Adrien

Alexandre Lädermann

Jean-Pierre Schwitzguébel

Muriel Genevay

Sophie Abrassart

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Case Report
Supraspinatus Intramuscular Calcified Hematoma or
Necrosis Associated with Tendon Tear
Alexandre Lädermann,1,2,3 Muriel Genevay,4
Sophie Abrassart,3 and Adrien Jean-Pierre Schwitzguébel1
1Division of Orthopaedics and Trauma Surgery, La Tour Hospital, rue J.-D. Maillard 3, 1217 Meyrin, Switzerland
2Faculty of Medicine, University of Geneva, rue Michel-Servet 1, 1211 Geneva, Switzerland
3Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals,
rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
4Laboratoire Dianapath, rue de la Colline 10, 1205 Geneva, Switzerland
Correspondence should be addressed to Adrien Jean-Pierre Schwitzguébel; adrien.schwitzguebel@latour.ch
Received 8 June 2015; Accepted 12 August 2015
Academic Editor: Christopher Chuinard
Copyright © 2015 Alexandre Lädermann et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Introduction. Rotator cuff intramuscular calcification is a rare condition usually caused by heterotopic ossification and myositis
ossificans. Case Presentation. We describe a patient with voluminous calcified mass entrapped in supraspinatus muscle associated
with corresponding tendon tear. Histological examination corresponded to a calcified hematoma or necrosis. Patient was surgically
managed with open excision of the calcified hematoma and rotator cuff arthroscopic repair. At 6months, supraspinatus muscle was
healed, and functional outcome was good. Discussion and Conclusion. We hypothesized that supraspinatus intramuscular calcified
hematoma was responsible for mechanical stress on the tendon. This association has never been described.
1. Introduction
Rotator cuff ossification is a rare condition, poorly docu-
mented in the literature, except in case of heterotopic ossifi-
cation, a well-known complication of severe acute neurologic
disease [1] and surgery [2]. Enclosed rotator cuff muscles
ossification is an exceptional condition [3] that might be
caused by secondary calcified muscle hematoma or necrosis
[4], myositis ossificans [3, 5–8], and congenital diseases like
progressive fibrodysplasia ossificans that has a prevalence of
1/2,000,000 [9]. Calcified intramuscular hematoma or necro-
sis is often deep seated slowly enlarging lesions that may be
discovered as long as 20 years after the initial traumatic event.
Histologically they are centered by blood clot, fibrin, and
prominent amorphous debris. Dystrophic calcifications and
scar tissuemay also be seen [10].Myositis ossificans is defined
as a benign solitary self-limiting ossifying soft tissue mass
that typically occurs in skeletal muscle [11] and is described
as commonly associated with trauma, reported by a small
number of case reports [6, 12–14]. It has been proposed that
when no clear traumatic mechanism is reported, repetitive
microtraumatic injuries, ischemia, and chronic inflammation
could be myositis ossificans etiological factors [15]. In this
way, repetitive microtrauma in shoulder area in soldiers
has been described as an etiologic mechanism of myositis
ossificans [16]. Histologically, myositis ossificans can present
different maturation stages. It has been postulated that
intramuscular hematoma is the initial lesion contributing to
myositis ossificans and that lesions are considered as fully
calcified or “mature,” 5 months after initial trauma [17, 18].
2. Case Presentation
A 75-year-right-hand-dominant woman presented with right
shoulder pain that evolved over 5 years. She had history
of right supraspinatus muscle trauma 30 years ago, but she
had not noticed any traumatic, infectious, or iatrogenic
event on the right shoulder on those 5 last years. Although
she had done well previously, in recent months she had
worsening symptoms that was affecting her quality of life,
Hindawi Publishing Corporation
Case Reports in Orthopedics
Volume 2015, Article ID 496313, 4 pages
http://dx.doi.org/10.1155/2015/496313
2 Case Reports in Orthopedics
(a) (b) (c)
Figure 1: Radiological evaluation of supraspinatus muscle and tendon. MRA showed a calcified mass, as well as a supraspinatus tendon
thinning (a). Preoperative CT was performed for a better definition of the volume of the well-delimited calcified mass into supraspinatus
muscle (b). Five years ago, a supraspinatus muscle MRI excluded intramuscular mass on this time (c).
(a) (b)
(c) (d)
Figure 2: In situ, macroscopic, and histologic aspects of calcified mass. In situ (a) and postextraction (b) macroscopic aspects of calcified
mass showed a 7 × 4 × 4 cm well-delimited whitish solid tumor. Histologic evaluation ((c) and (d)) showed a highly hyalinized collagenous
scar tissue devoid of any inflammatory cells, with some dystrophic calcifications at the periphery of the lesion (d).
with a visual analog scale score for pain of 9 on a scale of
10, a Single Assessment Numeric Evaluation score of 40 [19],
and a Constant Shoulder Score of 64 [20]. Symptoms were
refractory to pain killers and physical therapy. No limitation
in shoulder range of motion was observed.
MRI showed a thinned supraspinatus tendon (Fig-
ure 1(a)). A complementary CT scan showed a well-delimited
voluminous supraspinatus muscle calcification (Figure 1(b)),
