportwas available for consultation. MDCT was performed in 2 patients. All patients wereevaluated with MRI. 3 cases showed a lytic lesion with internal calcification. 5 casessowed cortical erosion. All cases presented intense bone marrow edema. Soft tissuecalcifications were demonstrated in all the cases. 3 patients were treated conservativelyand 3 cases required surgical intervention. All the patients showed a favourable outcomefollowing treatment. Histopathologic analysis of the cases requiring surgery was notavailable, in one case due to transfer to another Hospital and in 2 cases because it wasnot performed.

CASE 1:

A 53-year-old woman consulted for right shoulder pain of recent onset, without precedingtrauma. A radiography obtained in another Center, which could not be assessed, wasreported as lacking significant findings. An MRI was requested to rule out supraspinatustendinopathy.

MRI ( Fig. 2 on page 12 ) revealed the existence of a subchondral lesion in theposterior region of the greater tuberosity, mixed lytic and with a peripheral scleroticrim and a markedly hipointense center that suggested a calcified nodule, with aninterposed line with high signal intensity on T2WI. There was cortical erosion. Moderateperilesional bone marrow edema was present. The adjacent infraspinatus tendon showedthickening and increased signal intensity, indicating inflammatory changes, and a subtlehypointense linear dotting that suggested the possibility of intratendinous calcifications.There was also a slight focal thickening of the SASD bursa. Performance of CT wasindicated to confirm the presence of intratendinous calcifications, but the patient wastransferred to a public Hospital, since it was deemed that the lesion did not accountfor a professional disease (we'd like to point out that our Center belongs to the mutualinsurance company for occupational accidents and professional diseases ASEPEYO),but it was never performed.

On clinical follow-up, the patient referred having received an anesthetic and steroidinfiltration, and was being treated with NSAIDs and rehabilitation, and showed importantclinical improvement.

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CASE 2:

A 35-year old woman consulted for right shoulder pain and movement limitation. Thepatient had a history of bilateral calcific tendonitis of the shoulder, which had beenevaluated 3 years before with MRI, and had required surgery (performed in anotherCenter) in the contralateral shoulder. In the right shoulder ( Fig. 3 on page 13 ) non-complicated calcific tendonitis of the supraspinatus tendon could be appreciated, withslight irregularity of the adjacent subchondral bone.

Radiographs ( Fig. 4 on page 13 ) performed for suspicion of calcific tendinopathyrevealed presence of comet-tail calcifications near the greater tuberosity, in thetheoretical location of the supraspinatus and infraspinatus tendons, without being ableto specify which of the two, since they could not be clearly identified on the Y view. Nobone lesions were observed.

MRI ( Fig. 5 on page 14 ) showed intense bone marrow edema in the greatertuberosity at the insertion of the supraspinatus tendon, and loss of cortical definition.There was high signal intensity in the distal portion of the supraspinatus tendon, and asmall hypointense image suggesting intratendinous calcification could be appreciated.The neighbouring soft tissues showed slight inflammatory changes and there was a mildSASD bursitis.

The patient received conservative therapy with NSAIDs and shoulder rehabilitation, buther symptoms did not improve, so she was eventually operated, performing bursectomyand removal of the intratendinous calcifications, with complete resolution of symptoms.

CASE 3:

A 46-year-old woman consulted in a regional centre for left shoulder pain and restrictedmovement.

An MRI of the shoulder had been performed 3 months earlier in that centre, and the reportsuggested the possibility of neoplastic lesion. For assessment of this lesion the patientwas referred to our Hospital.

She provided a radiograph performed 4 months earlier ( Fig. 6 on page 15 ) in which alarge calcification overlapping with the glenohumeral joint line and an ill-defined scleroticlesion in the lesser tuberosity could be identified.

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A CTwas then performed ( Fig. 7 on page 16 ), which revealed the presence ofmultiples rounded foci of calcium density inside the lytic lesion of the lesser tuberosity,which coincided with the insertion site of the subscapularis tendon and showed corticalerosion. Confluent calcium deposits with comet-tail morphology could be appreciatedin the distal portion of the subscapularis tendon. The large calcification seen on theradiograph was not identified on CT, but a large hypointense nodule in the subscapularistendon was recognized in the previous MRI, therefore we considered this calcificationhad probably been partially resorbed.

