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Calcareous Tendinitis
Calcareous Tendinitis From the Department of Surgery, Orthopaedic Division, 'The Albany Medical College of Union University, Albany, New York
JOHN W. GHORMLEY, M.D. Associate Clinical Professor of Orthopaedic Surgery
INTRODUCTION
Calcification in General
The deposition of various forms of amorphous calcium phosphate and/or calcium carbonate in diseased tissues of the body is a well known phenomenon. Tendons, bursae, lipomata, uterine fibroids, tuberculous glands and many other tissues may be the site of these deposits. There are differences of opinion as to the etiology of this calcification. Robinson 6 in 1923 presented the concept that the precipitation resulted when the tissue fluids became locally supersaturated with phosphate ions by the action of alkaline phosphatase on phosphate esters present in the calcifying area. Many modifications of this theory have been advanced. In 1959 Weidman 8 proposed the "epitactic" concept, that the "bone salt crystallizes out from a supersaturated but otherwise stable tissue fluid onto a primary seed of the organic matrix." Local calcification is not dependent upon generalized hypercalcemia. There is a deposition of calcium phosphate, etc., in calcinosis circumscripta, occasionally associated with hypercalcemia. It may also be seen in hypervitaminosis (vitamin D) and in massive destruction of bone by tumors. Soft tissue calcification may occur in collagen diseases. Wheeler, Curtis, Cawley, Grekin and Zheutlin 9 reported upon this in 1952. This calcification is often of the nature of a calcinosa circumscripta and not a tendinitis. McCarroll3 offers the opinion that "it seems obvious in the light of our present knowledge that problems of soft tissue calcification may, in many instances, be related to the over-all problem of collagen diseases and result in primary degenerative changes in the connective tissues." Pedersen and Key4 studied the material removed from the shoulders
1721
1722
JOHN
W.
GHORMLEY
Fig. 1. Calcification in the conjoined tendon of the elbow.
of 55 patients suffering from subdeltoid bursitis with calcification, and they came to the conclusion that the basic process is a degeneration of the tendon or muscle in the rotator cuff. Calcification of Tendons
Calcium deposits may be found in any tendon that is necrotic or diseased. It has been noted that the condition occurs bilaterally. Perhaps there is a congenital factor in the etiology. Clinically we note varying degrees of calcification. Sometimes in the acute stages there is only a minor deposition of calcium salts, hardly discernible by x-ray. This may increase in a few days, or at least in a week or two, until an area of tendon several millimeters in dimension may be replaced by a creamy, cheese-like calcified mass. This shows in the x-ray as a rounded radiopaque mass. Later, sometimes, especially following treatment, but sometimes without it, the degree of calcification diminishes and often entirely disappears. In some cases, the calcium persists and is replaced by heterotopic bone formation. The diagnosis of calcified tendinitis is a relatively simple matter. Localization of tenderness over a known tendon and x-ray evidence of calcification are sufficient for at least a tentative diagnosis of calcification of the tendon. It is possible, therefore, that almost any tendon of the body may be the site of calcification. A great majority of the cases, however, are in the supraspinatus or possibly in the tendon of the
Calcareous Tendinitis
1723
infraspinatus or teres minor at the shoulder joint. Calcification in the tendon of the subscapularis, in the common extensor as well as common flexor tendon of the elbow, in the tendon of the gluteus medius, in the tendo achillis and others have been noted. Codman,! of course, was the first to recognize that the so-called subdeltoid bursitis with calcification is actually a calcified tendinitis. Hughes,2 in 1950, reported nine cases of calcification of the common extensor tendon of the elbow. Van De Mark and Myrab0 7 added two cases of their own and stated that x-rays had shown areas of calcification distal and lateral to the lateral epicondyle of the elbow. These areas were incised and tissue was removed, which showed microscopically degenerated tendon cells with calcification. We have seen two patients within the past year with calcification in the common extensor tendon of the elbow (Fig. 1). In 1938, I reported a case of ossification of the tendo achillis which had caused rupture of that tendon. This ossification had undoubtedly been preceded by calcification. Up until that time 21 cases of ossification of the tendo achillis had been reported. A great number of these were due to periosteal bone formation and the new bone was attached to the os calcis. Some, however, were due to heterotopic bone formation which had been preceded by calcification. TREATMENT
