0:00

<v ->So let's look at calcific tendonitis

0:03

and I will use this term for the disease,

0:05

but it should be really

0:07

basic calcium phosphate deposition disease.

0:11

The general rule about calcification

0:13

in the tendons about the shoulder and elsewhere

0:17

is the calcification occurs

0:19

close to where the tendon attaches the bone.

0:22

So I show you numerous examples

0:24

and some of the cadaver that we've examined,

0:27

coronal section, supraspinatus tendon calcification.

0:32

here the long head of the biceps

0:34

calcification adjacent to its glenoid attachment.

0:37

Here in a coronal section, calcification

0:40

and the infraspinatus minor tendons

0:43

and here calcification at the glenoid attachment

0:47

of the long head of the triceps.

0:49

So the general rule, and there's one exception

0:52

and I'll mention in a moment.

0:54

The calcification, be it an appetite of some sort,

0:59

maybe not calcium hydroxyapatite

1:02

occurs close to where the tendon attaches to bone.

1:07

The exception is the biceps tendon,

1:11

because sometimes although I show you an example

1:14

where it's close to bone sometimes

1:17

the long head of the biceps tendon

1:19

calcifies at the myotendinous junction

1:22

along the proximal portion of the humerus.

1:26

Now, when we see calcific tendonitis,

1:29

indeed it may be asymptomatic.

1:32

Because if in fact the calcium is well defined

1:36

sitting within a tendon close to where it attaches the bone,

1:40

many such patients are totally asymptomatic.

1:45

When you see it

1:46

I know the natural thing is to say it's hydroxyapatite

1:49

but a common cause of tendon calcification

1:53

is pyrophosphate crystal deposition.

1:56

Typically with pyrophosphate crystal deposition,

1:59

there are no symptoms

2:01

that calcification is thin, linear or curvilinear,

2:06

and it extends over a longer distance within the tendon.

2:10

I'm not gonna talk anymore about CPPPD

2:13

but let's go back to the hydroxyapatite.

2:18

Often it is asymptomatic and this calcium is stationary.

2:22

It's the movement of the calcium that can lead to symptoms.

2:26

And there are three basic directions in which it may move.

2:31

The first of these,

2:32

it can be expelled beneath the floor of the bursal

2:36

or within the bursal.

2:38

I show you an example here

2:40

in which there has been expulsion of calcium

2:43

within the sub tendon

2:46

probably within the subacromial subdeltoid bursa

2:50

with associated bursitis.

2:53

This patient is symptomatic.

2:55

The second direction in which it may move

2:58

is immediately within the tendon

3:01

associated with laminating tears of the tendon.

3:05

What comes first, the calcium movement

3:09

or the tear could be argued.

3:11

I don't know the answer, but this too can be symptomatic.

3:16

The example I show you again

3:18

is subscapularis tendon calcification

3:21

migrating along a delaminated tear of the subscapularis.

3:27

Here's another example

3:29

of calcium extending immediately

3:31

this time in the infraspinatus

3:34

involving perhaps a bit of the teres minor

3:37

as well, low signal intensity

3:39

with extensive surrounding muscle edema.

3:43

This is medial migration.

3:46

Certainly can be symptomatic.

3:49

The final direction

3:50

in which the calcium may move is inferior.

3:53

And by that it moves

3:55

from the tendon to the subjacent bone.

3:58

Here's an example

3:59

a beautiful example of Calcific tendonitis.

4:02

The discrete calcium within the tendons

4:05

with deposits also occurring within the bone,

4:09

note the marrow edema about that area

4:12

of intraosseous penetration clearly symptomatic.

4:17

Another example, this one from Marcello's father,

4:20

Armando Da Bru, showing you calcific tendonitis

4:24

that has penetrated the proximal humus.

4:27

And look how far down in the humeral head

4:31

at the junction now with the surgical neck that we see

4:34

that calcification migrating with associated marrow edema.

4:42

When we look for calcium hydroxyapatite deposition elsewhere

4:46

in the wrist, the most common site is shown here

4:49

was in the flexor carpi ulnaris tendon.

4:52

Typically we see that calcium, again as areas of low signal

4:57

just proximal to the attachment of that tendon

5:00

on the pisiform

5:02

or a surrounding edema clearly can be evident.

5:06

This again, hydroxyapatite deposition

5:10

or so we call it involving a tendon.

5:14

And do not be disturbed

5:16

that when you have these areas of calcification

5:19

you may get bone erosion.

5:21

Gluteus maximus tendon calcification

5:25

recurring at the femoral attachment site.

5:28

You can see the erosion of bone

5:30

even some marrow edema and extensive soft tissue edema.

