Magnetic resonance imaging evaluation of patients with clinically diagnosed medial Epicondylitis

Is calcification integral to enthesopathy and tendinopathy rather than a separate disease process?

Background

The pathophysiology of enthesopathy and tendinopathy is mucoid degeneration, which includes chondroid metaplasia. The chondroid metaplasia can be associated with calcification. Inflammation is typically absent unless calcification triggers a self-limited immune response representing acute calcific tendinitis. It is therefore important to address the hypothesis that calcific deposits within various entheses and tendons throughout the body are an inconsequential epiphenomenon of enthesopathy and tendinopathy and do not merit a distinct diagnosis or specific treatment.

Methods

We searched PubMed, Embase, and Web of Science for studies that address the prevalence of calcium in tendons and entheses with or without symptoms of tendinopathy, specifically excluding likely acute calcific tendinitis, and analyzed 35 studies meeting inclusion and exclusion criteria. Response variables included prevalence of calcification in and enthesis or tendon among people with no symptoms, among people seeking care for symptoms, and in the opposite asymptomatic limb, and the association between calcification and rotator cuff degeneration.

Results

Calcification of tendons and entheses was present on between 2.7 % and 8.6 % of radiographs of the shoulder, elbow, and ankle among people without symptoms and not seeking care, with higher percentages in older populations. Calcification was common among patients with symptoms: 44 % for rotator cuff tendinopathy, 25 % for enthesopathy of the origin of the extensor carpi radialis brevis, and 53 % for medial elbow enthesopathy. Most people with calcification had it bilaterally. Among people with calcification of the rotator cuff on MRI, nearly all of them (96 %) had tendon degeneration.

Conclusions

The collective evidence regarding calcification in tendons and entheses suggests that it is related to mucoid degeneration and is not a separate disease process. Acute calcific tendinitis rapidly runs its course and is treated only to alleviate symptoms. It's not clear that acute calcific tendinitis or rotator cuff tendinopathy with calcification benefit from specific treatment of the calcium deposits.

Level of evidence

Not applicable.

[MRI or ultrasound-which imaging technique do we need?]

Diagnostic imaging of epicondylitis is primarily performed using widely available, radiation-free ultrasound. The dynamic examination allows a rapid point-of-care assessment. Typical imaging findings of epicondylitis include intratendinous hypoechogenic foci at the humeral origin, ossification at the enthesis, intratendinous calcifications, or (partial) rupture. In particular, Doppler sonography increases sensitivity by assessing possible neovascularization within the tendon. When sonographic findings are unclear or extensive, or when ultrasound machines or the required expertise in elbow examinations are not available, magnetic resonance imaging is indicated. Here, the use of proton density-weighted sequences is appropriate for assessing bone marrow and soft tissue edema and tendon tears, while ossifications are best delineated in T1weighted sequences. Projection radiography and computed tomography can be helpful for larger ossifications, although they are not part of the standard imaging protocol.

How to Report: Elbow MRI

The elbow is the least common of the main joints examined with magnetic resonance imaging (MRI), thus radiologists may be less familiar with writing these reports. This article addresses the main pathologies encountered in and around the elbow, emphasizing the specific features that need reporting and providing examples of terminology to use when describing these abnormalities.