Isolated avulsion fracture of the lesser tuberosity of the humerus

Three cases of isolated avulsion fracture of the lesser tuberosity are described together with a review of six previously reported cases. Of the total cases, six had a well-documented mode of injury, in which a strong abducting force was applied to the medial aspect of the upper arm, causing exaggerated abduction and external rotation. The contracting subscapularis muscle displaces the avulsed bony insertion to a position below the glenoid to give a characteristic appearance on the radiograph. This appearance should not be confused with calcific tendonitis. The lesion may warrant surgical intervention which has been successful in half the cases.     

Bilateral gluteus medius and minimus calcific tendonitis in a patient with previous bilateral calcific tendonitis of the shoulder: A case report

Calcific tendonitis of the gluteus medius and minimus tendons is a rare complication of hydroxyapatite deposition disease, with bilateral involvement even more so. Although patients can be asymptomatic, there is often an acute-on-chronic presentation of pain. We present a case of bilateral calcific tendonitis of the gluteus medius and minimus tendons on a background of previous bilateral rotator cuff calcific tendonitis in a middle-aged woman. This patient''s long-standing history of multi-focal involvement required a multidisciplinary approach between orthopedics, rheumatology, and musculoskeletal radiology for optimal management, requiring different treatment options for different affected sites.     

Arthroscopic treatment of calcifying tendonitis of subscapularis and supraspinatus tendon: a case report

Reports concerning the surgical treatment of calcifying tendinits of the subscapularis tendon are rare. We present the case of a symptomatic calcifying tendonitis involving the subscapularis and supraspinatus tendons. The patient was treated with an arthroscopic removal of the calcific deposits. One year after the surgical procedure the patient was completely pain free, had full range-of-motion and negative supraspinatus and subscapularis signs on manual muscle testing. The overall constant score was 93 points. Radiographic evaluation revealed a complete removal of the calcific deposits immediately after the procedure without recurrence after 1 year. We conclude that a combined arthroscopic removal of the calcific deposits of the subscapularis and supraspinatus tendons can lead to an excellent clinical outcome without compromising the functional integrity of the rotator cuff tendons. No potential conflict of interest declared by both authors.     

Bone scan in enthesopathy involving tendo Achilles

Inflammatory enthesitis is a hallmark of spondyloarthropathies (SSA) and may antedate other clinical manifestations. The involvement of Achilles tendon and plantar aponeurosis is common, with strong tendency toward fibrosis and calcification. We are describing imaging characteristics in a patient with positive HLA B-27 antigen with bilateral calcific achilles tendonitis who had pain in heels for 3 years.     

Popliteus tendon tenosynovitis

This case report highlights an unusual cause of anterolateral knee pain. The popliteus muscle arises from three origins--that is, the lateral femoral condyle, the fibula head, and the lateral meniscus--and inserts into the proximal tibia above the soleal line. It may be subjected to a number of pathologies including tenosynovitis, acute calcific tendonitis, rupture, and even avulsion. In this case, the diagnosis of popliteus tendon tenosynovitis was not made from magnetic resonance imaging findings, but was confirmed and successfully treated during arthroscopic examination.     

Arthroscopic management of calcific tendinitis of the subscapularis tendon

Calcific tendinitis is a common disorder of the rotator cuff. Conservative treatment is frequently successful. For the patients remaining symptomatic after conservative treatment, excision of the calcium deposits offers a generally reliable pain relief. While calcific tendinitis is seen commonly affecting the supraspinatus tendon, it has been rarely reported involving the subscapularis tendon. We report on the clinical features, radiographic findings, arthroscopic treatment and results of one patient who presented a calcific tendonitis involving the subscapularis tendon of the left shoulder unresponsive to conservative treatment and associated subcoracoid stenosis and coracoid impingement.     

Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review

The treatment of patients with calcific tendonitis is typically conservative, including physical therapy, iontophoresis, deep friction, local or systemic application of noninflammatory drugs, needle irrigation–aspiration of calcium deposit, and subacromial bursal steroid injection. If the pain becomes chronic or intermittent after several months of conservative treatment, arthroscopic and open procedures are available to curette the calcium deposit, and additional subacromial decompression can be performed if necessary. As an alternative, minimally invasive extracorporeal shock wave therapy (ESWT) has been postulated to be an effective treatment option for treating calcific tendinitis of the shoulder, before surgery. Herein we discuss the indications, mechanism of therapeutic effect, efficacy of treatment, and complications after ESWT application.     