5:35

Calcium hydroxyapatite deposition disease had

5:40

can also involve some other sites.

5:43

One of the interesting sites occurs in the cervical spine.

5:47

Patients come in with pain and soft tissue.

5:51

Swelling are viewed by radiographs.

5:53

And if you look closely in these cases

5:56

you will see area of calcification

5:59

typically just below the anterior arch of C1.

6:03

In this particular case,

6:05

you can appreciate not only extensive soft tissue swelling.

6:09

With CT and MR we can see some extrusion

6:12

and movement of that calcification.

6:16

Typically the symptoms and the swelling

6:18

go away over a period of weeks or months

6:21

but be aware of this calcification

6:24

within the tendon of the longest colli muscle.

6:28

Here's another example.

6:30

On the plain film on your left,

6:32

we can see the calcification with the black hours.

6:34

We can see the soft tissue swelling with arrow heads.

6:39

As we look at the MR,

6:40

we can see the low signal of the area of calcification

6:44

and dramatic edema along the anterior aspect

6:47

of the cervical spine with some enhancement in that area.

6:52

So be aware of it

6:53

because otherwise you're gonna be concerned

6:55

about infection and tumor

6:57

when you see these particular cases.

7:03

calcium hydroxyappetite deposition disease

7:06

can involve soft tissues anywhere in the human body.

7:10

And because of that, what we may see is extensive edema.

7:15

And if we don't pick up the calcification,

7:17

we be become really concerned

7:20

about what is the diagnosis.

7:22

Here we can see with conventional radiography

7:25

and with CT and the coronal plane

7:28

and the areas of calcification

7:31

with MR imaging and the coronal and surgical planes

7:34

we see the low signal intensity

7:36

and the extensive edema along the lateral aspect

7:41

the level of the knee extending upward

7:44

to the level of the femoral shaft.

7:47

So this is again what we call

7:50

calcium hydroxyapatite deposition disease.

7:53

Although, again, I would remind you

7:55

it's not always that specific crystal,

7:58

it's a basic calcium phosphate deposition disease.

8:04

Now another pattern of involvement

8:06

with basic calcium phosphate deposition,

8:11

tumor-like masses that occur around joints.

8:15

Whenever you see this,

8:17

there can be secondary causes of this

8:20

or rarely a primary inherited syndrome

8:24

may lead to this sort of arrangement.

8:27

When we think of secondary processes,

8:30

or a process that leads to secondary calcification,

8:34

there are two categories that I think of.

8:37

The first is chronic renal disease.

8:40

So the calcification in there calcium phosphate

8:45

can be tumor-like,

8:46

it can involve a single or multiple joint.

8:49

This is one example that was sent to me

8:52

by a previous visiting scholar from the Philippines

8:56

showing you not only the clinical picture

8:58

but look at the size of these calcifications

9:01

tumor-like in multiple sites in the skeleton

9:08

probably the largest occurring at the level of the shoulder.

9:13

The other category of disease that I think of

9:16

is a collagen vascular disease.

9:18

And of these, the one that dominates is scleroderma.

9:23

Here's an example

9:24

of polyarticular tumor-like hydroxyapatite

9:28

type crystal deposition involving the hip and elbow,

9:33

the MR, bottom right,

9:35

well defined mass of low signal intensity

9:39

typical of calcification.

9:43

One of the other manifestations of scleroderma

9:46

that is not well recognized by radiologists but should be,

9:50

is a predilection for the first carpal

9:53

metacarpal joint of the wrist.

9:56

Now, I have seen a number of cases of scleroderma

9:58

occurring in this particular location

10:01

some with calcium, some without.

10:04

So what we see typically

10:06

is erosion of the metacarpal basin of the trapezium.

10:10

And in fact the metacarpal may rotate or move approximately.

10:16

And then in some cases I've shown here

10:18

there's extensive calcification

10:21

representing basic calcium phosphate deposition

10:24

occurring in and around the joint.

10:26

So this is a pathognomonic pattern

10:30

that you're gonna see with scleroderma.

10:31

It's not common, but when you see it,

10:34

there's really I don't think any differential diagnosis.

10:39

And in scleroderma it is not unheard of

10:42

to see para spinal calcification.

10:46

In my experience

10:48

the most common site is in the cervical spine

10:51

more specifically involving the facet joints

10:55

in the cervical spine at multiple levels

10:58

sometimes only at a single level.

11:00

This is what it looks like

11:01

in one of the cases in which we have seen it.

11:03

Here's another case.

11:05

Note again, the tumor like deposits in and around joints.

11:09

And in this case about the ischial tuberosity

11:13

and the paraspinal calcification.

11:16

Here at L5S1 involving mainly,

11:19

the region of the facet joints.