Since the great majority of the cases of calcareous tendinitis occur in the tendon of the supraspinatus, detailed discussion of treatment will be confined to this disorder. In general, treatment of calcification of other tendons is carried out in the same manner. It is probable that the narrow confines of the subacromial area is one reason why this disorder most frequently gives symptoms. Also, it should be noted that the unusual mechanical factors involved in elevating the arm may cause degeneration of the tendon and resultant calcification. This disease is usually self-limited, so that most treatments sooner or later have resulted in an abatement of the symptoms. Rest, heat, cold applications, ethyl chloride sprays, Novocain (procaine) injection, irrigation of the calcified area with normal saline (usually with two needles and washing out the calcified material), multiple needling, surgical excision of the calcified mass, systemic cortisone therapy, local Hydrocortone (hydrocortisone) injection (sometimes followed by ultrasonic therapy), Butazolidin (phenylbutazone) and other methods of treatment have been used. Pedersen and K ey4 found that some patients were relieved by diathermy, x-ray treatments or needling, but offered the opinion that operative evacuation of the offending forces was the most certain way of obtaining relief. Quigley5 reported that the injection of 25 to 50 mg.
1724
JOHN
W.
GHORMLEY
Fig. 2. A slender annular area of calcification, hardly visible in this x-ray, high in the supraspinatus tendon.
of Hydrocortone acetate, 150 units of hyaluronidase and 6 to 10 cc. of 1 per cent Novocain locally relieved the patients with calcium deposits at or near the greater tuberosity of the humerus. Treatment, then, has varied greatly with the physician or surgeon who is in charge of the patient. He may base his judgment upon the duration of the disorder, the severity of the symptoms, the degree and state of the calcification, the possibility of getting a hospital bed, the patient's ability or willingness to be operated upon, etc. We have had occasion to use, at one time or another, all the methods mentioned except cold applications, ethyl chloride sprays and ultrasonic therapy. Patients who show minimal calcification (Fig. 2) and whose pain is not severe may obtain satisfactory results from putting the extremity at rest in a sling and applying short wave diathermy, microtherm or other form of heat along with proper analgesics or sedatives. Within a day or two, the pain will have largely subsided and an exercise program may be instituted. Injection Therapy In cases of chronic tendinitis with minimal calcification, but with considerable limitation of motion, we have used three to six injections of 50 mg. of Hydrocortone along with an active and passive exercise program. The results in these cases are usually satisfactory. We have not had occasion to use such injections in the acute cases in which there is a large calcified mass. In patients with calcification of the supraspinatus tendon whose symptoms are not too severe and whose x-rays do not show a large, rounded opaque mass, but rather smaller and less circumscribed masses
Calcareous Tendinitis
1725
(Fig. 3), Novocain injections, multiple needling or irrigation with normal saline may be the treatment of choice. About 15 cc. of 1 per cent Novocain is used and multiple punctures of the calcified area are made. It is important that the Novocain not be injected until the needle strikes a tender area. Then a few cc. may be injected. The needle may then be partially withdrawn, but not entirely, and a new tender area sought out and a few additional cc. of Novocain injected. Thus, perhaps a half a dozen different tender areas may be injected and the bursal sac well needled. In some cases it is possible to aspirate some of the calcified material. It is desirable to put the scapulohumeral joint through a full range of motion immediately after the injection in order to disseminate the calcified particles and to break down adhesions. Through-and-through irrigation of the joint with two large gauge needles inserted perpendicular to each other has been used. This treatment is painful and general anesthesia is desirable. Since the results are often not satisfactory, we no longer use this treatment. Following all of these Novocain injections, needling, aspiration or irrigation treatments, local heat and later active and passive exercises are important. Surgical Therapy Surgical excision of the calcified mass is indicated when the pain is unbearable and the x-rays show a large, dense, rounded, circumscribed mass (Fig. 4). By this means one is assured of giving the patient relief. Operative intervention may also be indicated in chronic cases or in recurrent attacks. The operation is not difficult. Adequate preoperative x-rays are essential. It is also necessary that the arm be draped in sterile towels or sheets
Fig. 3. Several small rounded masses of calcification, presumably in the supraspinatus tendon and obviously of some duration.
