Z Orthop Ihre Grenzgeb 1997 Sep;135(5):451-457
Knappschaltskrankenhaus Dortmund.
PURPOSE: The aim of this study is to analyse the mid-term clinical and sonographical results of non-operative therapy of calcifying tendinitis. METHODS: Retrospectively the anamnestical, clinical and sonographical results after various non-operative treatment of patients with calcifying tendinitis were reviewed. For this purpose 159 patients with 178 calcifying deposits in the rotator cuff were evaluated on an average of 60 months after their first examination in our clinic (mean age: 49.2 years; sex ratio: 58% women). RESULTS: During a mean symptomatic period of 49 months, an average of 4.2 different therapeutic modalities were applied. After this time 70% of all patients showed an excellent or good result. With regard to the age-correlated Constant-Score 85% of all patients had more than 81 points, i.e. a good result. The mid-term results on a visual analogous scale from 10 (pain) to 0 (no pain) showed a decrease from 7.7 to 2.2 and this correlated with the shoulder function scores (Constant-/Patte-Score, r -0.8). After an average of 104 months 82% of the hydroxyapatite deposits could not be diagnosed by sonography (7.5 MHz.) anymore. CONCLUSION: In the treatment of calcifying tendinitis the conservative methods achieve good and excellent results in 70%. Patients should be treated with analgetics, subacromial injections, physiotherapy and ice therapy up to a period of twelve months, above all with small deposits and radiologic resorptive stadiums. The results of this study should be compared with any invasive regimen.
Clin Rheumatol 1997 May;16(3):269-274
Klinik fur Rheumatologie une Rehabilitation, Zurich, Switzerland.
In an open study the therapeutic value of percutaneous needle aspiration and lavage performed in local anaesthesia under image intensifier control in patients with chronic calcifying shoulder tendinitis was investigated. 60 patients (62 shoulders) were included in the study. The average age was 48 years, and the median duration of shoulder pain and calcification was 24 months and 7 months respectively. The right shoulder was affected in 34 and the left in 24 patients; two patients had painful calcifications in both shoulders. In 47% X-ray showed calcium deposits in the contralateral shoulder. 77% of the painful deposits projected on the supraspinatus tendon and in most cases image intensifier examination showed multiple calcifications. Calcareous material could be removed by needle aspiration and lavage in 76% of all cases. There was no correlation regarding the preferred working hand and the side of calcifying tendinitis. X-ray controls performed after 2 months revealed a significant reduction of the size of calcifications. The clinical follow-up 2 and 6 months after needling showed a significant reduction of global pain intensity. There were also significant improvements in the areas of pain on movement, pain at night and impairment of sleep. Clinical success was independent of the radiological aspect of the calcifications.
J Shoulder Elbow Surg 1996 Jul;5(4):314-319
Department of Orthopaedic Surgery, University of Heidelberg, Germany.
In a prospective study radiographs and magnetic resonance images of 75 patients with calcifying tendinitis of the rotator cuff were analyzed. The aim was to evaluate any relation between calcifying tendinitis and subacromial impingement. A total of 83% of the calcifications were located in the supraspinatus or the adjoining part of the subscapularis tendon. On T1-weighted images they could be demonstrated with high accuracy as areas of decreased signal intensity. A magnetic resonance imaging categorization of the calcium deposits was carried out by means of a differentiation of form, outline, and density. A partial rotator cuff tear was found in one shoulder; in 11% variable aspects of degenerative alteration of the affected tendon were seen. By analysis of the radiographic outlet view 16% of the cases had a type III acromion. In conclusion, little correlation exists between calcifying tendinitis and additional findings associated with subacromial impingement.
Schweiz Rundsch Med Prax 1996 Apr 16;85(16):526-533
Abteilung fur Rheumatologie, Medizinische Klinik, Kantonsspital, Luzern.
In 106 shoulder joints of 94 patients suffering from calcifying shoulder (calcifying tendinitis), needling and lavage were performed. Patients were prospectively investigated before and after treatment to examine if location, size, number and density of calcium deposits would predict outcome after the above-mentioned lavage. Excellent and good results were seen for subacromial calcifications and those situated near the tuberculum majus. Density and number of calcifications were without discriminating value, whereas large calcium deposits (> 1,5 cm) and fairly small calcifications (< 1,0 cm) responded very well to conservative treatment as described above.
