1. Ultrasound Case of the Month October 2013

2. 61 year old male with right shoulder pain and limited range of motion 3. Grayscale Images of the Infraspinatus 4. Grayscale Images of the Infraspinatus Calipers denote a hypoechoic focus with a hyperechoic rim and posterior acoustic shadow within the infraspinatus tendon representing calcium hydroxyapatite deposition 5. Diagnosis: Calcific Tendinitis 6. Calcium Hydroxyapatite Deposition Primary/Idiopathic Secondary End stage renal disease Collagen vascular disease Vitamin D intoxication Tumoral calcinosis 7. Calcific Tendinitis: Case Points Pathogenesis Unknown Hypotheses include: Abnormal pressure and compression (Codman) Decreased localized vascularity and pre-existing tissue degeneration (Sandstrom) Local changes in pH and secondary necrosis (Pederson & Key) Trauma (Gondos) 8. Calcific Tendinitis: Case Points Predominantly affects 40-70 year olds, men slightly more than women 50% in the shoulder, though deposition can be found at nearly every joint Clinical Presentation Severe pain, tenderness, erythema, limited range of motion 9. Calcific Tendinitis: Case Points Pathogenesis Three phases (Morley et al) 1. Silent 2. Mechanical 3. Adhesive Periarthritis 10. Calcific Tendinitis: Case Points 1. Silent phase - Calcium within the substance of the tendon itself - Minimal/no symptoms 2. Mechanical - Enlargement of the deposits - Deposit becomes liquified (may no longer see the deposit on radiographs) increased pressure/bursitis impingement-like symptoms - Recurrent bursitis leads to eventual rupture of the deposit 3. Adhesive Periarthritis - Variable sized calcium deposits, destructive changes - Worsened pain, limited range of motion 11. Calcific Tendinitis: US Calcium hydroxyapatite deposition looks like calcium anywhere else in the body: Anechoic Hyperechoic shadow Posterior acoustic shadow 12. Calcific Tendinitis : Radiographs AP view of the left shoulder Transscapular Y view (different patient) 13. Calcific Tendinitis : Radiographs Well-defined calcium deposit within the supraspinatus tendon Most deposits are ovoid, although they may be linear or triangular This radiograph was taken during the silent / first phase of calcific tendinitis 14. Calcific Tendinitis: MRI Hypointense on T1 and T2 Oblique sagittal proton density and FS T2 weighted sequences through the left shoulder 15. Calcific Tendinitis: MRI Sagittal and axial T2 fat suppressed images in the same patient demonstrate focal calcium hydroxyapatite deposition within the supraspinatus in the silent/first phase of calcific tendinitis 16. Calcific Tendinitis: MRI No intervention was performed and the patients symptoms continued to worsen The following images are from the MRI on the same patient performed 8 months later 17. Calcific Tendinitis: MRI Oblique coronal proton density and T2 fat suppressed 18. Calcific Tendinitis: MRI Oblique sagittal proton density and T2 fat suppressed 19. Calcific Tendinitis: MRI The previously seen calcium hydroxyapatite deposit has eroded into the humeral head Marked surrounding bone marrow edema 20. Calcific Tendinitis : Treatment Conservative NSAIDs Oral steroids Image guided steroid/anesthetic injection Image guided aspiration/lavage 21. Calcific Tendinitis : Treatment Utilizing ultrasound guidance, a needle is advanced into the deposit and a small volume of lidocaine is injected around and within the deposit 22. Calcific Tendinitis : Treatment The deposit is then lavaged with 2% lidocaine (A: injection, B: aspiration) A B 23. Calcific Tendinitis : Treatment 24. Calcific Tendinitis : Treatment Once the deposit is aspirated as much as possible, a solution of anesthetic and steroid is injected into the region and the needle is withdrawn 25. Calcific Tendinitis : Treatment Syringes a) immediately and b) delayed after lavage with lidocaine. The calcified material has layered onto the bottom of the syringe over time. (a) (b) 26. References Aina R, Cardinal E, Bureau NJ, et al. Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique. Radiology 2001; 221:455461. Flemming D, Murphey M, Shkitka K, et al. Osseous involvement in calcific tendonitis: a retrospective review of 50 cases. AJR 2003; 181:965972. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics 1990; 10(6):1031-48. Serafini G, Sconfienza LM, Lacelli F, et al. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle US- guided percutaneous treatment-nonrandomized controlled trial. Radiology 2009; 157164