1726
JOHN W.GHORMLEY
. Fig. 4. Two large creamy, caseous masses in the supraspinatus tendon.
in order that the humerus may be rotated so that the bulging, grayish, calcified mass which lies beneath the floor of the bursa may be brought into view in the center of the incision. A skin incision 2 inches long is made, beginning at the acromio-clavicular joint and extending down parallel with the fibers of the deltoid muscle. The incision in the deltoid muscle is made in the anterior third and by splitting it in the line of the fibers. The incision through the muscle begins at the acromion and stops short of the anterior circumflex vessels and the anterior branch of the axillary nerve. The incision into the calcified mass is made in line with the tendon fibers. It is essential that all of the calcified material be removed, and it is important that an intact tendon be left. The inflamed bursal sac need not be excised. The application of heat and proper active and passive exercises are instituted within a day or two of the operation. The patient is usually symptom-free within a few days of the operation, and should have complete range of motion within two or three weeks if he had no previous contractures. CASE REPORTS CASE I. J.B.,43 years old; white, married male; self-employed auto body and fender mechanic. Present Illness. One week before seeking medical attention the patient had slipped on an icy sidewalk and had fallen. directly upon his right shoulder. He went on to his shop and continued his work. The right shoulder became painful, and the patient took some APC tablets which gave his some relief. He tried a heating pad, but discontinued this because it made the pain worse. The pain became so bad the day before he sought medical attention that he had to give up work, and he slept very little that night. R.xamination. Thefl~ was noswelling, deformity.or muscular atrophy of the right shoulder. Little or no active motion was allowed; and resisted abduction
Calcareous Tendinitis
1727
caused exquisite pain in the region of the subdeltoid bursa. Palpation revealed localized tenderness here. X-rays (Fig. 4) showed several large, rounded areas of calcific densities above the greater tuberosity. Calcified tendinitis of the supraspinatus tendon was diagnosed, and immediate surgical excision was advised . .lIt is our opinion that this is the type of case in which immediate surgical excision offers the most certain method of complete relief.] The masses were very large, extensive, and dense, and obviously of a cheesy, creamy consistency. The patient's pain was exquisite, and his disability complete. Treatment. The patient's wife was ill and he did not think that hospitalization for himself was possible, so the area was injected with 15 cc. of a 1 per cent Novocain solution and needled widely, and the shoulder joint was manipulated. The patient seemed to be completely relieved but was given a prescription for Demerol (meperidine). His relief lasted for less than 12 hours, however, so he was admitted to the hospital as an emergency case. At 6:30 that evening, under general anesthesia, the supraspinatus tendon was explored, and two large creamy calcified areas were removed. The patient's relief was almost complete, and he was discharged from the hospital 2 days later. He continued on the Demerol, now found that the heating pad helped to relieve the pain, and was put on an exercise program even though it was very painful for him. He returned to work 2 weeks after the operation, and when last seen, 1 week later, he had essentially no complaint and very little limitation of motion of the shoulder. CASE II. M.C., 36 years old; white, married female; housewife. Present Illness. The patient was peeling apples 12 days before consulting us, and felt a pain in the left shoulder. She thought she "had caught cold in it" and so rubbed the shoulder with an analgesic ointment. This seemed to relieve the pain for a few days, but later it no longer helped. The patient states that if she kept the arm quiet and at her side, she had no pain in the shoulder. However, the day before seeking medical advice, the pain had become intolerable. Examination. There was no swelling, deformity or muscular atrophy. Very little active motion was present, and the patient allowed only 30 degrees of flexion and extension, 20 degrees of abduction, and little or no internal or external rotation. Resisted abduction was very painful, and palpation showed localized tenderness over the tendon of the supraspinatus. X-rays (Fig. 3) revealed several rounded areas of calcification, presumably in the supraspinatus tendon. The appearance