Calcific tendinitis

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ICD10 = ICD10|M|65|2|m|65
ICD9 = ICD9|727.82
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Calcific Tendinitis (also calcific/calcifying/calcified/calcareous tenonitis/tendonitis/tendinopathy, and tendinosis calcarea) is a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body, but most commonly in the tendons of the rotator cuff (shoulder), causing pain and inflammation.

Pain is often aggravated by elevation of the arm above shoulder level or by lying on the shoulder. Pain may waken the patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder.

The condition is related to and may cause frozen shoulder.

The calcific deposits are visible on X-ray as discrete lumps or cloudy areas. The deposits look cloudy on X-ray if they are in the process of re-absorption, and this is also when they cause the most pain. The deposits are crystalline when in their resting phase and like toothpaste in the re-absorptive phase. However, poor correlation exists between the appearance of a calcific deposit on plain x-rays and its consistency on needling.

Treatment

Dietary calcium restriction

A controversial topic, this conservative treatment can be very effective for some patients, and reports of pain cessation with strict dietary calcium restriction have been documented. Dietary restriction applies to all milk products, nuts that have a high calcium content, calcium-fortified products and high calcium vegetables and snacks. Food nutritional labels are helpful in determining foods to restrict. If no improvement is noted after three months, other treatment modalities should be tried.

It is assumed the body scavenges the pathological calcium deposits when dietary calcium is restricted. Studies are required in this area.

Magnesium supplementation

Low magnesium levels can result in calcium deposition in soft tissues. Therefore magnesium supplementation may prevent the formation of calcifications.cite journal | author=Planells E, Llopis J, Perán F, Aranda P.| title=Changes in tissue calcium and phosphorus content and plasma concentrations of parathyroid hormone and calcitonin after long-term magnesium deficiency in rats.| journal=J Am Coll Nutr. | year=1995| volume=14| issue=3| pmid=8586780| url=| pages=292–8]

Extracorporeal shock wave therapy (ECSW)

ECSW uses sound waves focused onto the deposit. It works by an unknown mechanism in this disorder. In some German studies, 30-70% of patients obtained pain relief, and, in 20-77% of cases, the calcific deposit disappeared or disintegrated.

Medications

Analgesics and non-steroidal anti-inflammatory drugs (NSAID) are useful to a limited extent.

Physical therapy

Electroanalgesia, ice therapy, and heat offer symptomatic relief. The benefit of ultrasound in calcific tendinitis is debated; most studies are negative but a study by Ebenbichler et al (1999) showed resolution of deposits and clinical improvement.

Iontophoresis

In studies, acetic acid iontophoresis combined with ultrasound provided no better clinical results or shrinkage of the calcific deposits than did no treatment.

Injections, needling, and lavage

Under local anesthetic, the calcific deposits can be mechanically broken up by puncturing them repeatedly with a needle and then aspirating the calcific material with the help of a sluice of saline. About 75% of patients are helped by this procedure. Ultrasound can be used to help localize the deposit and to visualize the needle entering the deposit in real time.

Corticosteroid injections

These may be useful when the shoulder is acutely inflammed but otherwise are not generally useful.

urgery

Removing the deposit/s either with open shoulder surgery or arthroscopic surgery are both difficult operations, but with a high success rates (around 90%). About 10% require re-operation. If the deposit is large then frequently the patient will require a rotator cuff repair to fix the defect left in the tendon when the deposit is removed or to reattach the tendon to the bone if the deposit was at the tendon insertion into the bone.

ee also

* Tendinitis

References

*cite journal |author=Ebenbichler GR, Erdogmus CB, Resch KL, "et al" |title=Ultrasound therapy for calcific tendinitis of the shoulder |journal=N. Engl. J. Med. |volume=340 |issue=20 |pages=1533–8 |year=1999 |month=May |pmid=10332014 |doi= |url=http://content.nejm.org/cgi/content/abstract/340/20/1533