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Calcific tendinitis of the trapezius insertion
CASE REPORTS Calcific tendinitis Charles C. Nofsinaer, MD, NY; and Philadelpvhio, Pa
of the trapezius Gerald
R. Williams,
_Ir, MD,
c a I CI‘f’IC ten d’ ml‘t’IS is a painful condition characterized by intratendinous calcium formation.‘~6~9~12~17~19~20~23 Its occurrence in the shoulder region was first described in the nineteenth century.6 Calcific tendinitis of the shoulder is a relatively common cause of shoulder pain and has been reported to affect 3% of all shoulders.Qu It has been reported most often in the rotator cuff tendons but has also been described in the long head of the biceps brachii and the pectoralis rnaior.lJ~4~12J3 We report a case of calcific tendinitis affecting the trapezius insertion that was initially diagnosed as septic arthritis of the acromioclavicular joint. The correct diagnosis was made by considering patient history and the results of physical examination and plain radiography. Symptoms responded to needle aspiration and injection.
CASE REPORT A 43-year-old, right-handed housewife was referred to our shoulder and elbow service with a 2day history of severe left shoulder pain. The pain began spontaneously, was not associated with antecedent trauma, was localized to the superolateral aspect of the shoulder, and was nonradiating. The patient noted progressive warmth and redness in the shoulder, became concerned, and consulted her family physician, who diagnosed possible septic arthritis of the acromioclavicular joint and referred the patient for potentially urgent surgical drainage. The patient denied having fevers or chills and reported a past medical history of multiple sclerosis, trigeminal neuralgia, anemia, and chronic sinusitis associated with allergies. There was no history of gout, pseudogout, or other metabolic disorders. Past medications included iron supplements, vitamin B12 From the Department Surgery; and the Orthopaedic
of Orthopaedrc Shoulder and
Surgery,
Hospital
Surgery, Hosprtal for Specral Elbow Servrce, Department of of the Universrty
of Pennsylvania
Reprmt requests. Gerald R. Williams, Jr, MD, Penn Musculoskeletal Institute, 1 Cupp Pavillion, Presbytenan Medical Center, 39th and
Market,
J Shoulder Copyright Board
Philadelphia,
Elbow 0
Surg
1999
by Journal
of
Shoulder
of Trustees
1058-2746/99/$8.00
162
PA 19104.
1999,8:162-4
+0
32/4/90177
and
Elbow
Surgery
insertion
and Joseph
P. lannotti,
MD,
PhD, New
York,
supplements, and pseudoephedrine. Surgical history was significant for cryosurgery for trigeminal neuralgia. Physical examination revealed swelling and erythema of the superolateral aspect of the left shoulder in the general region of the acromioclavicular joint (Figure 1). There was exquisite point tenderness within this erythematous region. The maximal area of point tenderness was located slightly posterior and lateral to the acromioclavicular joint. Active and passive motion was equal to that of the unaffected shoulder and could be performed without severe pain. Shoulder shrugging, particularly against resistance, was associated with significant pain. However, cross-body adduction did not exacerbate the discomfort. Anteroposterior and scapular lateral (ie, ‘9”‘) radiographs were obtained. The radiographs revealed 1 small area of calcification just superior to the glenoid in the region of the superior labrum and biceps tendon insertion. This calcification was thought to be clinically insignificant. A second area of calcification was observed superior and lateral to the acromioclavicular joint (Figure 2). This deposit was rounded, flocculent, and accompanied by soft-tissue swelling. Except for mild sclerosis of the greater tuberosity, the results of the remainder of the radiographic evaluation were normal. Laboratory evaluation results, including erythrocyte sedimentation rate, white blood cell count, serum glucose, alkaline phosphatase, and uric acid levels, were normal. Sterile aspiration of the flocculent calcium deposit superior and lateral to the acromioclavicular joint was attempted. The skin over the area of maximal point tenderness was anesthetized with 1% lidocaine (Xylocaine). An 18gauge needle equipped with a 1 O-mm syringe containing a combination of 1% lidocaine and 0.25% bupivacaine was then inserted into the area superior and lateral to the acromioclavicular joint that corresponded to the point of maximal tenderness. Aspiration yielded a small amount of a milky white substance. The solution of lidocaine and bupivacaine was “flushed” into the area by alternating injection and aspiration. The patient had almost immediate and complete relief of her pain and has not returned for follow-up evaluation. However, the patient was contacted by telephone approximately 1 year after the aspiration. She
I Shoulder Elbow Surg Volume 8, Number 2
Figure
Figure deposit
1 Soft-tissue
swelling
and
erythema
2 Anteroposterior (A) and scapular superior and lateral to acromioclavicular
reported that her symptoms she considered her shoulder
had not returned to be normal.
