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Calcific Tendonitis of the Subscapularis Tendon Causing Subcoracoid Stenosis and Coracoid Impingement
Case Report
Calcific Tendonitis of the Subscapularis Tendon Causing Subcoracoid Stenosis and Coracoid Impingement Paolo Arrigoni, M.D., Paul C. Brady, M.D., and Stephen S. Burkhart, M.D.
Abstract: Calcific tendonitis is a common disease of the shoulder which usually responds to conservative treatment. In cases unresponsive to conservative management, arthroscopic treatment is sometimes required. While there are several reports on calcifications within the supraspinatus tendon, documented cases involving the subscapularis tendon are rare. We present a case of a 47 year old farmer with recurrent anterior shoulder pain. An MRI revealed calcium deposits as well as a large subcoracoid cyst. Arthroscopic excision of the multiple calcific deposits left a large defect in the subscapularis tendon which was repaired back to the lesser tuberosity using arthroscopic techniques. A coracoplasty resulted in an increased coracohumeral space. The patient followed a conservative postop rehabilitation protocol and ultimately regained full strength and was pain free at the latest follow-up. We postulate two possible etiologies of subscapularis calcific tendonitis: either an idiopathic calcific tendonitis caused a secondary coracoid impingement or a primary subcoracoid stenosis resulted in an interstitial subscapularis tear which eventually resulted in calcium deposition. This report describes the clinical and technical details of arthroscopic excision of calcific deposits of the subscapularis tendon as well as arthroscopic repair of the resulting subscapularis defect. Key Words: Calcific tendonitis—Subscapularis repair—Coracoid impingement
C
alcific tendonitis is an unusual condition with characteristic clinical and radiological findings.1 Surgical treatment is usually reserved for chronic cases of calcific tendonitis that are unresponsive to conservative measures.2 Recently, arthroscopic procedures have provided an excellent treatment option for resistant calcific tendonitis.3 Whereas the supraspinatus tendon has been recognized as the most frequently
affected tendon, the subscapularis tendon is rarely involved. This report highlights a case of calcific tendonitis involving the subscapularis tendon and the resultant finding of subcoracoid stenosis and coracoid impingement.4,5 We report the clinical details of this case as well as the technical aspects of arthroscopic excision of calcific deposits of the subscapularis tendon. CASE REPORT
From The San Antonio Orthopaedic Group and the Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A. Address correspondence and reprint requests to Stephen S. Burkhart, M.D., 540 Madison Oak Dr, Suite 620, San Antonio, TX 78258, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America Cite this article as: Arrigoni P, Brady PC, Burkhart SS. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139.e11139.e3 [doi:10.1016/j.arthro.2005.06.028]. 0749-8063/06/2210-0589$32.00/0 doi:10.1016/j.arthro.2005.06.028
The patient, a 47-year-old farmer, was first evaluated by the senior author (S.S.B.) in December 2004. Six years previously he had undergone an open distal clavicle excision by another surgeon. He experienced a long pain-free period after that surgery. Approximately 9 months before our evaluation, the patient noted increasing anterior shoulder pain. His first surgeon referred him for a computed tomography– guided aspiration of a large fluid-filled cyst anterior to the subscapularis tendon. Approximately 15 mL of syno-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 10 (October), 2006: pp 1139.e1-1139.e3
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P. ARRIGONI ET AL. author. A magnetic resonance imaging scan showed reaccumulation of the cyst (Fig 1). On clinical evaluation, the patient had negative liftoff and negative belly-press tests but a positive bearhug test. Internal and external rotation strength were normal. He had anterior tenderness to palpation at the coracoid process but no tenderness at the acromioclavicular joint. The patient had normal range of motion. On plain radiographic examination, dense calcific deposits were identified within the subscapularis tendon. Magnetic resonance imaging confirmed the calcific tendonitis and, as well, indicated the presence of a large (2 ⫻ 1.5 cm) fluid-filled cyst situated anterior to the subscapularis tendon (Fig 1). The subcoracoid space was narrow. The patient elected to proceed with arthroscopic evaluation and treatment. The preoperative diagnosis was calcific tendonitis of the subscapularis tendon with secondary coracoid impingent.
FIGURE 1. Magnetic resonance image of the left shoulder showing the limited coracohumeral distance (broad yellow line) measuring approximately 5 mm between the tip of the coracoid and the calcific deposit within the subscapularis tendon. This is in comparison to the normal coracohumeral distance (thin white line). A large calcific deposit (large black arrow) is seen within the substance of the subscapularis tendon. The inset picture shows the large subcoracoid cyst (small yellow arrow).
vial fluid was aspirated from the cyst. The procedure relieved his symptoms for several months. When his symptoms recurred, the patient presented to the senior
Technique and Operative Findings On initial arthroscopic examination, inspection of the subscapularis tendon revealed what appeared to be a large, dense calcific deposit within the substance of the upper subscapularis tendon (Fig 2A). On further inspection, the anatomic relationship between the upper subscapularis tendon and the coracoid tip was examined. It was evident that the deposit within the subscapularis tendon caused a significant narrowing of the subcoracoid space; consequently, the clinical condition of coracoid impingement was diagnosed and a
FIGURE 2. (A) Arthroscopic image of the left shoulder from the posterior portal showing the large calcific deposit (dotted line) within the substance of the subscapularis tendon. (B) The final surgical specimens retrieved were all removed from within the substance of the subscapularis tendon.
