Introduction
Acute calcific tendinitis (ACT) is a benign painful inflammatory disorder characterized by the resorptive process of calcific deposit following the formation of calcium hydroxyapatite crystals in tendons. It can occur at various sites, especially shoulder or hip joint. ACT involving the lateral epicondyle of humerus and cervical spine is very rare. Also, there have been few reports demonstrating successive ACT at different sites. We report three female cases with successive ACT, one with the lateral epicondyle after subscapularis, another with supraspinatus after flexor carpi ulnaris, and the last with iliopsoas following longus colli.
Case
Three females with successive ACT were studied. A summary of the findings in three patients is shown in Table 1. Figure 1 and 2 demonstrate the imaging studies in case 1 and 3 respectively. Case 1 is described representatively.
A 55-year-old female presented with one-day history of acute right shoulder pain. She had no history of recent trauma or vigorous sports activity. Active shoulder movement was impossible because of severe pain. Laboratory study revealed increase of ESR and CRP level without leukocytosis. A plain radiography revealed homogenous ill-defined calcifications in the region of subscapularis tendon (Fig. 1A). MRI showed calcific deposit with muscle edematous change in the subscapularis (Fig. 1B). Based on the clinical presentation and imaging findings, a diagnosis of ACT of the subscapularis was made. After administering NSAID, her symptoms were marked resolved within 2 days. Follow-up plain radiography at 2 months showed complete solution of calcific deposit (Fig. 1C).
Two years later, she presented with one-day history of acute right elbow pain. On examination, there was severe focal tenderness over the lateral epicondyle with local heatness. A plain radiographs showed curvilinear calcification adjacent to the lateral epicondyle (Fig. 1D). Ultrasonography revealed hyperechoic calcific foci of the common extensor tendon at the lateral epicondyle (Fig. 1E). With the barbotage procedure and peritendon steroid injection (a mixture with 2cc 1% lidocaine and 20mg triamcinolone acetonide), the patient had marked improvement of her symptoms within 2 days with no recurrence at two-months follow-up. Follow-up radiographs showed near complete dissolution of the calcific foci with faint residual linear calcifications (Fig. 1F).
Discussion
In conclusion, we report three female cases of successive ACT at different sites including unusual site such as elbow or neck. The bibliographic references for the successive ACT are limited. However, it is estimated that the incidence of successive ACT is not uncommon, considering the fact that nearly every tendon in the body is vulnerable to calcific tendinitis. Our cases may enhance the understanding of various clinical manifestations of ACT for the clinicians.
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Summary of the clinical findings
Images of case 1. (A) A radiograph of the right shoulder demonstrates 10 mm sized homogenous ill-defined calcifications (arrow) in the region of subscapularis tendon. (B) MRI shows calcific deposit (arrow) with muscle edematous change (arrowhead) in the subscapularis. (C) Two-months follow-up radiograph reveals resolved calcific mass. (D) A radiograph of the right elbow demonstrate 9 mm sized ill-defined calcification (arrows) in the common extensor tendon. (E) Ultrasonography reveals hyperechoic calcific deposit (arrows) with increased vascularity in the common extensor tendon. (F) Two-months follow-up radiograph demonstrates partial dissolution of the calcific foci with residual linear calcifications (arrow).
Images of case 3. (A) A radiograph of cervical spine demonstrates small calcific deposit (arrow) in the C2 body anteriorly with the widening of prevertebral soft tissue space. (B) MRI reveals calcific deposit (arrow) with muscle edematous change (arrowhead) in the longus colli. (C) Coronal view of hip MRI shows calcific deposit (arrow) around anterior inferior iliac spine with muscle edematous change (arrowhead) in the iliacus.
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