A 45 year old woman presents with several days of gradually worsening right shoulder pain and stiffness. Her shoulder is very warm to the touch but not erythematous. You obtain shoulder x-rays and see a linear density in the AP view (photo credit).
What is the most likely diagnosis, the differential diagnosis, and management plan?
Calcific tendinitis of the supraspinatus muscle – in the resorptive phase.
This phase is extremely painful and can be associated with a concomitant subacromial bursitis. Rarely, the calcium hydroxyapatite crystals can migrate into the bursa [1].
Ultrasound!
Consider utilizing this easy-to-access tool to visualize the calcification. In the photo below, you can note the hyperechoic density with acoustic shadowing representing the calcification. Often in a sports medicine clinic, the calcification can be broken up and aspirated under ultrasound guidance.
Patel MS. Supraspinatus calcific tendinosis (2010).
Septic arthritis and septic bursitis. Ultrasound-guided aspiration is recommended if there is an effusion at the glenohumeral joint or bursa.
The underlying cause is unclear, although there is typically an associated rotator cuff disease. Because diabetes mellitus and hypothyroidism may be risk factors for developing calcific tendinitis [2], one could consider checking a basic metabolic panel (BMP) and thyroid function tests in an outpatient setting.
If the arthrocentesis cell count and gram stain are not concerning for septic arthritis, provide analgesia with NSAIDs, rest, and early physical therapy [3]. Typically the body will resorb the calcium with time. If analgesia is not fully adequate and if you are comfortable with this procedure, administer a subacromial injection of lidocaine or ropivicaine.
Follow up with sports medicine in 1-2 weeks where a variety of non-invasive techniques can be performed. If the pain is recalcitrant, surgery may be required.
NOTE: Do not sling the patient, because adhesive capsulitis can occur with this disease. Maintaining range of motion is important.
If there is concomitant infection or concern for inadequate pain control.
For more cases like these, you can subscribe to the Ortho EM Pearls email series hosted by Drs. Will Denq, Tabitha Ford, and Megan French, who have kindly shared some of their content with ALiEM.
References
- Della Valle V, Bassi EM, Calliada F. Migration of calcium deposits into subacromial–subdeltoid bursa and into humeral head as a rare complication of calcifying tendinitis: sonography and imaging. J Ultrasound. 2015;18(3):259-263. doi:10.1007/s40477-015-0163-4
- Rasidakis A, Mavrikakis ME, Kontoyannis DA, Kontoyannis S, Drimis S, Moulopoulou ES. Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis. 2008;48(3):211-214. doi:10.1136/ard.48.3.211
- Siegal DS, Wu JS, Newman JS, del Cura JL, Hochman MG. Calcific Tendinitis: A Pictorial Review. Can Assoc Radiol J. 2009;60(5):263-272. doi:10.1016/j.carj.2009.06.008
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