of the calcification suggested that it had been present for several weeks, and possibly several months. Treatment. This did not seem to be a case in which surgical excision of the calcified areas would be feasible, so 15 cc. of 1 per cent Novocain was injected into the calcified tendon areas, they were extensively needled and a measurable quantity of calciuD! salts was removed through an 18-gauge needle. The upper . left arm was immobilized in a sling, the patient was given a prescription for thirty 50 mg. Demerol tablets, and she was advised to use an electric heating pad on the shoulder for relief of pain. She was seen on the next day. and examination showed very little limitation of passive motion of the left shoulder, but active motion was only 60 per cent normal. Palpation revealed considerable residual tenderness over the supraspinatus tendon. The patient was instructed to exercise the shoulder more, to continue the Demerol until the 30 tablets were used up and to continue the use of the heating pad. She telephoned a week later and said that she was doing all of her regular housework and had very little pain and limitation of motion of the shoulder. She was told to continue her exercises and heat applications, and to see us only if necessary. She did not see us again, and so was presumably entirely relieved.
1728 CASE
JOHN
W.
GHORMLEY
III. H.K., 50 years old; white, married, male; office worker.
Present Illness. Three weeks before coming in for advice the patient developed, without associated accident or illness, an aching pain in the anterior aspect of his left shoulder. The patient had some pain in the shoulder all of the time, but the pain was made worse when he flexed the slightly abducted left humerus. Examination. There was no swelling, deformity or muscular atrophy. All motions were carried out without pain, discomfort or limitation. Resisted motions were not painful. Palpation revealed no tenderness or other abnormality. X-rays (Fig. 2) showed, in the view made with the humerus in extreme external rotation, that there was a slender annular calcification, 1 cm. in length, lying above, proximal and medial to the greater tuberosity. It was thought that the calcification was probably in the tendon of the supraspinatus. Treatment. In view of the fact that essentially the only objective findings were in the x-rays, it was obvious that no very radical procedures would be necessary. The patient was given 12 short-wave massage and exercise treatments in the course of a month, and at the end of that month, he had obtained complete subjective and objective relief. CONCL USIONS
Calcareous tendinitis may be found in any diseased or necrotic tendon, but the vast majority of the cases that come to treatment involve the supraspinatus, or perhaps the infraspinatus or teres minor, at the shoulder. Many forms of treatment are available and in fact acceptable, but in most cases with severe pain and massive calcification, surgical excision is the treatment of choice. REFERENCES 1. Codman, E. A.: The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston, The Author, 1935. 2. Hughes, E. S. R.: Acute Deposition of Calcium Near the Elbow. J. Bone & Joint Surg. 32-B: 30, 1950. 3. McCarroll, H. B.: Some Clinical Observations in Problems of Soft Tissue Calcification. Arch. Surg. 74: 578, 1957. 4. Pedersen, H. E. and Key, J. A.: Pathology of Calcareous Tendinitis and Subdeltoid Bursitis. Arch. Surg. 62: 50, 1951. 5. Quigley, T. B.: Use of Corticosteroids in Treatment of Painful and Stiff Shoulder. Clin. Orthopedics 10: 182, 1957. 6. Robinson, R.: Possible Significance of Hexosephosphoric Esters in Calcification. Biochem. J. 17: 286, 1923. 7. Van De Mark, R. E. and Myrabo, A. K.: Calcareous Tendinitis at the Elbow. Clin. Orthopedics 7: 237, 1956. 8. Weidman, S. M.: Review of Modern Concepts on Calcification. Arch. Oral BioI. 1: 259,1959. 9. Wheeler, C. E., Curtis, A. C., Cawley, E. P., Grekin, R. H. and Zheutlin, B.: Soft Tissue Calcification, with Special Reference to Its Occurrence in the "Collagen Diseases." Ann. Int. Med. 36: 1050, 1952. Albany Medical College New Scotland Avenue Albany 8, New York
JOHN W. GHORMLEY, M.D. Associate Clinical Professor of Orthopaedic Surgery
INTRODUCTION
Calcification in General
