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Calcific tendinitis of the flexors of the forefoot
OASE REPORI tendinitis, calcific, flexors, foot
Calcific Tendinitis of the Flexors of the Forefoot Robert A Rhodes, MD Carol B Stelling, MD Lexington, Kentucky From the Department of Diagnostic Radiology, University of Kentucky College of Medicine, Lexington, Kentucky. Received for publication August 2, 1985. Accepted for publication September 24, 1985. Address for reprints: Carol B Stelling, MD, Department of Diagnostic Radiology, University of Kentucky, Albert B Chandler Medical Center, Lexington, Kentucky 40536-0084.
We report a case of calcific tendinitis in the flexor tendons of the forefoot. A 33-year-old woman presented with a two-day history of foot pain but she recalled no direct trauma to the foot. Physical examination revealed redness, warmth, and tenderness on the plantar surface of the foot near the head of the first metatarsal. Radiographs showed a small focus of calcification in the flexor tendons of the great toe, diagnostic of calcific tendinitis. The patient was treated with supportive therapy and recovered. [Rhodes RA, Stelling CB: Calcific tendinitis of the flexors of the forefoot. Ann Emerg Med June 1986;15:751-753.] INTRODUCTION Frequently pain and inflammation are associated with radiographically visible periarticular calcific deposits in tendons or other soft tissues. 1 This entity has been called by many names, including calcific tendinitis, calcific peritendinitis, calcific bursitis, peritendinitis calcarea, calcareous tendinitis, calcareous bursitis, periarthritis calcarea, and hydroxyapatite rheumatism. 1 The most common site of calcific tendinitis is in the shoulder, 69% to 79% of all cases. Other areas described are the hip, elbow, and wrist. 2 Calcification in the tendons of the foot and toes accounts for about 1% of cases.3, 4 We report a case of calcific tendinitis involving the flexor tendons in the forefoot to increase awareness of this clinical entity, CASE REPORT A 33-year-old woman complained of a two-day history of increasing right foot pain. She denied any history of trauma. The pain was greatest on the plantar surface of the foot just proximal to the first metatarsal head, and increased with walking, flexion of the big toe, and direct pressure. Redness and warmth in the area of pain developed on the second day, but the patient denied fever or chills. She stated that she could not sleep because of the pain, and that aspirin or acetaminophen gave no relief. Physical examination revealed a 2-cm area on the plantar surface of the foot near the head of the first metatarsal that was red, swollen, and tender to palpation. The pain was exacerbated by dorsiflexion of the big toe. There was no pain to palpation directly on the first metatarsophalangeal joint. The patient's vital signs were as follows: blood pressure, 124/94 m m Hg~ pulse, 76; temperature, 37.6 C; and respirations, 18. Anteroposterior (AP), lateral, and oblique radiographs of the right foot showed a 5-mm, rounded focus of homogeneous calcification just proximal to a line between the sesamoid bones beneath the first metatarsal head. On both the AP and oblique views the density was superimposed over the first metatarsal head (Figure 1). On the lateral view the calcification projected in the plantar tissues, corresponding to the location of the flexor tendons of the big toe (Figure 2). The calcification did not have a cortical rim of bone. Because of the characteristic clinical and radiographic findings, a diagnosis of calcific tendinitis of flexor tendons in the forefoot was made. The patient was treated with fenoprofen (Nalfon ®) 300 mg four times a day and warm soaks to the area, and recovered fully, DISCUSSION Four primary plantar muscles, the flexor hallucis longus, flexor hallucis
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Annals of Emergency Medicine
15:6 June 1986
brevis, flexor digitorum longus, and flexor digitomm brevis, flex the toes. The flexor hallucis longus and flexor digitorum longus originate in the lower leg, and their tendons pass along the plantar surface of the foot to insert on the plantar surface of the distal phalanges of the big (flexor hallucis longus) and second through fifth toes (flexor digitorum longus). The flexor hallucis brevis and flexor digitorum brevis originate in the hindfoot, their tendons insert on the sides of the proximal phalanx of the big toe and the middle phalanges of the second through fifth toes, respectively. The two sesamoid bones characteristically seen beneath the first metatarsal head are within the heads of the flexor hallucis brevis near their insertion. When the foot is lifted off the ground, the flexor muscles act to flex the toes. When the foot is on the ground and under load, they act synergistically with the lumbricals and interossei to maintain the pads of the 15:6 J une 1986