on superior
aspect
of shoulder
lateral (8) radiographs joint.
and that
DlSCUSSION Calcific tendinitis is a common cause of shoulder pain. It was described as early as 1872 by Duplay.6
reveal
Nofsinger,
Williams,
in the region
of acromioclavicular
inhomogeneous,
flocculent
and
lannotti
163
joint.
calcium
Calcific tendinitis of the shoulder region most often occurs in the tendons of the rotator cuff.s,12~19J0,*3 It typically affects people who are 40 to 60 years old, and occurs slightly more frequently in women than in men.19,*0 The cause of calcific tendinitis is not completely understood and is probably multifactori-
164
Nofsinger,
Williams,
and
lannotti
al.7r9~10~1*-2u There is some evidence for a genetic link to human leukocyte antigen Al .15 According to Uthoff et al 19~0 there are 3 stages in the course of calcific tendinitis: (1) precalcification, (2) formation, and (3) resorption. In the precalcification stage, tenocytes undergo metaplasia to chondrocytes. The factor that incites this metaplasia is not known but may be a local decrease in oxygen tension, pressure, trauma, or a combination of these factors. The formation of amorphous hydroxyapatite crystals then occurs.7 The calcification process may remain dormant for many months before the resorptive process commences. The beginning of the resorptive process is characterized by vascular proliferation and transformation of the calcium from a solid to a toothpaste-like material. This does not correspond to a change in the crystalline structure of the calcium but to a change in the adhesive factors in the surrounding tissues.15 During this phase pain reaches its most severe intensity because of increased intratendinous pressure. There are numerous causes of shoulder pain. In this case the patient was initially thought to have an infectious process in the acromioclavicular joint, which is what the acute onset of severe pain and accompanying swelling and erythema suggested. Although symptoms could be referred to the general vicinity of the acromioclavicular joint, tenderness was located slightly posterior and lateral to the joint and compression of the joint was not painful. Appropriate radiographs demonstrated a locus of calcification within the soft tissues posterior and lateral to the acromioclavicular joint. Although we have no surgical confirmation, we believe the calcific deposit was located within the tendinous insertion of the superior portion of the trapezius, posterior and lateral to the acromioclavicular joint and acromion. Radiographic characteristics of calcific tendinitis depend on the phase of the process. In the formative phase, calcifications are dense and homogeneous.*JO During the resorptive phase, the calcifications are inhomogeneous and are sometimes not visible on routine radiographs. 8~0 In these cases, computed tomography may help identify the calcium deposit, though it may not be cost effective.1 Calcific tendinitis is often a self-limited process.5f20 Treatment options include oral anti-inflammatory medications (both steroidal and nonsteroidal), analgesics, physiotherapy, needle aspiration with or without corticosteroids, ultrasound, radiotherapy, and surgical excision.*~5~11~13,14,16~20~** Our patient presumably was in the resorptive phase and potentially may have had spontaneous resolution of the symptoms while resorption of the deposit progressed. She was given the option of expectant treatment along with the option of needle aspiration. Because of the prospect of potentially rapid relief with needle aspiration, she elected the latter of the 2 options. We succeeded in entering the calcium deposit and evacuating it either partially