as well as an infra-acromial spur. Five years ago, a prior
MRI excluded any supraspinatus muscle mass (Figure 1(c)).
At this point and with described elements, we suspected the
diagnosis of supraspinatus intramuscular calcification.
Surgery was performed in order to remove the calci-
fied supraspinatus mass. A small type A [21] rotator cuff
lesion was also repaired under arthroscopy. First, tension
on supraspinatus tendon was reduced by extracting cal-
cific mass (Figure 2(a)). Next, an open approach between
the trapezius and supraspinatus muscles was performed.
A cleavage plane between calcific mass and supraspinatus
muscle was well-delineated.Therefore, excisionmargins were
not necessary. Then, arthroscopic procedure was performed
to repair supraspinatus and superior subscapularis tendons
with side to side point. Lateral acromioplasty, as well as
bursectomy, was also performed.
Case Reports in Orthopedics 3
Figure 3: Supraspinatus muscle six months after surgery radiologic
evaluation. MRA showed a good healing of the supraspinatus
muscle. However, a Goutallier stage 2 fatty infiltration remains.
Macroscopically, the lesion was a well-defined 7 × 4
× 4 cm whitish fusiform lesion (Figure 2(b)). Histologic
examination revealed a highly hyalinized collagenous stroma
almost acellular. Few scattered capillary vessels could be
seen. The thickness of their wall was normal and they were
surrounded by few plasma cells. Less than 1mm foci of
fat tissue and lamellar bone formation could also be seen.
Dystrophic calcifications were observed at the periphery
of the lesion. There was neither inflammatory nor giant
cell reaction around it. A Congo-red coloration has been
performed to exclude an amyloidoma that was negative
(Figures 2(c) and 2(d)). Diagnosis of calcified hematoma or
necrosis was confirmed.
Follow-up included 2 weeks of immobilization in 30∘
abduction and then passive motion in all directions. Six
months after surgery, the patient was satisfied of her con-
dition, with a complete shoulder range of motion recovery,
a visual analog scale score for pain of 4 on a scale of 10,
a Single Assessment Numeric Evaluation score of 40 [19],
and a Constant Shoulder Score of 66 [20]. MRA showed a
supraspinatus muscle with Goutallier stage 2 fatty infiltration
[22], as well as the absence of “fish backbone sign” [23] or
recurrence of calcified mass (Figure 3).
3. Discussion
Circumscribed ossifications into rotator cuff muscles are rare
conditions. We only found myositis ossificans case reports in
the English literature [3, 5–8]. However, these conditions are
poorly described in the literature. To our knowledge, volumi-
nous calcified hematoma or necrosis into the rotator cuff has
never been described. We suppose that calcified hematoma
or necrosis might be confused with myositis ossificans in
absence of pathological examination or that publications
concerning those entities considered as “basic” or “simple”
might be omitted.Moreover, intramuscular hematomamight
be on the origin of myositis ossificans or calcified hematoma.
In this way, myositis ossificans is discussed in a large-scale
review of the literature on the subject by King [4], but not
calcified hematoma.
The patient in question had a typical clinical presentation
of chronic superior rotator cuff tendinopathy evolving since
5 years; the symptoms began before the calcific mass was
present. It is therefore possible that calcific mass appear-
ance decompensated a chronic supraspinatus tendon tear
by increasing mechanical traction on supraspinatus mus-
cle. The effectiveness of conservative management for that
supraspinatus tendon tear was therefore compromised. For
this reason, surgical management of both calcified mass and
supraspinatus tendon tear was proposed, even if calcific mass
was not painful and could have been subject to conservative
management, especially with NSAIDs [3, 24]. Note that
when therapeutic management was set up, the presumptive
diagnosis was a myositis ossificans.
Typically, stress on the supraspinatus arises in the context
of a subacromial impingement [25]. This case report illus-
trates a rare case of intramuscular mechanical stress factor on
the supraspinatus tendon.We could find only one case report
of supraspinatus tendon surgery that included alleviation of a
muscular stress factor, dating from 1992 [8]. Clinical outcome
was good.
For the first time in arthroscopic rotator cuff surgery,
to the best of our knowledge, we cured a muscular factor
that might decompensate chronic rotator cuff pathology.This
association between chronic supraspinatus tendinopathy and
supraspinatus muscle calcific mass was managed by associa-
tion muscular mechanical stress alleviation and arthroscopic
rotator cuff repair, with a good muscle healing and satisfying
functional outcome at 6-month-postsurgery checkup.
Consent
Written informed consent was obtained from the patient for
publication of this case report and accompanying images.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
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Case Report Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear

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Case Report Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear

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