Ann Rheum Dis: first published as 10.1136/ard.42.Suppl_1.49 on 1 January 1983. Downloaded from Ann Rheum Dis (1983), 42, Supplement p 49 Calcified tendinitis: a review G. FAURE,' G. DACULSI2 From the 'Clinique Rhumatologique et Laboratoire d'immunologie, Faculte A de Medecin, Universite de Nancy I, 54500 Vandoeuvre les Nancy, France and 2U225 INSERM, Faculte de Chirurgie Dentaire, Place Alexis Ricordeau, 44042 Nantes, France Introduction Calcified tendinitis in clinical practice Calcified tendinitis is a common CLINICAL FEATURES disorder. Many names have been used According to Welfling calcific to describe it: some of them, such as periarthritis is responsible for 7% of 'calcific periarthritis', emphasise the painful shoulder syndromes,' which extra-articular site of the deposit; have various presentations. others, such as 'periarticular apatite (1) Chronic symptoms-more or deposition', mention the nature of the less severe pain; tenderness leading to compound found in the calcification; various degrees of incapacitation. and more recent ones, such as These symptoms induce the demand 'calcifying tendinitis',-'3 emphasise the. for radiographs, which reveal the Fig. 1 Calcific periarthritis ofthe active process that might explain the presence of deposits. shoulder. Calcification is obvious; it deposition. Differentiated from (2) Acute inflammatory crisis with has already migrated from copyright. arthritis at the end of the nineteenth severe pain, tenderness, and local supraspinatus region to bursa area. century, this syndrome has only oedematous inflammation sometimes recently been related to the presence leading to restricted active an*d passive of apatite in tendon sheaths.4'5 It can motion. Fever and malaise may be affect almost any tendon at its observed. usually varies between a few insertion and is most common around (3) Totally asymptomatic deposits. millimetres and about 1-5 cm. Calcification has been described the shoulder joint. Rheumatologists According to Bosworth et al., near almost every joint"2 although the and radiologists have often described clinical symptoms occur in from 34% this shoulder abnormality, leading to to 45% of patients in whom precise intratendinous or paratendinous location of the stone is its progressive differentiation from calcifications are found.' Biochemical not always seen. The deposits may be other painful shoulder syndromes. 12 and haematological tests are not This review will discuss calcific useful, and will only show non-specific multiple,'4 which French authors http://ard.bmj.com/ periarthritis of the shoulder as a evidence of inflammation. identify as 'maladie des calcifications model. Clinical features of the tendineuses multiples'.' 1" Bilateral syndrome are variable and include calcification is seen in about half of pain and inflammation. The key RADIOLOGICAL FEATURES shoulder cases and deposits are often diagnostic feature is the radiograph. Simple anteroposterior and lateral seen in other locations-for example, Clinical evolution is simple and the x-ray films are usually sufficient to see near the hip joint-if other condition often resolves shoulder calcification, though special radiographs are taken. views in internal or external spontaneously. Some cases are rotation on October 2, 2021 by guest. Protected persistent and may require aggressive may be necessary.'2 Other techniques treatment, including surgery. have been described to obtain better Numerous questions are still pick up, including xerography and unanswered about this disorder, which scanning, but many small deposits are is rarely associated with metabolic probably missed. abnormalities of calcium and The calcification is usually in the phosphorus. These include: (a) the supraspinatus tendon, and various nature of the mechanism leading to appearances have been described. The calcium salt deposition; (b) the deposits may be very thin, outlining frequent asymptomatic tolerance of the tendon sheath, or hazy, and they such calcification, and, conversely, (c) vary in density and definition (Fig. 1). the initiating agent of inflammatory Only in cases of disturbance of the Fig. 2 Acute bursitis ofthe shoulder flares; and (d) the way in which the calcium to phosphorus ratio-for (same patient). Morphological aspects material disperses. example hyperparathyroidism ofprevious calcification is modified; it secondary to renal failure-is there is less dense and probably located Request for reprints to: G. Faure. massive calcification.'3 The size inside bursa. Ann Rheum Dis: first published as 10.1136/ard.42.Suppl_1.49 on 1 January 1983. Downloaded from Suppl p 50 Annals of the Rheumatic Diseases Sequential x-ray films may show or articular origin present with prove necessary, and some authors static calcification, a