J Shoulder Elbow Surg March/April 7 999
or completely, thereby relieving the intratendinous pressure. Calcific tendinitis of the trapezius insertion is a rare cause of shoulder pain. We are unaware of any previous report of this condition. It should be considered in the differential diagnosis of superior shoulder pain. It can be easily distinguished from acromioclavicular joint disease on the basis of patient history and the results of physical examination and routine radiography. REFERENCES 1
2 3 4
5
6
Archer B, Frredman L, Strlgenbauer S, et al Symptomatrc calcific tendrmtis at unusual sates. Can Assoc Rad J 1992;43. 203-7 Ark JW, Flock TJ, Flatow EL, et al. Arthroscoprc treatment of calcrfrc tendrnrtrs of the shoulder. Arthroscopy 1992;8 183-8 Reference deleted In proofs, Bosworth DM Calcrum deposits In the shoulder and subacromial bursrtrs: a survey of 12,122 shoulders JAMA 1941,l 16: 2477-82 DePalma AF, KruperJS tong ed with and treated for 1961,206-72 Duplay ES De la periarthrrtrs de I’epaule qui sont la 1872.5 13542
term study of shoulder oints afflrctcalcrfic tendrnrtrs C In Orthop scapulohumerale consequence
et des radieurs Arch Gen Med
Gartner J, Srmons B. Analysrs of calcrfrc deposrts tendinitis. Clin Orthop 1990,254 1 1 l-20. Holt P, Keats T. Calcric unusual Skeletal Radrol
tendrnrtrs, 1993.22:
a revlew 1-9
Hsu H-C, WV J-J, Jrm YF, et al Calcific tearing: a clinical and radrographic Surg I994,3 159-64 10
11
In calcrfyrng
of the usual
and
tendrnrtrs and rotator cuff study J Shoulder Elbow
Jim YF, Hsu HC, Chang CY, et al Coexistence of calcrfrc tendinitis and rotator cuff tear an arthroaraohrc studv Skeletal v Radrol 1993,22,183-5. taprdus PW lnfrltration therapy of acute tendinrtrs with calrfrcatlon Surgery, Gynecology, Obstetrrcs 1943,76.715-25
12
Painter Journal
13
Plenk HP Calcrfyrng tendinrtrs of the shoulder A critrcal study of the value of Roentgen-Therapy Radiology 195259 384-9. Rompe JD, Rumler F, Hopf C, et al Extracorporal shock wave therapy for calcrfytng tendinitis of the shoulder Clin Orthop 1995, 321.196-201 Senaar DPS, McKendrv RI, Uhthoff HK, et al. Increased frequency of HLA-Al in calcifyrng tendrnrtis. Tissue Antigens 1987,29.173-4
14
1.5
16. 17 18 19. 20.
CF Subdeltord bursrtrs. 1972,156 345-9
I
Boston
Medical
and
Surgrcal
-
Tamai K, Hayashi M. Calcrfic tendinitis of the shoulder indrcatrons for sterord rntections. Acta Orthop Stand 1992;63 S247. Uhthoff HK Calcifying tendrnrtrs versus rotator cuff ruptures J Bone Jornt Surg [abstract] 1975i578.53 1 Uhthoff HK, Sarkar K Calcifying tendinitis. An active, cell-medrated process J Bone Joint Surg [abstract] 1975,57A,566. Uhthoff HK, Sarkar K. Calcifying tendinitis Barllreres Clrnrc Rheumatol 1989.3567-8 1 Uhthoff HK, Sarkar K Cal&yin tendrnrtrs In: Rockwood CA, Matsen FA. editors. The shoul f er 1st ed. Philadelohra WB Saunders, i990 p 774-88
21. 22.