SUBSCAPULARIS CALCIFIC TENDONITIS coracoplasty was performed.5 The capsule of the cyst anterior to the subscapularis was then resected. Next, the large dense intratendinous deposit (measuring 18 ⫻ 13 mm) was addressed. The deposit was removed from the substance of the subscapularis tendon using a combination of arthroscopic scissors, shaver, and electrocautery. Five osteocartilaginous deposits were removed from the tendon, the largest measuring approximately 10 ⫻ 10 mm (Fig 2B). The excision of the deposits resulted in a large defect of upper subscapularis tendon necessitating arthroscopic repair back to the native bone bed as has been previously described.6 Finally, a refining coracoplasty was performed to create a distance greater than 7-mm between the coracoid and the subscapularis tendon. No other pathology was found in either the glenohumeral joint or the subacromial space. Postoperative Course The patient was discharged approximately 1.5 hours after surgery. He was instructed to keep his arm in a sling for 6 weeks except for showering and periodic flexion/extension of the elbow and the wrist. Even on his first postoperative clinic visit (on postoperative day 1) the patient expressed dramatic pain relief in comparison with his preoperative condition. The patient was allowed to work on limited passive external rotation (with the elbow at the side) to 15°. Six weeks postoperatively, a more aggressive passive motion program was initiated, including increased external rotation, internal rotation, and flexion. At 12 weeks, a strengthening program was initiated. At his 6-month follow-up examination, the patient had no pain, full range of motion, and full strength. DISCUSSION Surgical treatment of calcific tendonitis is rarely necessary because patients usually respond to conservative measures. Arthroscopic treatment of resistant cases of calcific tendonitis has recently been shown to be quite effective.1,3 In our review of the Englishlanguage literature, we could find no published case reports of arthroscopic excision of calcific deposits within the subscapularis tendon. This case illustrates 2 distinct but intimately related pathologic conditions. The first is calcific tendonitis of the subscapularis tendon and the second is the result-
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ant subcoracoid stenosis / coracoid impingement. Determining which of these conditions initiated the pathologic cascade is like the chicken and the egg debate. Perhaps the idiopathic development of a subscapularis calcific deposit occurred and resulted in the subcoracoid stenosis. Conversely, the subcoracoid stenosis may have caused interstitial damage to the subscapularis tendon, as has been described by the rollerwringer theory.5 The interstitial tendon damage may have initiated an abnormal healing response that resulted in the development of the calcium deposit. This etiology would not be unlike myositis ossificans in which a muscle contusion can result in ensuing calcium deposition.7 We hypothesize that the large cyst was the body’s response to create a sliding surface and let the tendon move more easily within the limited subcoracoid space. This enlarging cyst then resulted in increased pain. CONCLUSIONS We have presented a rare case of calcific tendonitis within the substance of the upper subscapularis tendon. This deposit resulted in (or resulted from) significant subcoracoid stenosis / coracoid impingement and was also associated with the formation of a large subcoracoid cyst. This case highlights important interactive mechanisms between calcium deposits of the subscapularis tendon and coracoid impingement. REFERENCES 1. Porcellini G, Paladini P, Campi F, Paganelli M. Arthroscopic treatment of calcifying tendonitis of the shoulder: Clinical and ultrasonographic findings at two to five years. J Shoulder Elbow Surg 2004;13:503-508. 2. Daecke W, Kusnierczak D, Loew M. Long-term effects of extracorporeal shockwave therapy in chronic calcific tendonitis of the shoulder. J Shoulder Elbow Surg 2002;11:476-480. 3. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendonitis of the shoulder. Arthroscopy 1992; 8:183-188. 4. Gerber C, Terrier F, Zehnder R, Ganz R. The subcoracoid space. An anatomic study. Clin Orthop 1987;215:132-138. 5. Lo IKY, Burkhart SS. The etiology and assessment of subscapularis tendon tears: A case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. Arthroscopy 2003;19:1142-1150. 6. Burkhart SS, Tehrany AM. Arthroscopic subscapularis repair: Technique and preliminary results. Arthroscopy 2002;18:454463. 7. Kaplan FS, Glaser DL, Hebela N, Shore EM. Heterotopic ossification. J Am Acad Orthop Surg 2004;12:116-125.