The deposition of various forms of amorphous calcium phosphate and/or calcium carbonate in diseased tissues of the body is a well known phenomenon. Tendons, bursae, lipomata, uterine fibroids, tuberculous glands and many other tissues may be the site of these deposits. There are differences of opinion as to the etiology of this calcification. Robinson 6 in 1923 presented the concept that the precipitation resulted when the tissue fluids became locally supersaturated with phosphate ions by the action of alkaline phosphatase on phosphate esters present in the calcifying area. Many modifications of this theory have been advanced. In 1959 Weidman 8 proposed the "epitactic" concept, that the "bone salt crystallizes out from a supersaturated but otherwise stable tissue fluid onto a primary seed of the organic matrix." Local calcification is not dependent upon generalized hypercalcemia. There is a deposition of calcium phosphate, etc., in calcinosis circumscripta, occasionally associated with hypercalcemia. It may also be seen in hypervitaminosis (vitamin D) and in massive destruction of bone by tumors. Soft tissue calcification may occur in collagen diseases. Wheeler, Curtis, Cawley, Grekin and Zheutlin 9 reported upon this in 1952. This calcification is often of the nature of a calcinosa circumscripta and not a tendinitis. McCarroll3 offers the opinion that "it seems obvious in the light of our present knowledge that problems of soft tissue calcification may, in many instances, be related to the over-all problem of collagen diseases and result in primary degenerative changes in the connective tissues." Pedersen and Key4 studied the material removed from the shoulders
1721
1722
JOHN
W.
GHORMLEY
Fig. 1. Calcification in the conjoined tendon of the elbow.
of 55 patients suffering from subdeltoid bursitis with calcification, and they came to the conclusion that the basic process is a degeneration of the tendon or muscle in the rotator cuff. Calcification of Tendons
Calcium deposits may be found in any tendon that is necrotic or diseased. It has been noted that the condition occurs bilaterally. Perhaps there is a congenital factor in the etiology. Clinically we note varying degrees of calcification. Sometimes in the acute stages there is only a minor deposition of calcium salts, hardly discernible by x-ray. This may increase in a few days, or at least in a week or two, until an area of tendon several millimeters in dimension may be replaced by a creamy, cheese-like calcified mass. This shows in the x-ray as a rounded radiopaque mass. Later, sometimes, especially following treatment, but sometimes without it, the degree of calcification diminishes and often entirely disappears. In some cases, the calcium persists and is replaced by heterotopic bone formation. The diagnosis of calcified tendinitis is a relatively simple matter. Localization of tenderness over a known tendon and x-ray evidence of calcification are sufficient for at least a tentative diagnosis of calcification of the tendon. It is possible, therefore, that almost any tendon of the body may be the site of calcification. A great majority of the cases, however, are in the supraspinatus or possibly in the tendon of the
Calcareous Tendinitis
1723
infraspinatus or teres minor at the shoulder joint. Calcification in the tendon of the subscapularis, in the common extensor as well as common flexor tendon of the elbow, in the tendon of the gluteus medius, in the tendo achillis and others have been noted. Codman,! of course, was the first to recognize that the so-called subdeltoid bursitis with calcification is actually a calcified tendinitis. Hughes,2 in 1950, reported nine cases of calcification of the common extensor tendon of the elbow. Van De Mark and Myrab0 7 added two cases of their own and stated that x-rays had shown areas of calcification distal and lateral to the lateral epicondyle of the elbow. These areas were incised and tissue was removed, which showed microscopically degenerated tendon cells with calcification. We have seen two patients within the past year with calcification in the common extensor tendon of the elbow (Fig. 1). In 1938, I reported a case of ossification of the tendo achillis which had caused rupture of that tendon. This ossification had undoubtedly been preceded by calcification. Up until that time 21 cases of ossification of the tendo achillis had been reported. A great number of these were due to periosteal bone formation and the new bone was attached to the os calcis. Some, however, were due to heterotopic bone formation which had been preceded by calcification. TREATMENT