Evaluation of the MRI ( Fig. 8 on page 16 ) also revealed a nodular lesion withsignal void in the lesser tuberosity, with slight perilesional edema, cortical erosion andinflammatory changes in the subscapularis tendon.

Alter suggesting probable osseous involvement secondary to calcific tendonitis, thepatient was transferred to the Public Health System, where she received surgicaltreatment with curettage of the bone lesion and removal of the calcium deposit remnants,with resolution of symptoms.

CASE 4:

A 46-year-old man consulted for a history painful right shoulder of over one month, withoutprior trauma. The patient associated it with repetitive movements of arm abduction.

Radiographs were performed in his reference centre, theoretically without significantfindings, but we could not evaluate them.

An MRI was requested for suspicion of rotator cuff lesion. Initially, an incomplete studywas obtained ( Fig. 9 on page 17 A and B), since the patient was claustrophobicand could not sustain the examination, obtaining only an axial sequence. In theseimages thickening and hyperintensity of the subescapularis tendon could be observed,without evidence of tear, and punctate hypointense images suggesting the presenceof intratendinous calcifications, as well as edema in the lesser tuberosity at the tendoninsertion site, without cortical erosion. There were also minor inflammatory changes inthe adjacent soft tissues.

CT was performed ( Fig. 9 on page 17 C), confirming the presence of multiplesmilimetric calcifications in the distal portion of the subescapularis tendons and alsodemonstrating a small cortical erosion not visible on the MRI.

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Conservative treatment with NSAIDs and rehabilitation was instituted, with relative clinicalimprovement.

3 months later, a follow-up MRI was performed ( Fig. 10 on page 18 ) in a high fieldopen MRI scanner (Philips Panorama 1.0T), which demonstrated improvement of thechanges in the subescapularis tendons, with less thickening and signal normalization, aswell as resolution of the bone marrow edema in the lesser tuberosity. However, there wasa new well defined cortical erosion in the previous location of the bone marrow edema,with high signal intensity on T2WI. This behaviour has been previously described in theliterature (5).

The patient completed rehabilitation treatment with total resolution of symptoms, henceno follow-up was advocated.

CASE 5:

A 57-year-old man consulted for a 1 month history of pain in the left shoulder.

Radiographs were initially obtained ( Fig. 11 on page 19 A), which demonstrateda calcification in the location of the supraspinatus tendon, and did not reveal bonyabnormalities.

Since the patient referred intense pain that did not subside with symptomatic treatment,an MRI was performed ( Fig. 11 on page 19 B-E), which showed an area of intensebone marrow edema in the anterior region of the greater tuberosity, without corticaldisruption, and a hypointense image in the supraspinatus tendon corresponding to theintratendinous calcification. Slight thickening of the SASD bursa was also present.

The patient was managed conservatively, with SASD bursa anesthetic and steroidinfiltration, rehabilitation and NSAIDs, with progressive clinical improvement untilresolution of symptoms in a 3-month period.

CASE 6:

58-year-old woman who consulted for long-term left shoulder pain. There was no historyof trauma.

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Radiographs performed in another centre, which we could not evaluate, describedrounded soft-tissue calcifications. No bone lesion was mentioned.

An MRI was performed ( Fig. 12 on page 20 ) demonstrating a well-definedsubchondral lytic lesion with sclerotic rim in the lesser tuberosity, with a cortical defect.The lesion was filled with a markedly hypointense nodule that suggested intralesionalcalcification, surrounded by a halo of high signal intensity. Moderate perilesional bonemarrow edema was also present. In the adjacent insertion of the subescapularis tendonsthere were several calcifications. In addition, there was a profuse SASD bursitis, withhypointense nodules consistent with calcifications (calcific bursitis).

Surgical treatment was performed, with bursectomy, curettage of the bone lesion andremoval of the intratendinous subescapularis calcifications, after which the patientsignificantly improved.

REVIEW OF THE LITERATURE

Cases of calcific tendonitis with predominance of osseous involvement are rare, andhave been described sporadically in the literature. The most frequent locations are thehumeral diaphysis, in the insertion of the pectoralis major, and in the femoral insertionof the gluteus maximus (1, 3-5). Although simple calcific tendonitis is very common inthe rotator cuff, osseous involvement of the humeral tuberosities is less frequent than inother anatomic locations (1, 3).

