We present the case of a 13-year-old girl with painful calcific tendinitis of the supraspinatus tendon of the left shoulder. The pathologic finding was the presence of a small calcium deposit within the supraspinatus tendo

Bittmann, Stefan

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CASE REPORTStefan BittmannCalcific tendinitis of the supraspinatus tendon in childrenReceived: 8 December 2003 / Accepted: 19 February 2004 / Published online: 5 May 2004 Springer-Verlag 2004Abstract We present the case of a 13-year-old girl withpainful calciﬁc tendinitis of the supraspinatus tendon ofthe left shoulder. The pathologic ﬁnding was the pres-ence of a small calcium deposit within the supraspinatustendon.Keywords Calciﬁcation Æ Tendinitis Æ Child Æ DiabetesCalcification du tendon sus-e´pineux chez un enfantRe´sume´ Nous rapportons un cas de calciﬁcation doulo-ureuse du tendon sus-e´pineux de l’e´paule gauche chezune jeune ﬁlle de 13 ans. Un ﬁn de´poˆt de calcium futtrouve´ au controˆle anatomo-pathologique.Mots cle´s Calciﬁcation Æ Tendinite Æ Enfant Æ Diabe`teIntroductionCalciﬁc tendinitis of the shoulder is a reactive calciﬁca-tion of the rotator cuﬀ tendons. The disorder is mostcommon among people between 30 and 60 years of ageand very rare in childhood. It is slightly more oftenfound in females. Bilateral involvement is possible. Ahistory of minor trauma has been reported to be presentin up to one-third of patients [1]. The deposition ofcalcium hydroxyapatite crystals, usually medial to theinsertion of the supraspinatus tendon, may be associatedwith acute, severe inﬂammation and shoulder pain.Similar lesions may occur around ligaments and tendonsof the ankle, knee, hip, and elbow. Acute or chronicpainful restriction of the range of motion (ROM) of theshoulders limits patients’ activities of daily living(ADLs). Approximately 50% of patients with calciﬁctendonitis have shoulder pain, particularly nocturnaldiscomfort.Many methods have been applied in the treatment ofcalciﬁc tendinitis of the shoulder, including the use ofnonsteroidal anti-inﬂammatory drugs, local injectionwith steroid, percutaneous needle aspiration, ESWT(extracorporal shock wave therapy), physical modalitieswith therapeutic ultrasound, or transcutaneous electricnerve stimulation (TENS), and other conservativemanagement methods such as therapeutic exercises. Incases, where conservative treatment is without success,surgical intervention is necessary.Case reportA 13-year-old girl attended at our emergency depart-ment because of pain and swelling of the left shoulderfollowed by a disseminated erythema of the deltoidalregion since 2 days. Physical examination showed painwhen abducting and elevating the left arm. Shouldermovement was restricted. The shoulder was painful overthe humeral head. A disseminated erythema of thedeltoidal region on the left side was found. WBC,C-reactive protein and temperature were normal. X-rayinvestigations showed a calciﬁcation in the middleportion of the supraspinatus tendon of 2 mm in diam-eter. Veriﬁcation of calciﬁcation was done by ultraso-nography. Osseous lesions were not found. MRI was notperformed. The child was treated with nonsteroidal anti-inﬂammatory drugs. One day later, pain and erythemawas relieved and shoulder movement was painless.DiscussionCalciﬁc tendinitis is an uncommon disorder caused bycalcium hydroxyapatite deposition in a tendon thatoccurs rarely in children [8, 4, 9, 5, 6]. The causes andpathogenesis of rotator cuﬀ calciﬁcations remainsS. BittmannDepartment of Pediatric Surgery, Childrens Hospital,University of Zurich, Steinwiesstrasse 75, 8032 Zu¨rich, SwitzerlandE-mail: stefan.bittmann@kispi.unizh.chTel.: +41-1-2667111Eur J Orthop Surg Traumatol (2004) 14: 180–181DOI 10.1007/s00590-004-0141-6unclear. Relative ischemia as a result of hypovascular-ization in the critical zone of the rotator cuﬀ, degener-ative tendons, and metabolic disturbances have beenmentioned. Clinically, patients may be asymptomatic ormay present with either acute or chronic pain. Thediagnosis of calciﬁc tendinitis accounts for approxi-mately 7% of painful shoulder syndromes [11]. Theacute symptoms may be dramatic, including erythema,swelling, painful range of motion, and fever. The mostcommonly aﬀected sites, in decreasing order of fre-quency, are the shoulder, hip, elbow, wrist, and knee [3].The pathogenesis of calcium hydroxyapatite crystaldeposition in or near a tendon is unclear. Several theo-ries have been proposed, including degeneration of atendon as a result of recurrent trauma [3], local hypoxialeading to alkaline pH [7], and neurologic or metabolicfactors. The leading theory at present is that calciﬁctendinitis is a primary disorder in susceptible tendons[10]. Tendon degeneration has been considered to be theresult of the reparative response to crystal depositionrather than the cause of presentation [10]. Local hypoxiais thought to lead to ﬁbrocartilaginous metaplasia, andit is the cartilaginous tissue that produces the radio-graphically and pathologically identiﬁable calciﬁcation.High-quality, properly positioned radiographs andultrasonography are necessary to diagnose calciﬁc ten-dinitis using imaging. MRI is also used in diagnosing thedisease. Treatment of calciﬁc tendinitis is usually limitedto the use of nonsteroidal anti-inﬂammatory drugs [2].Supportive therapy is all that is necessary in most casesbecause the disease is self-limiting and typically spon-taneously resolves. Surgical resection of the concretionor intralesional injection of steroids have also been usedbut are not necessary in most cases. Especially in adults,ESWT is eﬀective in the treatment of chronic calciﬁctendinitis of the shoulder. To date, there are no largerstudies concerning ESWT to treat calciﬁc tendinitis inchildren.References1. Carroll RE, Sinton W, Garcia A (1955) Acute calcium depositsin the hand. JAMA 157:422–4262. Fritz P, Bardin T, Laredo JD et al (1994) Paradiaphyseal cal-ciﬁc tendinitis with cortical bone erosion. Arthritis Rheum5:718–7233. Gondos B (1957) Observations on periarthritis calcarea. AmJ Roentgenol 77:93–1084. Lassoued S, Billey T, Millet JP, Henia AO (1999) Acute calﬁcictendinitis in children. Rev Rhum Engl Ed 66:422–4245. Millon SJ, Bush DC, Harrington TM (1993) Acute calciﬁctendinitis in a child: a case report. J Hand Surg 18:592–5936. Nutton RW, Stothard J (1987) Acute calciﬁc supraspinatustendinitis in a three-year-old child. J Bone Joint Surg 69:1487. Pedersen HE, Key JA (1951) Pathology of calcareous tendinitisand subdeltoid bursitis. Arch Surg 62:5–638. Sakamoto K, Kozuki K (2002) Calciﬁc tendinitis at the bicepsbrachii insertion of a child: a case report. J Shoulder ElbowSurg 11:88–919. Stothard J (1994) Acute calciﬁc tendinitis in children. J HandSurg 19:34310. Uhthoﬀ HK, Sarkar K, Maynard JA (1976) Calcifying tendi-nitis: a new concept and its pathogenesis. Clin Orthop 118:164–16811. Welﬁng J (1964) Les calciﬁcations de l’epaule. I. Diagnosticclinique. Rev Rhum Mal Osteoartic 31:265–271181

Calcific tendinitis of the supraspinatus tendon in children

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Calcific tendinitis of the supraspinatus tendon in children

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