Reference deleted in proofs. Vebostad A. Cal& tendrnrtis in the shoulder 43 operated shoulders Acta Orthop Stand
23
Wrede L Uber kalkablagerungen der umgebung des schultergelenks und rhre bezie hungen zur penarthritis scapulo-humeral/s. Arch Klin Chir 1912;99,259-71.
region. a review fo 1975,46,205-l 0
of the trapezius Gerald
R. Williams,
_Ir, MD,
c a I CI‘f’IC ten d’ ml‘t’IS is a painful condition characterized by intratendinous calcium formation.‘~6~9~12~17~19~20~23 Its occurrence in the shoulder region was first described in the nineteenth century.6 Calcific tendinitis of the shoulder is a relatively common cause of shoulder pain and has been reported to affect 3% of all shoulders.Qu It has been reported most often in the rotator cuff tendons but has also been described in the long head of the biceps brachii and the pectoralis rnaior.lJ~4~12J3 We report a case of calcific tendinitis affecting the trapezius insertion that was initially diagnosed as septic arthritis of the acromioclavicular joint. The correct diagnosis was made by considering patient history and the results of physical examination and plain radiography. Symptoms responded to needle aspiration and injection.
CASE REPORT A 43-year-old, right-handed housewife was referred to our shoulder and elbow service with a 2day history of severe left shoulder pain. The pain began spontaneously, was not associated with antecedent trauma, was localized to the superolateral aspect of the shoulder, and was nonradiating. The patient noted progressive warmth and redness in the shoulder, became concerned, and consulted her family physician, who diagnosed possible septic arthritis of the acromioclavicular joint and referred the patient for potentially urgent surgical drainage. The patient denied having fevers or chills and reported a past medical history of multiple sclerosis, trigeminal neuralgia, anemia, and chronic sinusitis associated with allergies. There was no history of gout, pseudogout, or other metabolic disorders. Past medications included iron supplements, vitamin B12 From the Department Surgery; and the Orthopaedic
of Orthopaedrc Shoulder and
Surgery,
Hospital
Surgery, Hosprtal for Specral Elbow Servrce, Department of of the Universrty
of Pennsylvania
Reprmt requests. Gerald R. Williams, Jr, MD, Penn Musculoskeletal Institute, 1 Cupp Pavillion, Presbytenan Medical Center, 39th and
Market,
J Shoulder Copyright Board
Philadelphia,
Elbow 0
Surg
1999
by Journal
of
Shoulder
of Trustees
1058-2746/99/$8.00
162
PA 19104.
1999,8:162-4
+0
32/4/90177
and
Elbow
Surgery
insertion
and Joseph
P. lannotti,
MD,
PhD, New
York,
supplements, and pseudoephedrine. Surgical history was significant for cryosurgery for trigeminal neuralgia. Physical examination revealed swelling and erythema of the superolateral aspect of the left shoulder in the general region of the acromioclavicular joint (Figure 1). There was exquisite point tenderness within this erythematous region. The maximal area of point tenderness was located slightly posterior and lateral to the acromioclavicular joint. Active and passive motion was equal to that of the unaffected shoulder and could be performed without severe pain. Shoulder shrugging, particularly against resistance, was associated with significant pain. However, cross-body adduction did not exacerbate the discomfort. Anteroposterior and scapular lateral (ie, ‘9”‘) radiographs were obtained. The radiographs revealed 1 small area of calcification just superior to the glenoid in the region of the superior labrum and biceps tendon insertion. This calcification was thought to be clinically insignificant. A second area of calcification was observed superior and lateral to the acromioclavicular joint (Figure 2). This deposit was rounded, flocculent, and accompanied by soft-tissue swelling. Except for mild sclerosis of the greater tuberosity, the results of the remainder of the radiographic evaluation were normal. Laboratory evaluation results, including erythrocyte sedimentation rate, white blood cell count, serum glucose, alkaline phosphatase, and uric acid levels, were normal. Sterile aspiration of the flocculent calcium deposit superior and lateral to the acromioclavicular joint was attempted. The skin over the area of maximal point tenderness was anesthetized with 1% lidocaine (Xylocaine). An 18gauge needle equipped with a 1 O-mm syringe containing a combination of 1% lidocaine and 0.25% bupivacaine was then inserted into the area superior and lateral to the acromioclavicular joint that corresponded to the point of maximal tenderness. Aspiration yielded a small amount of a milky white substance. The solution of lidocaine and bupivacaine was “flushed” into the area by alternating injection and aspiration. The patient had almost immediate and complete relief of her pain and has not returned for follow-up evaluation. However, the patient was contacted by telephone approximately 1 year after the aspiration. She
I Shoulder Elbow Surg Volume 8, Number 2
Figure
Figure deposit
1 Soft-tissue
swelling
and
erythema
2 Anteroposterior (A) and scapular superior and lateral to acromioclavicular
reported that her symptoms she considered her shoulder
had not returned to be normal.