Calcific tendinitis of the gluteus maximus tendon: CT findings

Two cases of calcific tendinitis of gluteus maximus muscle are presented. The CT findings, including amorphous calcification without soft tissue mass and possible cortical erosion at the femoral enthesis of the gluteus maximus muscle, are highly suggestive of calcific tendinitis at this unusual but classical location. Ossifying entheses with well-defined cortical defect are frequent at the femoral insertion of the gluteus maximus muscle in asymptomatic subjects and must be differentiated from a real cortical erosion sometimes associated with these calcific tendinitis. Received: 16 July 1998; Revision received: 14 September 1998; Accepted: 13 October 1998     

Calcific tendinitis of the long head of the biceps brachii distal to the glenohumeral joint: plain film radiographic findings

Calcific tendinitis is a painful condition related to deposition of hydroxyapatite crystals; it favors large joints. The shoulder, specifically the tendons of the rotator cuff and the insertion of the long head of the biceps on the superior glenoid rim, is a well-recognized location for this abnormality. The purpose of this article is to describe a second site of calcific tendinitis of the biceps, distal to the joint and corresponding to the junction of the tendon and muscle. Radiographs in 119 cases of calcific tendinitis of the shoulder, obtained between 1980 and 1988, were reviewed. Twenty had calcific tendinitis in the region of the tendon of the long head of the biceps (nine at the glenoid insertion and 11 adjacent to the humeral shaft). All 11 patients with calcific tendinitis at the more distal site had a small, homogeneous deposit adjacent to the proximal humeral shaft. The densities in these 11 cases followed the normal course of the tendon of the long head of the biceps and were therefore medial to the proximal humeral shaft on the internal rotation view, lateral to the proximal humeral shaft on the external rotation view, and anterior to the proximal humeral shaft on the axillary projection. The major differential diagnosis of calcific tendinitis of the tendon of the long head of the biceps is loose bodies trapped in the biceps tendon sheath. Although the position of the soft-tissue densities in these two entities is similar, loose bodies have an appearance of bone, and their source (degenerative arthritis or recurrent dislocations) is usually apparent. A site of calcific tendinitis distal to the glenohumeral joint that is detectable on plain films is reviewed. Accurate diagnosis depends on understanding the anatomy of the tendon of the long head of the biceps brachii. The clinical charts of the 11 patients also are summarized, with emphasis on the association between the roentgen finding and bicipital tendinitis and impingement syndrome.     

Evaluation of shoulder pathology: three-dimensional enhanced T1 high-resolution isotropic volume excitation MR vs two-dimensional fast spin echo T2 fat saturation MR

Objective:

To evaluate the diagnostic accuracy of three-dimensional (3D) enhanced T₁ high-resolution isotropic volume excitation (eTHRIVE) shoulder MR for the detection of rotator cuff tears, labral lesions and calcific tendonitis of the rotator cuff in comparison with two-dimensional (2D) fast spin echo T₂ fat saturation (FS) MR.

Methods:

This retrospective study included 73 patients who underwent shoulder MRI using the eTHRIVE technique. Shoulder MR images were interpreted separately by two radiologists. They evaluated anatomic identification and image quality of the shoulder joint on routine MRI sequences (axial and oblique coronal T₂ FS images) and compared them with the reformatted eTHRIVE images. The images were scored on a four-point scale (0, poor; 1, questionable; 2, adequate; 3, excellent) according to the degree of homogeneous and sufficient fat saturation to penetrate bone and soft tissue, visualization of the glenoid labrum and distinction of the supraspinatus tendon (SST). The diagnostic accuracy of eTHRIVE images compared with routine MRI sequences was evaluated in the setting of rotator cuff tears, glenoid labral injuries and calcific tendonitis of the SST.