toes in firm contact with the ground. This enlarges the weight-beating area and helps to stabilize the heads of the metatarsals, aiding the formation of the fulcrum on which the body is propelled forward. There also is marked activity of these muscles during takeoff and tip-toe movements. Because o~ this, such actions as running, dancing, or other activities requiring a great deal of "footwork" place increased demands on the flexor tendons in the forefoot, s The pathogenesis of calcium deposition in calcific tendinitis is uncertain. It has been thought that calcium is deposited in injured and necrotic tissues. This hypothesis assumed the presence of inflammation, which was thought to be proportionate to the size of the calcifications.1 Unthoff and colleagues have demonstrated that there is no inflammatory infiltrate or scarring in affected areas. 6 They propose that these Annals of Emergency Medicine
FIGURE 1. Oblique radiograph of the right foot shows a rounded calcific density (arrow) projecting over the cortical bone of the first metatarsal proximal to the medial sesamoid bone of the big toe. FIGURE 2. Lateral radiograph pro-
jects the calcific deposit (arrow) free of surrounding bone. calcifications occur in areas of poor blood supply. Persistently decreased perfusion may lead to the transformation of a tendon into fibrocartilage, which may mineralize. A subsequent accumulation of phagocytes with associated vascular proliferation may increase perfusion to the affected area, leading to the resorption of the calcium deposits. Clinically, a distinct episode of trauma is obtained only rarely. 3 Often, 752/131
CALClFIC TENDINITIS Rhodes & Stelling
however, t h e r e is a h i s t o r y of repetitive mild trauma. A bus driver with a stiff brake pedal previously was reported to have developed calcific tendinitis in the forefoot.7 In addition, a genetic predisposition, or neurologic or metabolic factors may play a role. 1 Patients usually present with pain, frequently intense, in the area of calcification. A forced passive m o v e m e n t opposite to the d i r e c t i o n of physiologic action of the tendon in quest i o n u s u a l l y causes pain. T h e r e is often local swelling, redness, and tendemess as well as restricted mobility. These s y m p t o m s were noted in our patient. Temperature and erythrocyte sedimentation rate may be mildly elevated, but no other systemic symptoms or signs are characteristic. 4 T h e radiograph u s u a l l y indicates the correct diagnosis. 1 Early in the course of the disorder the calcification may be thin, cloudlike, or poorly defined. 4 Typically at the time of presentation the calcification is more dense, homogeneous, and sharply defined, in a linear or circular configuration (Figure 3). With time, the deposits may remain stable, enlarge, or may even disappear. 1 When calcification is within a tendon, its location frequently is a clue to the identification of the involved tendon.
F I G U R E 3. Anteroposterior radiograph of the foot of another patient shows a calcific deposit (arrow) projected proximal to the medial sesamoid of the first metatarsal. be overlooked easily radiographically. Dense calcific deposits must be differentiated from normally occurring sesamoid bones. Faint cloudlike calcifications m a y be difficult to see, and if close to skeletal parts, may disappear against the shadow of bone. The deposits m a y be seen only on one of the three routine projections of the foot, and be obscured on the other views. Currently the treatment of calcific tendinitis is entirely supportive. Formerly this disorder was treated with radiation therapy, often with good results. 4 Now, however, the standard therapy is analgesics and limitation of activity. Local injection of anesthetic agents or steroids, other antiinflammatory agents, mechanical disruption, or surgical excision are reserved for very severe or refactory cases. The pain typically resolves promptly with conservative measures. U s u a l l y the calcifications d i m i n i s h or resolve. They may remain, but almost all become asymptomatic.
REFERENCES SUMMARY Calcific tendinitis in the flexors of the forefoot, particularly around the first metatarsophalangeal joint, may
132/753
1. Resnick D, Niwayama G: Diagnosis of Bone and Joint Disorders. Philadelphia, WB Saunders, 1981, pp 1576-1587. 2. Gandee RW, Harrison RB, Dee PM:
Annals of Emergency Medicine
Peritendinitis calcarea of flexor carpi ulnaris. AJR 1979;133:1139-1141. 3. Gondos B: Observations on periarthritis calcarea. AJR 1957;77:93-108. 4. Sandstrom C: Peritendinitis calcarea.
AJR 1938;40:1-21. 5. William PL, Warwick R (ed): Gray's Anatomy. Philadelphia, WB Saunders, 1980, pp 609-618. 6. Uhthoff HK, Sarkar K, Maynard JA: Calcifying tendinitis: A new concept of its pathogenesis. Clin Orthop 1976;118: 164-168 7. Gruneberg R: Calcifying tendinitis in the forefoot. Br J Radiol 1963;36:378-379.