Ann Chir Gynaecol 1996;85(2):111-115
Division of Orthopaedic Surgery, University of Ottawa, Canada.
Calcifying tendinitis is not due to a dystrophic calcification of the degenerative tendinous tissue but due to a cell mediated reactive process. In fact, following formation of a deposit resorption usually ensues which in turn will be followed by a tendon reconstitution. If patent conservative measures fail, surgery should only be contemplated in the presence of radiologically dense, homogenous and well delineated deposits which indicate that the resorptive activity has not set in. If, on the other hand, there is evidence of ongoing resorption the decision for surgery should be postponed since only exceptionally natural resorption will not occur.
Orthopade 1995 Jun;24(3):284-302
Orthopadische Universitatsklinik Kiel.
Degenerative ossification is formed directly at the major tubercle. Like in any other gliding tendon, fibrocartilage cells lie on the articular side of the rotator tendon at the pivot of the humerus head. Typically, the calcific deposits of calcifying tendinitis are found between these two areas. At this site, hydroxyapatite is usually formed by fibrocartilage cells through an unknown stimulus. There is no ossification. This is a two-phase disease. During the chronic initial phase, a calcific deposit is formed in the tendon of the rotator cuff. In the X-ray, it is clearly circumscribed and has a dense appearance (type I). Pain is inconsistent and may exist for years. In the acute phase, the deposit undergoes spontaneous resolution. Now it takes on a translucent and cloudy appearance without clear circumscription (type III). Patients experience severe pain for 2-3 weeks. Finally, a normally functioning shoulder joint will result. The X-ray therefore allows a prognostic conclusion. In a study including 235 calcific deposits, it became clear that there are some cases where it is not possible to designate the specific X-ray morphology to a given deposit (type II). Irrespective of the phase of disease, the so-called calcific deposit is composed of poorly mineralized hydroxyapatite. For a diagnosis, we require: a typical history, clinical findings consistent with tendinitis of the rotator cuff, calcific deposits in the tendon associated with signs and symptoms of tendinitis. It is recommended that radiographs be taken at least in AP projections with the shoulder in internal and external rotation to demonstrate the deposits without super-imposition. Ultrasound shows concomitant bursitis and is useful for the differential diagnosis of rupture of the rotator cuff. Radiographic diagnosis is most difficult when there are small opacifications near the rotator attachment. In this case, allocation may become possible only later in the course of disease. Initial treatment should always be non-operative. Almost all therapeutic modalities are said to be quite successful. Needles under local anesthesia is recommended only for patients with marked pain who lack any signs of resolution in the X-ray. According to a prospective study, the success rates of needles depend on the roentgenologic findings: in type I deposits, resolution occurs in 33%, in typq II deposits in 71%. Freedom from pain is seen in about 50% of the patients. Type III deposits undergo resolution with and without therapy in about 2-3 weeks. Post-operative results are reported to lie between 77% and 96% irrespective of the method used.
Z Orthop Ihre Grenzgeb 1993 Sep;131(5):461-
Orthopadische Universitatsklinik Kiel.
In a prospective study, 33 patients with calcifying tendinitis had a needling in local anaesthesia performed under control of an image converter. There was at least a one year follow-up period. Resorption of the hydroxyapatite deposits was seen in 23 instances; 75% of all patients were free of symptoms or had considerably improved (Table 3). For better assessment of these results we embarked on an additional retrospective study observing the spontaneous evolution of 235 hydroxyapatite deposits for 3 years on average. On the x-ray, these deposits had a characteristic appearance and could be classified into one of three types: either sharply outlined and densely structured (type I), or with cloudy limitations and transparent in structure (type III). In addition we saw deposits combining the features of both of the above named types (type II) (Table 5, Fig. 6). Based on this classification, a clear correlation was revealed to exist between initial x-ray findings and the frequency of resorption after needling: with type I, complete resorption was seen in 33% of the cases, with type II in 71%, and with type III in 85% of the cases (Table 6). With type II, however, only half of the patients were free of symptoms. Surgical removal of the hydroxyapatite deposits became necessary in 3 patients because of persisting heavy pains. As complication we observed intraoperatively an incomplete tear of the rotator cuff, the relation of which to the needling remained unsure. In this context, the question is discussed whether calcifying tendinitis and rupture of the rotator cuff may represent two disease entities of identical origin.
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