CALCIFIC TENDONITIS
Deposit
of calcium mineral with the rotator cuff tendons occurs as a result of a
hypoxic state within degenerative tendon tissue. In the phase of deposit for
mation there are few symptoms. During the phase of deposit absorption the
tissues exhibit an acute inflammatory reaction associated with severe pain and
a local increase in tissue temperature and, on occasion, local redness and
swelling. In an acute phase of absorption, the clinical picture can appear to
be an infection.
The acute phase can be treated with
local cortisone injection to the subacromial bursae with the use of oral
anti-inflammatory medication. In chronic conditions of persistent pain
refractory to nonoperative management, aspiration of the lesion can be done
under ultrasound guidance.
The clinical presentation of calcium
deposits in the rotator cuff is variable. In some patients the calcium deposit
is seen on radiographs as an incidental finding with a patient reporting a lack
of a history of shoulder symptoms or only a remote history of shoulder pain
that may have been associated with the deposit. In some patients, an acute
episode of pain and inflammation is associated with resorption of the deposit,
in which case the symptoms resolve. Other patients have recurrent bouts of
acute and severe shoulder pain associated with intervals of no symptoms, and
still others have chronic low-grade to moderate pain on a continual basis with
some bouts of severe pain. In most cases it is the patients with multiple episodes
of severe pain or chronic symptoms whose condition does not respond to
nonoperative management and in whom removal of the calcium deposit is
indicated.
Arthroscopic surgery can also
visualize and locate the calcific deposit within the rotator cuff tendon
tissue. Under direct visualization the lesion can be removed with a motorized
shaving tool; and if the defect is large, repair of the tissue can be performed
with arthroscopic technique. At the time of surgery, the deposit can be seen as
a bump within the tendon often surrounded by increased blood vessels. The
operative finding is variable, as is the clinical presentation. In most cases
requiring surgery, when the calcium deposit is opened a large amount of calcium
debris is extruded under pressure and the material is infiltrated within the
tendon substances. The material is granular. Removal of the deposit often
results in a defect in the tendon. In many cases with a large calcium deposit,
the defect remaining after removal of the deposit is large and the benefit of arthroscopic
removal is the ability to repair the cuff defect at that time. At other times,
after opening the deposit the material
found is more the consistency of toothpaste. Other techniques used for removal
of calcium deposits in the rotator cuff include the use of high or low-energy
ultrasound and needle aspiration under fluoroscopic control. Open surgery is
rarely performed with current minimally invasive techniques being so effective
with less morbidity than with open surgery.