15:6 June 1986
Calcific Tendinitis of the Flexors of the Forefoot Robert A Rhodes, MD Carol B Stelling, MD Lexington, Kentucky From the Department of Diagnostic Radiology, University of Kentucky College of Medicine, Lexington, Kentucky. Received for publication August 2, 1985. Accepted for publication September 24, 1985. Address for reprints: Carol B Stelling, MD, Department of Diagnostic Radiology, University of Kentucky, Albert B Chandler Medical Center, Lexington, Kentucky 40536-0084.
We report a case of calcific tendinitis in the flexor tendons of the forefoot. A 33-year-old woman presented with a two-day history of foot pain but she recalled no direct trauma to the foot. Physical examination revealed redness, warmth, and tenderness on the plantar surface of the foot near the head of the first metatarsal. Radiographs showed a small focus of calcification in the flexor tendons of the great toe, diagnostic of calcific tendinitis. The patient was treated with supportive therapy and recovered. [Rhodes RA, Stelling CB: Calcific tendinitis of the flexors of the forefoot. Ann Emerg Med June 1986;15:751-753.] INTRODUCTION Frequently pain and inflammation are associated with radiographically visible periarticular calcific deposits in tendons or other soft tissues. 1 This entity has been called by many names, including calcific tendinitis, calcific peritendinitis, calcific bursitis, peritendinitis calcarea, calcareous tendinitis, calcareous bursitis, periarthritis calcarea, and hydroxyapatite rheumatism. 1 The most common site of calcific tendinitis is in the shoulder, 69% to 79% of all cases. Other areas described are the hip, elbow, and wrist. 2 Calcification in the tendons of the foot and toes accounts for about 1% of cases.3, 4 We report a case of calcific tendinitis involving the flexor tendons in the forefoot to increase awareness of this clinical entity, CASE REPORT A 33-year-old woman complained of a two-day history of increasing right foot pain. She denied any history of trauma. The pain was greatest on the plantar surface of the foot just proximal to the first metatarsal head, and increased with walking, flexion of the big toe, and direct pressure. Redness and warmth in the area of pain developed on the second day, but the patient denied fever or chills. She stated that she could not sleep because of the pain, and that aspirin or acetaminophen gave no relief. Physical examination revealed a 2-cm area on the plantar surface of the foot near the head of the first metatarsal that was red, swollen, and tender to palpation. The pain was exacerbated by dorsiflexion of the big toe. There was no pain to palpation directly on the first metatarsophalangeal joint. The patient's vital signs were as follows: blood pressure, 124/94 m m Hg~ pulse, 76; temperature, 37.6 C; and respirations, 18. Anteroposterior (AP), lateral, and oblique radiographs of the right foot showed a 5-mm, rounded focus of homogeneous calcification just proximal to a line between the sesamoid bones beneath the first metatarsal head. On both the AP and oblique views the density was superimposed over the first metatarsal head (Figure 1). On the lateral view the calcification projected in the plantar tissues, corresponding to the location of the flexor tendons of the big toe (Figure 2). The calcification did not have a cortical rim of bone. Because of the characteristic clinical and radiographic findings, a diagnosis of calcific tendinitis of flexor tendons in the forefoot was made. The patient was treated with fenoprofen (Nalfon ®) 300 mg four times a day and warm soaks to the area, and recovered fully, DISCUSSION Four primary plantar muscles, the flexor hallucis longus, flexor hallucis
130/751
Annals of Emergency Medicine
15:6 June 1986
brevis, flexor digitorum longus, and flexor digitomm brevis, flex the toes. The flexor hallucis longus and flexor digitorum longus originate in the lower leg, and their tendons pass along the plantar surface of the foot to insert on the plantar surface of the distal phalanges of the big (flexor hallucis longus) and second through fifth toes (flexor digitorum longus). The flexor hallucis brevis and flexor digitorum brevis originate in the hindfoot, their tendons insert on the sides of the proximal phalanx of the big toe and the middle phalanges of the second through fifth toes, respectively. The two sesamoid bones characteristically seen beneath the first metatarsal head are within the heads of the flexor hallucis brevis near their insertion. When the foot is lifted off the ground, the flexor muscles act to flex the toes. When the foot is on the ground and under load, they act synergistically with the lumbricals and interossei to maintain the pads of the 15:6 J une 1986