on superior
aspect
of shoulder
lateral (8) radiographs joint.
and that
DlSCUSSION Calcific tendinitis is a common cause of shoulder pain. It was described as early as 1872 by Duplay.6
reveal
Nofsinger,
Williams,
in the region
of acromioclavicular
inhomogeneous,
flocculent
and
lannotti
163
joint.
calcium
Calcific tendinitis of the shoulder region most often occurs in the tendons of the rotator cuff.s,12~19J0,*3 It typically affects people who are 40 to 60 years old, and occurs slightly more frequently in women than in men.19,*0 The cause of calcific tendinitis is not completely understood and is probably multifactori-
164
Nofsinger,
Williams,
and
lannotti
al.7r9~10~1*-2u There is some evidence for a genetic link to human leukocyte antigen Al .15 According to Uthoff et al 19~0 there are 3 stages in the course of calcific tendinitis: (1) precalcification, (2) formation, and (3) resorption. In the precalcification stage, tenocytes undergo metaplasia to chondrocytes. The factor that incites this metaplasia is not known but may be a local decrease in oxygen tension, pressure, trauma, or a combination of these factors. The formation of amorphous hydroxyapatite crystals then occurs.7 The calcification process may remain dormant for many months before the resorptive process commences. The beginning of the resorptive process is characterized by vascular proliferation and transformation of the calcium from a solid to a toothpaste-like material. This does not correspond to a change in the crystalline structure of the calcium but to a change in the adhesive factors in the surrounding tissues.15 During this phase pain reaches its most severe intensity because of increased intratendinous pressure. There are numerous causes of shoulder pain. In this case the patient was initially thought to have an infectious process in the acromioclavicular joint, which is what the acute onset of severe pain and accompanying swelling and erythema suggested. Although symptoms could be referred to the general vicinity of the acromioclavicular joint, tenderness was located slightly posterior and lateral to the joint and compression of the joint was not painful. Appropriate radiographs demonstrated a locus of calcification within the soft tissues posterior and lateral to the acromioclavicular joint. Although we have no surgical confirmation, we believe the calcific deposit was located within the tendinous insertion of the superior portion of the trapezius, posterior and lateral to the acromioclavicular joint and acromion. Radiographic characteristics of calcific tendinitis depend on the phase of the process. In the formative phase, calcifications are dense and homogeneous.*JO During the resorptive phase, the calcifications are inhomogeneous and are sometimes not visible on routine radiographs. 8~0 In these cases, computed tomography may help identify the calcium deposit, though it may not be cost effective.1 Calcific tendinitis is often a self-limited process.5f20 Treatment options include oral anti-inflammatory medications (both steroidal and nonsteroidal), analgesics, physiotherapy, needle aspiration with or without corticosteroids, ultrasound, radiotherapy, and surgical excision.*~5~11~13,14,16~20~** Our patient presumably was in the resorptive phase and potentially may have had spontaneous resolution of the symptoms while resorption of the deposit progressed. She was given the option of expectant treatment along with the option of needle aspiration. Because of the prospect of potentially rapid relief with needle aspiration, she elected the latter of the 2 options. We succeeded in entering the calcium deposit and evacuating it either partially
