Ultrasound-guided Percutaneous Lavage in the Treatment of Calcific Tendinopathy of Elbow Extensor Tendons: A Case Report

Calcific tendonitis of the right epicondyle of the elbow: A case report

RATIONALE

Calcific tendinitis frequently occurs in the shoulder, and while it may also occur in other joints, such as the hip, knee, wrist, and finger joints, its occurrence in the elbow joint is relatively rare. Therefore, it is susceptible to delayed diagnosis or misdiagnosis at the initial occurrence. Appropriate imaging and treatment should be considered immediately when suspecting calcific tendonitis.

PATIENT CONCERNS

We detailed a young female who presented with progressive right elbow pain for the past 3 years with no past injury to the elbow. She had undergone conservative management for 2 years but was unsuccessful. Her pain became more intense 1 week prior, to the extent that she could not use her right upper limb to perform daily activities, and her sleep was severely disturbed. Therefore, she needed a possible therapeutic relief.

DIAGNOSIS

Clinical findings included elbow stiffness and tenderness of the lateral epicondyle of the humerus, and Cozen assessment was positive. Computed tomography showed a high-density macular focus and smooth edge of the lateral condyle of the right humerus and dorsal side of the ulnar olecranon. The plain radiograph showed patches in the right lateral condyle of the humerus and the dorsal part of the olecranon, indicating calcification of common extensor tendinosis.

INTERVENTIONS

Initially, conventional care was given to the patient with analgesics, physical therapy, or a resting regimen to decrease the pain and reduce the tedious load on the extensor tendon. Measures such as pain score, range of motion, and follow-up imaging after 8 weeks began until 2 years. However, her pain did not improve. Therefore, she was advised for surgical therapy and subsequently underwent surgical exploration of the elbow under general anesthesia. Histopathological examination of the excised tissue revealed fibrous ligament tissue with calcifications.

OUTCOMES

At the 6-month follow-up, the postoperative plain radiograph showed complete removal of the heterotopic bony growth from the lateral epicondylar area with no recurrence of the heterotopic bone formation around the elbow joint. She had no pain with full elbow function and a full range of elbow extension and flexion (visual analog scale score of 0/10).

LESSONS

Calcific tendonitis of the elbow is uncommon; hence, its diagnosis and treatment may be late due to its scarcity. Therefore, appropriate imaging and treatment should be considered immediately when calcified tendonitis is suspected. A literature review is also necessary since it is not a daily condition.

Imaging of calcific tendinopathy: natural history, migration patterns, pitfalls, and management: a review

Calcific tendinopathy is characterized by the deposition of calcium hydroxyapatite crystals in various tendons of the body. Terms like calcium tendinitis, tendinosis, and tendinopathy are used interchangeably. Calcific tendinopathy is a common and well-documented ailment in the literature. Although common, the natural history, aetiology, and progression of calcific tendinitis are poorly understood. The treatment options include conservative and interventional measures. However, these measures cannot be applied as a blanket and are often tailored depending on the stage/phase of the disease. Out of the recognized stages of the disease, the resorptive stage causes the utmost symptoms when the calcium is rather soft and unstable. During this stage, the calcium may migrate beyond expected resorption and get deposited in the adjacent tissues contiguous with the calcium focus. The common destinations include bursal migration, intraosseous migration, muscular migration, and other less common migration sites. Such atypical presentations can lead to dilemmas in the diagnosis, prolongation of the diagnostic pathway, unwarranted apprehension, and treatment delay. Radiologists' role in this situation is to correctly recognize the imaging findings of atypical presentations of calcific tendinopathy and prevent unnecessary diagnostic and interventional studies. In this review article, we describe the pathogenic pathway and natural history of calcific tendinopathy from a radiologist's perspective and discuss different migratory patterns of calcium in calcific tendinopathy not only around the shoulder but also in other areas of the body on different imaging modalities. We also show a few examples of mimics and pitfalls on imaging. Finally, we discuss the appropriate management option of this condition.

Calcific Tendinopathy Atypically Located Outside the Rotator Cuff: A Systematic Review

BACKGROUND AND PURPOSE

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited. The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

METHODS

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

RESULTS

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

CONCLUSION

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

Calcific Tendonitis of the Elbow in an Adult - A Case Report and Review of the Literature

Introduction:

Calcific tendonitis occurs most commonly in the shoulder, and it is a rare entity in other parts including the elbow. We report a symptomatic case of calcific tendonitis of common extensor origin of the non-dominant elbow in a young female.

Case Presentation:

A 39-year-old female (right hand dominant) presented with the left elbow pain for the past 1 year. The diagnosis was achieved by radiography and confirmed by histopathology. Her pain did not respond to conservative treatment of analgesics, physiotherapy, and elbow support and a local steroid injection. She, therefore, underwent surgical exploration of the elbow, under general anesthesia. There was white-colored paste like a collection within the common extensor tendon origin, with dystrophic calcification of the tendon. The histology of the excised tissue revealed focal nodular aggregates of plump fibroblasts and osteoclastic giant cells around microcalcific foci. Large areas of fibrosis and calcific nodular deposits seen suggestive of calcific tendonitis.

Conclusion:

Calcific tendonitis is not a common condition around elbow joint. The diagnosis may be delayed due to its rarity. Hence, a high degree of suspicion in the absence of trauma, along with relevant investigations, leads to a definitive diagnosis and treatment. A review of literature also becomes important since it is not a day-to-day case.

Non-rotator cuff calcific tendinopathy: ultrasonographic diagnosis and treatment

Calcific tendinopathy is a condition that is related to the deposition of calcium, mostly hydroxyapatite crystals, within the tendons. The shoulder and the hip are commonly affected joints, but calcific tendinopathy may occur in any tendon of the body. While there is an extensive literature on the ultrasound diagnosis of calcific tendinopathy of the shoulder, there are only sporadic reports on other sites. This review combines the experience of our centers and a thorough analysis of the literature from the last 45 years (1972-2017) in order to highlight the localizations beyond the rotator cuff, their ultrasound characteristics and therapeutic possibilities.

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa's calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.