toes in firm contact with the ground. This enlarges the weight-beating area and helps to stabilize the heads of the metatarsals, aiding the formation of the fulcrum on which the body is propelled forward. There also is marked activity of these muscles during takeoff and tip-toe movements. Because o~ this, such actions as running, dancing, or other activities requiring a great deal of "footwork" place increased demands on the flexor tendons in the forefoot, s The pathogenesis of calcium deposition in calcific tendinitis is uncertain. It has been thought that calcium is deposited in injured and necrotic tissues. This hypothesis assumed the presence of inflammation, which was thought to be proportionate to the size of the calcifications.1 Unthoff and colleagues have demonstrated that there is no inflammatory infiltrate or scarring in affected areas. 6 They propose that these Annals of Emergency Medicine
FIGURE 1. Oblique radiograph of the right foot shows a rounded calcific density (arrow) projecting over the cortical bone of the first metatarsal proximal to the medial sesamoid bone of the big toe. FIGURE 2. Lateral radiograph pro-
jects the calcific deposit (arrow) free of surrounding bone. calcifications occur in areas of poor blood supply. Persistently decreased perfusion may lead to the transformation of a tendon into fibrocartilage, which may mineralize. A subsequent accumulation of phagocytes with associated vascular proliferation may increase perfusion to the affected area, leading to the resorption of the calcium deposits. Clinically, a distinct episode of trauma is obtained only rarely. 3 Often, 752/131
CALClFIC TENDINITIS Rhodes & Stelling
however, t h e r e is a h i s t o r y of repetitive mild trauma. A bus driver with a stiff brake pedal previously was reported to have developed calcific tendinitis in the forefoot.7 In addition, a genetic predisposition, or neurologic or metabolic factors may play a role. 1 Patients usually present with pain, frequently intense, in the area of calcification. A forced passive m o v e m e n t opposite to the d i r e c t i o n of physiologic action of the tendon in quest i o n u s u a l l y causes pain. T h e r e is often local swelling, redness, and tendemess as well as restricted mobility. These s y m p t o m s were noted in our patient. Temperature and erythrocyte sedimentation rate may be mildly elevated, but no other systemic symptoms or signs are characteristic. 4 T h e radiograph u s u a l l y indicates the correct diagnosis. 1 Early in the course of the disorder the calcification may be thin, cloudlike, or poorly defined. 4 Typically at the time of presentation the calcification is more dense, homogeneous, and sharply defined, in a linear or circular configuration (Figure 3). With time, the deposits may remain stable, enlarge, or may even disappear. 1 When calcification is within a tendon, its location frequently is a clue to the identification of the involved tendon.
F I G U R E 3. Anteroposterior radiograph of the foot of another patient shows a calcific deposit (arrow) projected proximal to the medial sesamoid of the first metatarsal. be overlooked easily radiographically. Dense calcific deposits must be differentiated from normally occurring sesamoid bones. Faint cloudlike calcifications m a y be difficult to see, and if close to skeletal parts, may disappear against the shadow of bone. The deposits m a y be seen only on one of the three routine projections of the foot, and be obscured on the other views. Currently the treatment of calcific tendinitis is entirely supportive. Formerly this disorder was treated with radiation therapy, often with good results. 4 Now, however, the standard therapy is analgesics and limitation of activity. Local injection of anesthetic agents or steroids, other antiinflammatory agents, mechanical disruption, or surgical excision are reserved for very severe or refactory cases. The pain typically resolves promptly with conservative measures. U s u a l l y the calcifications d i m i n i s h or resolve. They may remain, but almost all become asymptomatic.
REFERENCES SUMMARY Calcific tendinitis in the flexors of the forefoot, particularly around the first metatarsophalangeal joint, may
132/753
1. Resnick D, Niwayama G: Diagnosis of Bone and Joint Disorders. Philadelphia, WB Saunders, 1981, pp 1576-1587. 2. Gandee RW, Harrison RB, Dee PM:
Annals of Emergency Medicine
Peritendinitis calcarea of flexor carpi ulnaris. AJR 1979;133:1139-1141. 3. Gondos B: Observations on periarthritis calcarea. AJR 1957;77:93-108. 4. Sandstrom C: Peritendinitis calcarea.
AJR 1938;40:1-21. 5. William PL, Warwick R (ed): Gray's Anatomy. Philadelphia, WB Saunders, 1980, pp 609-618. 6. Uhthoff HK, Sarkar K, Maynard JA: Calcifying tendinitis: A new concept of its pathogenesis. Clin Orthop 1976;118: 164-168 7. Gruneberg R: Calcifying tendinitis in the forefoot. Br J Radiol 1963;36:378-379.
15:6 June 1986