Calcific Tendonitis of the Subscapularis Tendon Causing Subcoracoid Stenosis and Coracoid Impingement Paolo Arrigoni, M.D., Paul C. Brady, M.D., and Stephen S. Burkhart, M.D.
Abstract: Calcific tendonitis is a common disease of the shoulder which usually responds to conservative treatment. In cases unresponsive to conservative management, arthroscopic treatment is sometimes required. While there are several reports on calcifications within the supraspinatus tendon, documented cases involving the subscapularis tendon are rare. We present a case of a 47 year old farmer with recurrent anterior shoulder pain. An MRI revealed calcium deposits as well as a large subcoracoid cyst. Arthroscopic excision of the multiple calcific deposits left a large defect in the subscapularis tendon which was repaired back to the lesser tuberosity using arthroscopic techniques. A coracoplasty resulted in an increased coracohumeral space. The patient followed a conservative postop rehabilitation protocol and ultimately regained full strength and was pain free at the latest follow-up. We postulate two possible etiologies of subscapularis calcific tendonitis: either an idiopathic calcific tendonitis caused a secondary coracoid impingement or a primary subcoracoid stenosis resulted in an interstitial subscapularis tear which eventually resulted in calcium deposition. This report describes the clinical and technical details of arthroscopic excision of calcific deposits of the subscapularis tendon as well as arthroscopic repair of the resulting subscapularis defect. Key Words: Calcific tendonitis—Subscapularis repair—Coracoid impingement
C
alcific tendonitis is an unusual condition with characteristic clinical and radiological findings.1 Surgical treatment is usually reserved for chronic cases of calcific tendonitis that are unresponsive to conservative measures.2 Recently, arthroscopic procedures have provided an excellent treatment option for resistant calcific tendonitis.3 Whereas the supraspinatus tendon has been recognized as the most frequently
affected tendon, the subscapularis tendon is rarely involved. This report highlights a case of calcific tendonitis involving the subscapularis tendon and the resultant finding of subcoracoid stenosis and coracoid impingement.4,5 We report the clinical details of this case as well as the technical aspects of arthroscopic excision of calcific deposits of the subscapularis tendon. CASE REPORT
From The San Antonio Orthopaedic Group and the Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A. Address correspondence and reprint requests to Stephen S. Burkhart, M.D., 540 Madison Oak Dr, Suite 620, San Antonio, TX 78258, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America Cite this article as: Arrigoni P, Brady PC, Burkhart SS. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139.e11139.e3 [doi:10.1016/j.arthro.2005.06.028]. 0749-8063/06/2210-0589$32.00/0 doi:10.1016/j.arthro.2005.06.028
The patient, a 47-year-old farmer, was first evaluated by the senior author (S.S.B.) in December 2004. Six years previously he had undergone an open distal clavicle excision by another surgeon. He experienced a long pain-free period after that surgery. Approximately 9 months before our evaluation, the patient noted increasing anterior shoulder pain. His first surgeon referred him for a computed tomography– guided aspiration of a large fluid-filled cyst anterior to the subscapularis tendon. Approximately 15 mL of syno-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 10 (October), 2006: pp 1139.e1-1139.e3
1139.e1
1139.e2
P. ARRIGONI ET AL. author. A magnetic resonance imaging scan showed reaccumulation of the cyst (Fig 1). On clinical evaluation, the patient had negative liftoff and negative belly-press tests but a positive bearhug test. Internal and external rotation strength were normal. He had anterior tenderness to palpation at the coracoid process but no tenderness at the acromioclavicular joint. The patient had normal range of motion. On plain radiographic examination, dense calcific deposits were identified within the subscapularis tendon. Magnetic resonance imaging confirmed the calcific tendonitis and, as well, indicated the presence of a large (2 ⫻ 1.5 cm) fluid-filled cyst situated anterior to the subscapularis tendon (Fig 1). The subcoracoid space was narrow. The patient elected to proceed with arthroscopic evaluation and treatment. The preoperative diagnosis was calcific tendonitis of the subscapularis tendon with secondary coracoid impingent.
FIGURE 1. Magnetic resonance image of the left shoulder showing the limited coracohumeral distance (broad yellow line) measuring approximately 5 mm between the tip of the coracoid and the calcific deposit within the subscapularis tendon. This is in comparison to the normal coracohumeral distance (thin white line). A large calcific deposit (large black arrow) is seen within the substance of the subscapularis tendon. The inset picture shows the large subcoracoid cyst (small yellow arrow).
vial fluid was aspirated from the cyst. The procedure relieved his symptoms for several months. When his symptoms recurred, the patient presented to the senior
Technique and Operative Findings On initial arthroscopic examination, inspection of the subscapularis tendon revealed what appeared to be a large, dense calcific deposit within the substance of the upper subscapularis tendon (Fig 2A). On further inspection, the anatomic relationship between the upper subscapularis tendon and the coracoid tip was examined. It was evident that the deposit within the subscapularis tendon caused a significant narrowing of the subcoracoid space; consequently, the clinical condition of coracoid impingement was diagnosed and a
FIGURE 2. (A) Arthroscopic image of the left shoulder from the posterior portal showing the large calcific deposit (dotted line) within the substance of the subscapularis tendon. (B) The final surgical specimens retrieved were all removed from within the substance of the subscapularis tendon.