growing deposit, different symptoms. Analysis of fluid recommend adding colchicine as in change in the location, and even and radiological investigations are also gout and pseudogout. Aspiration of spontaneous disappearance without discriminative. Extra-articular fluid may also reduce symptoms. Local any acute clinical flare. During the ossification is radiologically different, injections of corticosteroids are used inflammatory crisis, the calcifications the deposits being trabeculated. and by some clinicians, but may themselves usually follow a very well described articular chondrocalcinosis also cause microcrystal-induced course. They become less defined, appears quite different on a inflammation, and the risk of infection more cloudy, and migrate into the radiograph. Tendinous calcification must be taken into account. Lavage bursa (Figs. 2 and 3); they may or may containing calcium pyrophosphate between attacks has been advocated, not disappear completely within a few dihydrate may be misleading2" but but does not always seem rewarding. days or weeks. The reappearance of is usually associated with Very painful resistant cases have calcification is not well substantiated chondrocalcinosis. received x-rav treatment. Calcium (Fig. 4). Some authors emphasise the inhibitors have also been tried but the relation of the deposit to the bone TREATMENT results are not convincing. surrounding the tendon insertion As both symptoms and deposits often Surgery may prove successful, and a point.17 Destructive changes have disappear spontaneously, both few well documented cases treated by been reported in advanced cases, and clinician and patient should generally surgical removal of the deposit have McCarty et al. have described a special abstain from interfering. Analgesics been described.:' syndrome associating a destructive and non-steroidal anti-inflammatory arthropathy of the shoulder, apatite drugs (NSAID) are useful, as well as LABORA1 ORY INVESTIGATIONS deposits. and high collagenase patience. The material aspirated from acutely activities in the synovial fluid. They During an acute inflammatory crisis painful shoulders has been studied call it the 'Milwaukee shoulder more powerful NSAID drugs such as thoroughly in a few cases, with syndrome'. 19 indomethacin or phenylbutazone may interesting results. Firstly. they DIFFERENI IAL D)IAGNOSIS The diagnosis is usually easy. Other copyright. painful shoulder syndromes of osseous http://ard.bmj.com/ Fig. 3 Sanme patient one month later. Calcification has comnpletel/v disappeared, though vestigial one remains in the supraspinatus region. on October 2, 2021 by guest. Protected NO .. '.. bm Fig. 4 Same patient one year later. Calcification has reappeared, patient Fig. 5 Scanning electron microscopy. Bar 5 in. One globule-like structure is presents with a moderately painful seen here in situ in section ofa tendon sheath calcification, appearing like a stone shoulder. engulfed in mortar. Ann Rheum Dis: first published as 10.1136/ard.42.Suppl_1.49 on 1 January 1983. Downloaded from Calcified tendinitis: a review Suppl p 51 allowed the identification of the in mortar (Fig. 5). Study of individual carbonate apatite,26" but the great material.4 Recent studies by our group crystals needed even more heterogeneity of the material is a new have also isolated another compound, sophisticated means. Transmission feature that may open new fields of unidentified so far, which is different electron microscopy (TEM) allows the research. The differences observed from stoichiometric apatite, and could visualisation, on ultrathin sections, of between patients also deserves study. be the result rather than the cause of dense globular structures among The exact location of deposits is not the inflammation.2' numerous isolated or clumped crystals well elucidated, but Welfling describes The usual specimens obtained at (Fig. 6). Individual crystals may be some as intratendinous and some operation consist of a gritty mass of seen in high resolution transmission superficial.9 sandy material or a toothpaste-like electron microscopy. The crystals are Sandstrom described necrosis fluid. These have been recognised much larger than classic apatite crys- interpreted as being secondary to since Codman first described the tals, such as those observed in bone or 'local anaemia and vascular changes', calcifications, and in 1934 the deposits dental enamel; some ofthem appear as which favoured deposition of were described as 'a white amorphous homogeneous hexagons, the width and calcifying material.7 Uhthoff's group mass composed of many small round thickness of which can be measured. favour an active mechanism of or ovoid bodies'.6 Microscopically, at The parameters differ from one calcification, with an initial