Clinically, the patients usually present with severe pain, but asymtpomatic cases doexist (1, 3-5).

The pathophysiology of calcific tendonitis is unknown (1, 3, 4) and it is believed itcould be related with hypoxic changes and mechanical insults, which bring about afibrocartilaginous transformation with posterior calcification that resorbs overtime. Theinflammatory changes of the resorptive phase, the inflammatory reaction caused bythe calcium deposits or an increased intratendinous pressure are believed to be theresponsible for the pain (3, 4). Bone migration of the calcium deposits is speculatedto be produced by the forces generated by the muscles at their insertions, thus beingrelatively infrequent in the rotator cuff since these muscles are not very potent (1, 3, 4).The theory of the increase in local vascularisation and the active inflammation in thetendon insertion as causal agents has also been proposed (1, 4). In truth, this entityrepresents an inflammatory and reactive process which implicates the enthesis (3).

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Imaging findings depend on the technique employed. Radiographs may revealcalcifications in the tendon or adjacent bursa, and signs of osseous involvement (1, 3, 4).Soft-tissue calcifications are usually smaller than in cases of isolated calcific tendonitis,there are even cases with no or very few soft-tissue calcifications , which are the mostdifficult to diagnose (1). The calcifications have been classically described as "comet-tail"calcifications (1, 3, 4). Osseous involvement may be represented in different ways: asa cortical erosion, the most frequent, a mixed lesions or even a sclerotic lesion (1-4, 7, 8).

Periosteal reaction is not very frequent (32%) and is usually limited to cases ofdiaphyseal involvement (1), therefore in cases of calcific tendonitis of the rotator cuff it isan uncommon finding. When it is present, solid benign periosteal reaction predominates(1).

CT and MRI allow a more complete assessment of this entity than radiographs, butparadoxically they may lead to confusion (1, 3). Also, osseous involvement is probablyunderestimated in patients evaluated solely with radiographs (1).

CT permits an optimal evaluation of the osseous involvement and is the most sensitivetechnique for detection of soft tissue calcifications (1, 3, 4). Cortical erosion is themost frequent form of presentation (78%) (1), but there are other forms such as osteolyticreaction in the tuberosities, filled or not with calcium deposits (1, 4) or a sclerotic lesionwith a radiolucent halo, (1-4, 5). The important fact here is that the bone lesion is alwaysimmediately adjacent to the soft-tissue calcifications (1). In some cases, the soft tissuecalcifications may reabsorb leaving only the bone lesion, so this diagnosis must beconsidered if a lesion is found in a tendon insertion typically affected by this entity (1),such as the humeral tuberosities in the insertion of the rotator cuff tendons. Overtime,even the bone lesion may disappear. On CT, the soft-tissue calcification may adopt a"flame shaped" appearance (3).

MRI allows an incomparable assessment of the bone marrow involvement. In the bonewe might observe a lytic lesion, with or without hypointense filling representing calciumdeposit, typically with extensive perilesional bone marrow edema (1-3). Bone marrowedema may appear without an identifiable cortical defect (1, 3). The presence of asoft tissue mass has been described but is not a frequent finding (1). Changes in thetendons are common, usually showing thickening and increased signal intensity, aswell as inflammatory changes in the adjacent soft tissues (1). Calcifications on MRIpredominantly show hypointense signal on T1 and T2WI (1), but it may be difficultto detect small calcifications, thus if there are doubts we should consider performingradiographs or CT (1, 3). If the possibility of a bone tumor is aroused by MR findings,correlation with radiographs should be obtained, since many times it simplifies thediagnosis.

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These lesiones show uptake on scintigraphy (1, 5).

The differential diagnosis is extensive when confronted with a solitary sclerotic or lyticlesion in the humeral head (2). The findings of bone marrow involvement with corticaldestruction and soft tissue participation may suggest a neoplasm, especially of chondroidnature, or cortical metastases (1, 3). There are also subchondral cysts of degenerativeetiology that are found frequently in patients with rotator cuff lesions, and bone marrowedema may also be associated with rotator cuff lesions and posttraumatic changes (9).In some cases, the findings may also mimic an infectious process (7).