J Shoulder Elbow Surg March/April 7 999
or completely, thereby relieving the intratendinous pressure. Calcific tendinitis of the trapezius insertion is a rare cause of shoulder pain. We are unaware of any previous report of this condition. It should be considered in the differential diagnosis of superior shoulder pain. It can be easily distinguished from acromioclavicular joint disease on the basis of patient history and the results of physical examination and routine radiography. REFERENCES 1
2 3 4
5
6
Archer B, Frredman L, Strlgenbauer S, et al Symptomatrc calcific tendrmtis at unusual sates. Can Assoc Rad J 1992;43. 203-7 Ark JW, Flock TJ, Flatow EL, et al. Arthroscoprc treatment of calcrfrc tendrnrtrs of the shoulder. Arthroscopy 1992;8 183-8 Reference deleted In proofs, Bosworth DM Calcrum deposits In the shoulder and subacromial bursrtrs: a survey of 12,122 shoulders JAMA 1941,l 16: 2477-82 DePalma AF, KruperJS tong ed with and treated for 1961,206-72 Duplay ES De la periarthrrtrs de I’epaule qui sont la 1872.5 13542
term study of shoulder oints afflrctcalcrfic tendrnrtrs C In Orthop scapulohumerale consequence
et des radieurs Arch Gen Med
Gartner J, Srmons B. Analysrs of calcrfrc deposrts tendinitis. Clin Orthop 1990,254 1 1 l-20. Holt P, Keats T. Calcric unusual Skeletal Radrol
tendrnrtrs, 1993.22:
a revlew 1-9
Hsu H-C, WV J-J, Jrm YF, et al Calcific tearing: a clinical and radrographic Surg I994,3 159-64 10
11
In calcrfyrng
of the usual
and
tendrnrtrs and rotator cuff study J Shoulder Elbow
Jim YF, Hsu HC, Chang CY, et al Coexistence of calcrfrc tendinitis and rotator cuff tear an arthroaraohrc studv Skeletal v Radrol 1993,22,183-5. taprdus PW lnfrltration therapy of acute tendinrtrs with calrfrcatlon Surgery, Gynecology, Obstetrrcs 1943,76.715-25
12
Painter Journal
13
Plenk HP Calcrfyrng tendinrtrs of the shoulder A critrcal study of the value of Roentgen-Therapy Radiology 195259 384-9. Rompe JD, Rumler F, Hopf C, et al Extracorporal shock wave therapy for calcrfytng tendinitis of the shoulder Clin Orthop 1995, 321.196-201 Senaar DPS, McKendrv RI, Uhthoff HK, et al. Increased frequency of HLA-Al in calcifyrng tendrnrtis. Tissue Antigens 1987,29.173-4
14
1.5
16. 17 18 19. 20.
CF Subdeltord bursrtrs. 1972,156 345-9
I
Boston
Medical
and
Surgrcal
-
Tamai K, Hayashi M. Calcrfic tendinitis of the shoulder indrcatrons for sterord rntections. Acta Orthop Stand 1992;63 S247. Uhthoff HK Calcifying tendrnrtrs versus rotator cuff ruptures J Bone Jornt Surg [abstract] 1975i578.53 1 Uhthoff HK, Sarkar K Calcifying tendinitis. An active, cell-medrated process J Bone Joint Surg [abstract] 1975,57A,566. Uhthoff HK, Sarkar K. Calcifying tendinitis Barllreres Clrnrc Rheumatol 1989.3567-8 1 Uhthoff HK, Sarkar K Cal&yin tendrnrtrs In: Rockwood CA, Matsen FA. editors. The shoul f er 1st ed. Philadelohra WB Saunders, i990 p 774-88
21. 22.
Reference deleted in proofs. Vebostad A. Cal& tendrnrtis in the shoulder 43 operated shoulders Acta Orthop Stand
23
Wrede L Uber kalkablagerungen der umgebung des schultergelenks und rhre bezie hungen zur penarthritis scapulo-humeral/s. Arch Klin Chir 1912;99,259-71.
region. a review fo 1975,46,205-l 0