Since the great majority of the cases of calcareous tendinitis occur in the tendon of the supraspinatus, detailed discussion of treatment will be confined to this disorder. In general, treatment of calcification of other tendons is carried out in the same manner. It is probable that the narrow confines of the subacromial area is one reason why this disorder most frequently gives symptoms. Also, it should be noted that the unusual mechanical factors involved in elevating the arm may cause degeneration of the tendon and resultant calcification. This disease is usually self-limited, so that most treatments sooner or later have resulted in an abatement of the symptoms. Rest, heat, cold applications, ethyl chloride sprays, Novocain (procaine) injection, irrigation of the calcified area with normal saline (usually with two needles and washing out the calcified material), multiple needling, surgical excision of the calcified mass, systemic cortisone therapy, local Hydrocortone (hydrocortisone) injection (sometimes followed by ultrasonic therapy), Butazolidin (phenylbutazone) and other methods of treatment have been used. Pedersen and K ey4 found that some patients were relieved by diathermy, x-ray treatments or needling, but offered the opinion that operative evacuation of the offending forces was the most certain way of obtaining relief. Quigley5 reported that the injection of 25 to 50 mg.
1724
JOHN
W.
GHORMLEY
Fig. 2. A slender annular area of calcification, hardly visible in this x-ray, high in the supraspinatus tendon.
of Hydrocortone acetate, 150 units of hyaluronidase and 6 to 10 cc. of 1 per cent Novocain locally relieved the patients with calcium deposits at or near the greater tuberosity of the humerus. Treatment, then, has varied greatly with the physician or surgeon who is in charge of the patient. He may base his judgment upon the duration of the disorder, the severity of the symptoms, the degree and state of the calcification, the possibility of getting a hospital bed, the patient's ability or willingness to be operated upon, etc. We have had occasion to use, at one time or another, all the methods mentioned except cold applications, ethyl chloride sprays and ultrasonic therapy. Patients who show minimal calcification (Fig. 2) and whose pain is not severe may obtain satisfactory results from putting the extremity at rest in a sling and applying short wave diathermy, microtherm or other form of heat along with proper analgesics or sedatives. Within a day or two, the pain will have largely subsided and an exercise program may be instituted. Injection Therapy In cases of chronic tendinitis with minimal calcification, but with considerable limitation of motion, we have used three to six injections of 50 mg. of Hydrocortone along with an active and passive exercise program. The results in these cases are usually satisfactory. We have not had occasion to use such injections in the acute cases in which there is a large calcified mass. In patients with calcification of the supraspinatus tendon whose symptoms are not too severe and whose x-rays do not show a large, rounded opaque mass, but rather smaller and less circumscribed masses
Calcareous Tendinitis
1725
(Fig. 3), Novocain injections, multiple needling or irrigation with normal saline may be the treatment of choice. About 15 cc. of 1 per cent Novocain is used and multiple punctures of the calcified area are made. It is important that the Novocain not be injected until the needle strikes a tender area. Then a few cc. may be injected. The needle may then be partially withdrawn, but not entirely, and a new tender area sought out and a few additional cc. of Novocain injected. Thus, perhaps a half a dozen different tender areas may be injected and the bursal sac well needled. In some cases it is possible to aspirate some of the calcified material. It is desirable to put the scapulohumeral joint through a full range of motion immediately after the injection in order to disseminate the calcified particles and to break down adhesions. Through-and-through irrigation of the joint with two large gauge needles inserted perpendicular to each other has been used. This treatment is painful and general anesthesia is desirable. Since the results are often not satisfactory, we no longer use this treatment. Following all of these Novocain injections, needling, aspiration or irrigation treatments, local heat and later active and passive exercises are important. Surgical Therapy Surgical excision of the calcified mass is indicated when the pain is unbearable and the x-rays show a large, dense, rounded, circumscribed mass (Fig. 4). By this means one is assured of giving the patient relief. Operative intervention may also be indicated in chronic cases or in recurrent attacks. The operation is not difficult. Adequate preoperative x-rays are essential. It is also necessary that the arm be draped in sterile towels or sheets
Fig. 3. Several small rounded masses of calcification, presumably in the supraspinatus tendon and obviously of some duration.
