Calcific tendinitis, also known as calcific tendinopathy or tendonitis, is a self-limiting condition due to the deposition of calcium hydroxyapatite within tendons, usually of the rotator cuff. It is a common presentation of hydroxyapatite crystal deposition disease (HADD).
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Epidemiology
Typically this condition affects middle-aged patients between the ages of 30 and 60, with a slight predilection for women 2.
Clinical presentation
The condition passes through four stages 2 (Uhthoff cycle):
-
precalcific
asymptomatic
fibrocartilaginous metaplasia (see below)
-
calcific or formative
symptoms are variable from none to pain on movement
-
resorptive
most symptomatic
pain due to extravasation of calcium hydroxyapatite into adjacent tissues, especially subacromial bursa, causing calcific bursitis
pain typically lasts two weeks
-
postcalcific
variable symptomatology
some restriction of movement is common
may last months
Pathology
Calcific tendinitis results from the deposition of calcium hydroxyapatite within the substance of a tendon and is thought to be due to decreased oxygen tension, leading to fibrocartilaginous metaplasia and secondary mineralization 1.
Location
This condition most frequently affects the rotator cuff of the shoulder 1.
supraspinatus: 80%
infraspinatus: 15%
subscapularis: 5%
periarticular soft tissues in addition to tendons
ligaments
capsule
bursae
However, the condition may occur anywhere in the body with the hip and knee joints being the 2nd and 3rd most common locations respectively 10,11.
Radiographic features
Plain radiograph
Calcific deposits are usually visualized as homogeneous hyperdensity with variable morphology, but typically globular/amorphous with smooth or ill-defined margins.
Ultrasound
Features of calcific tendinitis on ultrasound may include 7:
a curvilinear/ovoid calcification with acoustic shadowing
capsular soft tissue swelling
MRI
-
T1
hypointense homogeneous signal
the adjacent tendon may be thickened
some enhancement surrounding the deposit may be seen
-
T2
hypointense calcium deposits
hyperintense signal may be present peripherally due to edema
hyperintense subacromial-subdeltoid bursal fluid
T2*: calcifications may bloom
Treatment and prognosis
The treatment is controversial and its efficacy is difficult to assess due to the inherent variability of the symptoms and the self-limiting nature of the disease. Potential treatments include 2:
oral analgesic/anti-inflammatory medication
subacromial local anesthetic/steroid injection
extracorporeal shock wave therapy
arthroscopy
Complications
migration of calcium deposits from tendons into the subacromial-subdeltoid bursa or into the humeral greater tuberosity 15.
Differential diagnosis
In the shoulder consider:
incidental calcification: seen in 2.5-20% of "normal" healthy shoulders 1,2
-
degenerative calcification
seen in previously torn tendons
generally smaller
slightly older individuals
-
associated chondral defect
associated secondary osteoarthritis
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