The key to diagnosis is the coexistence or preexistenceof calcific tenoditis in the samelocation and the typical location should make us consider this entity. Biopsy may beavoided if the imaging findings suggest this entity (1-4).

Histopathologic analysis of these lesions reveals psammomatous calcifications,stromal fibrosis, chronic inflammation and proliferationof multinucleated giant cells,granulation tissue, bone formation, tenosynovial hyperplasia and even chondroidmetaplasia (1, 4). If biopsy is considered necessary, it is important to alert the pathologistof the possibility of this diagnosis, since the chondroid metaplasia forming part of thehistologic reaction in this entity may be mistaken for a chondral neoplasm (1).

Treatment is initially symptomatic , with NSAIDs and rehabilitation, since it is usually aself-limiting entity with tendency to spontaneous resolution (1, 3, 5). In very symptomaticor persistent cases intralesional injection of steroids or aspiration of the calcium depositsmay be considered (1, 3). Surgical resection is curative (1-3, 9, 10).

Images for this section:

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Fig. 2: Case 1.

Fig. 3: Case 2, prior MRI of the right shoulder, performed 3 years before the actualepisode.

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Fig. 4: Case 2, radiographs.

Fig. 5: Case 2, MRI of the right shoulder.

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Fig. 6: Case 3, AP radiograph of the left shoulder, 4 months prior to CT.

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Fig. 7: Case 3, CT of the left shoulder.

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Fig. 8: Case 3, MRI of the left shoulder performed in the patient's reference centre, 3months before CT.

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Fig. 9: Case 4, initial MRI of the right shoulder (incomplete due to claustrophobia) and CT.

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Fig. 10: Case 4, follow-up MRI of the right shoulder, performed 3 months after the initialMRI

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Fig. 11: Case 5.

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Fig. 12: Case 6, MRI of the left shoulder.

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Fig. 13

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Conclusion

Osseous involvement in calcific tendonitis usually manifests with an aggressiveappearance on imaging studies, with cortical destruction, lytic lesions, bone marrowedema or even periosteal reaction. Consequently, it is essential to have knowledge of thespectrum of appearances of calcific tendonitis, including the atypical forms, especiallyon MRI since it is many times the first technique performed in these patients and wherethe findings may be more misleading. The presence of soft tissue calcifications andthe typical location should make us consider this diagnosis, therefore correlation withradiographs or CT is very important in order to demonstrate these calcifications. We haveto be acquainted with this variant of calcific tendonitis to avoid confusing it with otherentities and avoid unnecessary studies or aggressive surgeries.

References

1. Flemming DJ, Murphey MD, Shektitka KM,TempleT, Jeline JJ, KransdorfMJ. Osseous Involvement in Calcific Tendinitis: A Retrospective Review of50 Cases. AJR Am J Roentgenol 2003; 181: 965-972.

2. Martin S, Rapariz JM. Intraosseous calcium migration in calcifying tendinitis:a rare cause of single sclerotic injury in the humeral head. Eur Radiol. 2010May;20(5):1284-6.

3. Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical erosions.Skeletal Radiol 2000;29:690-696.

4. Hayes CW, Rosenthal DI, Plata MJ,HudsonTM. Calcific tendinitis in unusualsites associated with cortical bone erosion. AJR 1987;149:967-970.

5. Chagnaud C, Gaubert J, Champsaur P, Marciano S, Petir P, Moulin G.Vanishing osteoesclerotic lesions of the humeral head. Skeletal Radiol1998;27:50-52.

6. Holt PD, Keats TE. Calcific tendinitis: a review of the usual and unusual.Skeletal Radiol 1993;22:1-9.

7. Porcellini G, Paladini P, Campi F, Pegreffi F. Osteolytic lesion of greatertuberosity in calcific tendinitis of the shoulder.

8. Porcellini G, Campi F, Battaglino M. Calcific tendinitis of the rotator cuff withtrochiteal osteolysis. A rare clinical-radiologic complication.

9. McCauley TR, Disler DG, Tam MK. Bone marrow edema in the greatertuberosity of the humerus at MR imaging: association with rotator cuff tearsand traumatic injury. Magn Reson Imaging. 2000 Oct;18(8):979-84.

10. Seyahi A, Demirhan M. Arthroscopic removal of intraosseous andintratendinous deposits in calcifying tendinitis of the rotator cuff.

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