1726
JOHN W.GHORMLEY
. Fig. 4. Two large creamy, caseous masses in the supraspinatus tendon.
in order that the humerus may be rotated so that the bulging, grayish, calcified mass which lies beneath the floor of the bursa may be brought into view in the center of the incision. A skin incision 2 inches long is made, beginning at the acromio-clavicular joint and extending down parallel with the fibers of the deltoid muscle. The incision in the deltoid muscle is made in the anterior third and by splitting it in the line of the fibers. The incision through the muscle begins at the acromion and stops short of the anterior circumflex vessels and the anterior branch of the axillary nerve. The incision into the calcified mass is made in line with the tendon fibers. It is essential that all of the calcified material be removed, and it is important that an intact tendon be left. The inflamed bursal sac need not be excised. The application of heat and proper active and passive exercises are instituted within a day or two of the operation. The patient is usually symptom-free within a few days of the operation, and should have complete range of motion within two or three weeks if he had no previous contractures. CASE REPORTS CASE I. J.B.,43 years old; white, married male; self-employed auto body and fender mechanic. Present Illness. One week before seeking medical attention the patient had slipped on an icy sidewalk and had fallen. directly upon his right shoulder. He went on to his shop and continued his work. The right shoulder became painful, and the patient took some APC tablets which gave his some relief. He tried a heating pad, but discontinued this because it made the pain worse. The pain became so bad the day before he sought medical attention that he had to give up work, and he slept very little that night. R.xamination. Thefl~ was noswelling, deformity.or muscular atrophy of the right shoulder. Little or no active motion was allowed; and resisted abduction
Calcareous Tendinitis
1727
caused exquisite pain in the region of the subdeltoid bursa. Palpation revealed localized tenderness here. X-rays (Fig. 4) showed several large, rounded areas of calcific densities above the greater tuberosity. Calcified tendinitis of the supraspinatus tendon was diagnosed, and immediate surgical excision was advised . .lIt is our opinion that this is the type of case in which immediate surgical excision offers the most certain method of complete relief.] The masses were very large, extensive, and dense, and obviously of a cheesy, creamy consistency. The patient's pain was exquisite, and his disability complete. Treatment. The patient's wife was ill and he did not think that hospitalization for himself was possible, so the area was injected with 15 cc. of a 1 per cent Novocain solution and needled widely, and the shoulder joint was manipulated. The patient seemed to be completely relieved but was given a prescription for Demerol (meperidine). His relief lasted for less than 12 hours, however, so he was admitted to the hospital as an emergency case. At 6:30 that evening, under general anesthesia, the supraspinatus tendon was explored, and two large creamy calcified areas were removed. The patient's relief was almost complete, and he was discharged from the hospital 2 days later. He continued on the Demerol, now found that the heating pad helped to relieve the pain, and was put on an exercise program even though it was very painful for him. He returned to work 2 weeks after the operation, and when last seen, 1 week later, he had essentially no complaint and very little limitation of motion of the shoulder. CASE II. M.C., 36 years old; white, married female; housewife. Present Illness. The patient was peeling apples 12 days before consulting us, and felt a pain in the left shoulder. She thought she "had caught cold in it" and so rubbed the shoulder with an analgesic ointment. This seemed to relieve the pain for a few days, but later it no longer helped. The patient states that if she kept the arm quiet and at her side, she had no pain in the shoulder. However, the day before seeking medical advice, the pain had become intolerable. Examination. There was no swelling, deformity or muscular atrophy. Very little active motion was present, and the patient allowed only 30 degrees of flexion and extension, 20 degrees of abduction, and little or no internal or external rotation. Resisted abduction was very painful, and palpation showed localized tenderness over the tendon of the supraspinatus. X-rays (Fig. 3) revealed several rounded areas of calcification, presumably in the supraspinatus tendon. The appearance of the calcification suggested that it had been present for several weeks, and possibly several months. Treatment. This did not seem to be a case in which surgical excision of the calcified areas would be feasible, so 15 cc. of 1 per cent Novocain was injected into the calcified tendon areas, they were extensively needled and a measurable quantity of calciuD! salts was removed through an 18-gauge needle. The upper . left arm was immobilized in a sling, the patient was given a prescription for thirty 50 mg. Demerol tablets, and she was advised to use an electric heating pad on the shoulder for relief of pain. She was seen on the next day. and examination showed very little limitation of passive motion of the left shoulder, but active motion was only 60 per cent normal. Palpation revealed considerable residual tenderness over the supraspinatus tendon. The patient was instructed to exercise the shoulder more, to continue the Demerol until the 30 tablets were used up and to continue the use of the heating pad. She telephoned a week later and said that she was doing all of her regular housework and had very little pain and limitation of motion of the shoulder. She was told to continue her exercises and heat applications, and to see us only if necessary. She did not see us again, and so was presumably entirely relieved.
