Hellenic Journal οf Radiology

Part a

A 52-year-old female patient presented with a his­tory of two-month right shoulder pain, more in­tense at night. Clinical examination showed a pain­ful joint with limited range of motion. The painful syndrome did not respond to non-steroidal anti-in­flammatory drugs (NSAIDs), analgesics and physio­therapy.Plain radiograph, CT and MR imaging are shown.

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Part b

Diagnosis: Intraosseous HADD

Rotator cuff hydroxyapatite deposition disease (HADD), also known as calcific tendinopathy, calcific periarthri­tis or basic calcium phosphate crystal deposition disease, is a common disorder with a reported incidence of up to 22% [1]. Supraspinatus represents the most common lo­cation of HADD followed by infraspinatus, teres minor, and subscapularis [2]. Other locations include the ten­dons around the knee and hip joints. One of the compli­cations of HADD is migration of the calcifications to adja­cent bone through the disrupted cortex at the insertion site of the initially affected tendon. An osteolytic lesion may coexist with the intraosseous calcifications. This rare complication is known as intraosseous HADD. Osse­ous involvement in HADD was first reported by Hayes et al. [3] with cortical erosions at the pectoralis major, glu­teus maximus, and adductor magnus tendinous inser­tions. Till today, several case reports and few larger se­ries have described the osseous involvement at different sites. Although the pathogenesis of bone erosion remains unclear, it is believed that active inflammation and local vascularization at tendon insertion or mechanical effects of muscle traction may play a role in the development of cortical erosions [4]. This complication can be mistaken as an osseous tumour or infection and thus familiarity with the imaging features is important [5,6].

Plain X-rays and ultrasound (US) are the first line im­aging modalities which can assist the diagnosis of HADD, as they can reveal the calcifications within or adjacent to the tendons. On MR imaging, tendinous and peritendi­nous calcific deposits appear as low or mixed low and in­termediate signal intensity lesions on both T1w and fat suppressed PDw MR images, with surrounded soft-tis­sue edema. Gradient echo sequences show the calcifica­tions to better advantage. The signal intensity at the site of the cortical erosion is low on T1w and heterogeneous on fat-suppressed PD/T2w sequences [7]. Intraosseous calcium deposits may be of very low signal intensity on both T1w and fluid sensitive MR images, or show heter­ogeneous T2 appearance, depending on the stage of the disease. Varying degree of surrounding BME is usually present. No major reports exist on the evaluation of in­traosseous HADD with US.

In our patient, radiologic investigation included plain films, CT and MR imaging of the right shoulder. Imag­ing showed parosteal calcification at the level of the in­fraspinatus insertion, cortical disruption at the later­al humeral head, an osteolytic lesion with calcification within it and extensive surrounding bone marrow ede­ma (Fig. 1-4).

NSAIDs combined with physiotherapy are the main­stay of nonoperative treatment for shoulder HADD [8]. Arthroscopic treatment is less effective than in classic location within or adjacent to a tendon [10]. Thus ar­throscopy is considered nowadays as the last option only when other methods have failed [9]. According to our ex­perience (unpublished data on 4 patients), a combined approach with US guided barbotage for the soft tissue and CT guided aspiration for the intraosseous calcifica­tions, is efficient in patients with persistent symptoms. HADD is self limited and our patient showed moderate improvement at the 6-month clinical follow-up follow­ing physiotherapy.

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Conflict of interest:

The authors declared no conflicts of interest.

Corresponding Author, Guarantor

Apostolos Karantanas, Professor of Radiology, University of Crete, Stavrakia, 71110, Heraklion, Crete, Greece, E-mail: akarantanas@gmail.com

References

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3.Hayes CW, Rosenthal DI, Plata MJ, et al. Calcific tendin­itis in unusual sites associated with cortical bone ero­sion.AJR Am J Roentgenol1987; 149(5): 967-970.

4.Durr HR, Lienemann A, Silbernagi H, et al. Acute cal­cific tendinitis of the pectoralis major insertion asso­ciated with cortical bone erosion.Eur Radiol1997; 7: 1215-1217.

5.Porcellini G, Paladini P, Campi F, et al. Osteolytic lesion of greater tuberosity in calcific tendinitis of the shoul­der.J Shoulder Elb Surg2009; 18(2): 210-215.

6.Martin S, Rapariz JM. Intraosseous calcium migration in calcifying tendinitis: A rare cause of single sclerotic injury in the humeral head.Eur Radiol2010; 1284-1286.

7.Flemming DJ, Murphey MD, Shekitka KM, et al. Osse­ous involvement in calcific tendinitis: A retrospec­tive review of 50 cases.AJR Am J Roentgenol2003; 181(4): 965-972.

8.Lanza E, Banfi G, Serafini G, et al. Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendi­nopathy: What is the evidence? A systematic review with proposals for future reporting.Eur Radiol2015; 25: 2176-2183.

9.Seyahi A, Demirhan M. Arthroscopic removal of in­traosseous and intratendinous deposits in calcifying tendinitis of the rotator cuff.Arthroscopy2009; 25(6): 590-596.

10.Porcellini G, Paladini P, Campi F, et al. Arthroscopic treatment of calcifying tendinitis of the shoulder: Clin­ical and ultrasonographic follow-up findings at two to five years.J Shoulder Elb Surg2004; 33(10): 596-599.

Ready - Made Citation

Mandrillo D, Psaras K, Karantanas A. Painful shoulder.Hell J Radiol2016; 1(1): 78-81.