SUBSCAPULARIS CALCIFIC TENDONITIS coracoplasty was performed.5 The capsule of the cyst anterior to the subscapularis was then resected. Next, the large dense intratendinous deposit (measuring 18 ⫻ 13 mm) was addressed. The deposit was removed from the substance of the subscapularis tendon using a combination of arthroscopic scissors, shaver, and electrocautery. Five osteocartilaginous deposits were removed from the tendon, the largest measuring approximately 10 ⫻ 10 mm (Fig 2B). The excision of the deposits resulted in a large defect of upper subscapularis tendon necessitating arthroscopic repair back to the native bone bed as has been previously described.6 Finally, a refining coracoplasty was performed to create a distance greater than 7-mm between the coracoid and the subscapularis tendon. No other pathology was found in either the glenohumeral joint or the subacromial space. Postoperative Course The patient was discharged approximately 1.5 hours after surgery. He was instructed to keep his arm in a sling for 6 weeks except for showering and periodic flexion/extension of the elbow and the wrist. Even on his first postoperative clinic visit (on postoperative day 1) the patient expressed dramatic pain relief in comparison with his preoperative condition. The patient was allowed to work on limited passive external rotation (with the elbow at the side) to 15°. Six weeks postoperatively, a more aggressive passive motion program was initiated, including increased external rotation, internal rotation, and flexion. At 12 weeks, a strengthening program was initiated. At his 6-month follow-up examination, the patient had no pain, full range of motion, and full strength. DISCUSSION Surgical treatment of calcific tendonitis is rarely necessary because patients usually respond to conservative measures. Arthroscopic treatment of resistant cases of calcific tendonitis has recently been shown to be quite effective.1,3 In our review of the Englishlanguage literature, we could find no published case reports of arthroscopic excision of calcific deposits within the subscapularis tendon. This case illustrates 2 distinct but intimately related pathologic conditions. The first is calcific tendonitis of the subscapularis tendon and the second is the result-
1139.e3
ant subcoracoid stenosis / coracoid impingement. Determining which of these conditions initiated the pathologic cascade is like the chicken and the egg debate. Perhaps the idiopathic development of a subscapularis calcific deposit occurred and resulted in the subcoracoid stenosis. Conversely, the subcoracoid stenosis may have caused interstitial damage to the subscapularis tendon, as has been described by the rollerwringer theory.5 The interstitial tendon damage may have initiated an abnormal healing response that resulted in the development of the calcium deposit. This etiology would not be unlike myositis ossificans in which a muscle contusion can result in ensuing calcium deposition.7 We hypothesize that the large cyst was the body’s response to create a sliding surface and let the tendon move more easily within the limited subcoracoid space. This enlarging cyst then resulted in increased pain. CONCLUSIONS We have presented a rare case of calcific tendonitis within the substance of the upper subscapularis tendon. This deposit resulted in (or resulted from) significant subcoracoid stenosis / coracoid impingement and was also associated with the formation of a large subcoracoid cyst. This case highlights important interactive mechanisms between calcium deposits of the subscapularis tendon and coracoid impingement. REFERENCES 1. Porcellini G, Paladini P, Campi F, Paganelli M. Arthroscopic treatment of calcifying tendonitis of the shoulder: Clinical and ultrasonographic findings at two to five years. J Shoulder Elbow Surg 2004;13:503-508. 2. Daecke W, Kusnierczak D, Loew M. Long-term effects of extracorporeal shockwave therapy in chronic calcific tendonitis of the shoulder. J Shoulder Elbow Surg 2002;11:476-480. 3. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendonitis of the shoulder. Arthroscopy 1992; 8:183-188. 4. Gerber C, Terrier F, Zehnder R, Ganz R. The subcoracoid space. An anatomic study. Clin Orthop 1987;215:132-138. 5. Lo IKY, Burkhart SS. The etiology and assessment of subscapularis tendon tears: A case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. Arthroscopy 2003;19:1142-1150. 6. Burkhart SS, Tehrany AM. Arthroscopic subscapularis repair: Technique and preliminary results. Arthroscopy 2002;18:454463. 7. Kaplan FS, Glaser DL, Hebela N, Shore EM. Heterotopic ossification. J Am Acad Orthop Surg 2004;12:116-125.