1728 CASE
JOHN
W.
GHORMLEY
III. H.K., 50 years old; white, married, male; office worker.
Present Illness. Three weeks before coming in for advice the patient developed, without associated accident or illness, an aching pain in the anterior aspect of his left shoulder. The patient had some pain in the shoulder all of the time, but the pain was made worse when he flexed the slightly abducted left humerus. Examination. There was no swelling, deformity or muscular atrophy. All motions were carried out without pain, discomfort or limitation. Resisted motions were not painful. Palpation revealed no tenderness or other abnormality. X-rays (Fig. 2) showed, in the view made with the humerus in extreme external rotation, that there was a slender annular calcification, 1 cm. in length, lying above, proximal and medial to the greater tuberosity. It was thought that the calcification was probably in the tendon of the supraspinatus. Treatment. In view of the fact that essentially the only objective findings were in the x-rays, it was obvious that no very radical procedures would be necessary. The patient was given 12 short-wave massage and exercise treatments in the course of a month, and at the end of that month, he had obtained complete subjective and objective relief. CONCL USIONS
Calcareous tendinitis may be found in any diseased or necrotic tendon, but the vast majority of the cases that come to treatment involve the supraspinatus, or perhaps the infraspinatus or teres minor, at the shoulder. Many forms of treatment are available and in fact acceptable, but in most cases with severe pain and massive calcification, surgical excision is the treatment of choice. REFERENCES 1. Codman, E. A.: The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston, The Author, 1935. 2. Hughes, E. S. R.: Acute Deposition of Calcium Near the Elbow. J. Bone & Joint Surg. 32-B: 30, 1950. 3. McCarroll, H. B.: Some Clinical Observations in Problems of Soft Tissue Calcification. Arch. Surg. 74: 578, 1957. 4. Pedersen, H. E. and Key, J. A.: Pathology of Calcareous Tendinitis and Subdeltoid Bursitis. Arch. Surg. 62: 50, 1951. 5. Quigley, T. B.: Use of Corticosteroids in Treatment of Painful and Stiff Shoulder. Clin. Orthopedics 10: 182, 1957. 6. Robinson, R.: Possible Significance of Hexosephosphoric Esters in Calcification. Biochem. J. 17: 286, 1923. 7. Van De Mark, R. E. and Myrabo, A. K.: Calcareous Tendinitis at the Elbow. Clin. Orthopedics 7: 237, 1956. 8. Weidman, S. M.: Review of Modern Concepts on Calcification. Arch. Oral BioI. 1: 259,1959. 9. Wheeler, C. E., Curtis, A. C., Cawley, E. P., Grekin, R. H. and Zheutlin, B.: Soft Tissue Calcification, with Special Reference to Its Occurrence in the "Collagen Diseases." Ann. Int. Med. 36: 1050, 1952. Albany Medical College New Scotland Avenue Albany 8, New York