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Introduction
  • Calcification and tendon degeneration near the rotator cuff insertion               
    • associated with subacromial impingement
  • Epidemiology
    • demographics
      • typically affects patients aged 30 to 60
      • more common in women
    • location
      • supraspinatus tendon is most often involved
    • risk factors
      • association with endocrine disorders
        • diabetes
        • hypothyroidism
  • Pathophysiology
    • unknown etiology
    • pathoanatomy
      • three stages of calcification
        • precalcific 
          • fibrocartilaginous metaplasia of the tendon
          • clinically this stage is pain-free
        • calcific
          • subdivided into three phases
            • formative phase 
              • characterized by cell-mediated calcific deposits
              • +/- pain
            • resting phase
              • lacks inflammation or vascular infiltration
              • +/- pain
            • resorptive phase
              • characterized by a phagocytic resorption and vascular infiltration
              • clinically this phase is most painful
        • postcalcific
    • cellular biochemistry
      • calcium hydroxyapatite crystals are deposited 
      • key molecular pathways involved
        • osteopontin
        • cathepsin K
        • transglutaminase 2
Classification
 
Gartner and Heyer Classification of Calcific Tendinitis  
Type I          • Well circumscribed, dense calcification, formative    
Type II  • Soft contour/dense or sharp/transparent
Type III
 • Translucent and cloudy appearance without clear circumscription, resorptive    

 

Mole et al. Classification of Calcific Tendinitis 
Type A   • Dense, homogeneous, sharp contours          
Type B  • Dense, segmented, sharp contours
Type C
 • Heterogeneous, soft contours
Type D  • Dystrophic calcifications at the insertion of the rotator cuff tendon

Presentation
  • History
    • similar to the clinical presentation of subacromial impingement
  • Symptoms
    • atraumatic pain (most severe in resorptive phase)
    • catching, crepitus
    • mechanical block
  • Physical exam
    • inspection
      • supraspinatus fossa muscle atrophy
    • motion
      • decreased active range of motion
      • scapular dyskinesia
      • may be associated with a decrease in rotator cuff strength 
    • provocative tests
      • subacromial impingement signs
Imaging
  • Radiographs
    • views
      • AP, supraspinatus outlet, and axillary views show supraspinatus calcification
      • internal rotation view shows infraspinatus and teres minor calcification
      • external rotation view shows subscapularis calcification
    • findings
      • deposits usually 1 to 1.5cm from supraspinatus tendon insertion
      • useful to monitor progression over time 
        • allow assessment of location, density, extent, and delineation of deposit  
  • CT
    • indications
      • rarely required
      • may characterize the three-dimensional shoulder anatomy
  • MRI
    • indications
      • limited utility in the diagnosis of calcific tendonitis
      • consider in patients with refractory pain as it can assess for concomitant pathology (e.g., rotator cuff tears)
    • findings
      • cacific deposits have low signal intensity on all sequences
  • Ultrasound
    • indications
      • may be useful to quantify the extent of the calcification
      • also utilized for guidance during needle decompression and injection
    • findings
      • deposits are hyperechoic
Treatment
  • Nonoperative
    • NSAIDs, physical therapy, stretching & strengthening, steroid injections
      • indications
        • first line of treatment for all phases 
      • techniques
        • steroid injections
          • commonly used but controversial
          • duration of relief is variable
      • outcomes
        • resolution of symptoms in 60-70% of patients after 6 months
        • increased probability of failure when:
          • bilateral or large calcifications
          • deposits underlying the anterior third of acromion
          • deposits extending medial to the acromion
    • extracorporeal shock-wave therapy
      • indications 
        • adjunct treatment 
        • most useful in refractory calcific tendonitis in the formative and resting phases
      • modalities
        • high- vs. low-energy therapy
      • outcomes
        • dose dependent outcomes
          • high-energy > low-energy in clinical outcome scores, and rate of calcific deposit resorption
          • high-energy > low-energy in procedural pain and local reaction (e.g. ecchymosis)
    • ultrasound-guided needle lavage vs. needle barbotage
      • indications
        • persistent symptomatic calcific tendonitis in the resorptive phase
      • outcomes
        • improved outcomes in patients with Type II/III calcific tendinitis vs Type I
  • Operative
    • surgical decompression of calcium deposit 
      • indications
        • progression of symptoms
        • refractory to nonoperative treatments
        • interference with activities of daily living
      • outcome
        • good results in short term outcome studies
        • longer return to work with subacromial decompression and/or rotator cuff repair
        • risk of shoulder stiffness with operative treatment
Techniques
  • Ultrasound-guided needle lavage
    • technique
      • two needles to maintain an outflow system for lavage  
        • small amount of saline+/-anesthetic injected around the calcification
        • aspiration of calcific material with other needle
  • Needle barbotage
    • technique
      • use needle to break up calcium deposit then follow with by corticosteroid injection
  • Surgical decompression of calcium deposit post  
    • approach
      • may be done arthroscopically or with mini-open approach
    • technique
      • +/- subacromial decompression
      • +/- rotator cuff repair
Complications
  • Recurrence
  • Persistent shoulder pain
  • Shoulder stiffness 
  • Iatrogenic injury to rotator cuff with operative treatment
 

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