Results:

Fat saturation scores for eTHRIVE were significantly higher than those of the T₂ FS for both radiologists. The sensitivity and accuracy of the T₂ FS in diagnosing rotor cuff tears were >90%, whereas sensitivity and accuracy of the eTHRIVE method were significantly lower. The sensitivity, specificity and accuracy of both images in diagnosing labral injuries and calcific tendonitis were similar and showed no significant differences. The specificity of both images for the diagnosis of labral injuries and calcific tendonitis was higher than the sensitivities.

Conclusion:

The accuracy of 3D eTHRIVE imaging was comparable to that of 2D FSE T₂ FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST. The 3D eTHRIVE technique was superior to 2D FSE T₂ FS in terms of fat saturation. Overall, 3D eTHRIVE was inferior to T₂ FS in the evaluation of rotator cuff tears because of poor contrast between joint fluid and tendons.

Advances in knowledge:

The accuracy of 3D eTHRIVE imaging is comparable to that of 2D FSE T₂ FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST.Decreasing MR examination time is important for improving patient comfort and reducing motion artefact.¹ Three-dimensional (3D) MRI with isotropic resolution can create multiplanar reformatted (MPR) images and enable the creation of similar sequences with different image planes, resulting in decreased scan time.^2–4 3D isotropic MR can minimize partial volume artefact using thin slice thickness (SL), which can analyse lesions without interslice gaps.⁵ Recently, a new 3D imaging sequence called 3D enhanced T₁ high-resolution isotropic volume excitation MR (eTHRIVE) was developed.⁶ The eTHRIVE is a 3D T₁ weighted gradient sequence with dual half-scan and improved fat suppression that enables fast dynamic scanning with submillimetre in-plane resolution.⁷ Lee et al⁶ reported that eTHRIVE has the advantage of high-contrast resolution that reveals better diagnostic results through multiplanar reconstruction. These techniques were used to evaluate ligaments of the wrist within a shorter imaging time. However, to the best of our knowledge, no preliminary study has used eTHRIVE to evaluate shoulder joint pathology. The purpose of this study was to evaluate the diagnostic accuracy of eTHRIVE shoulder MR regarding the detection of rotator cuff tears, labral lesions and calcific tendonitis of the rotator cuff in comparison with two-dimensional (2D) fast spin echo T₂ fat saturation (FS) MR.     

Chronic calcific tendinitis of the neck

The authors present the first three cases of chronic calcific tendinitis of the neck. This condition is diagnosed radiologically by the presence of calcification located just inferior to the anterior tubercle of C1. The calcification is at the insertion of the longus colli muscle. No soft tissue swelling is present and the patients are asymptomatic.     

The painful shoulder

Pain in the shoulder arises from a wide variety of abnormalities. The most common cause of acute pain in the nontraumatized shoulder is calcific tendonitis or bursitis readily identified by plain film radiography. On the other hand, the evaluation of chronic pain usually requires some combination of arthrography, CT, ultrasonography, and MRI to identify the source of the patients' complaints with certainty. The shoulder is rarely the site of a monoarticular process and is infrequently the dominant site of abnormality in a generalized articular disease. Clues to generalized disease processes are sometimes evidenced by changes within the shoulder present on the chest film. The source of pain in the shoulder was often elusive and puzzling to both the clinician and radiologist prior to the development of techniques such as arthrography, CT, and MRI that allow the precise delineation of soft tissue abnormalities. The judicious use of these techniques has, in large measure, helped to solve the puzzle.     

Stress fractures around the knee

Stress fractures of the lower extremities are common, especially in the younger athletic population. The current literature consists mainly a variety of case reports but is devoid of any sizeable series of knee stress fracture investigations. Diagnosing a stress fracture around the knee can be a challenge. The proximity of the stress fracture to the knee joint may lead the clinician to investigate intra-articular or other periarticular pathology. The differential diagnosis can be large, including bursitis, tendonitis, mechanical causes, insufficiency fracture, and tumor. A high index of suspicion is necessary to confirm the underlying diagnosis. A patient's medical history combined with a physical examination and imaging modalities will aid the physician in arriving at the diagnosis of stress fracture.     

Atypical calcific tendinitis with cortical erosions

Objective. To present and discuss six cases of calcific tendinitis in atypical locations (one at the insertion of the pectoralis major and five at the insertion of the gluteus maximus). Patients and results. All cases were associated with cortical erosions, and five had soft tissue calcifications. The initial presentation was confusing and the patients were suspected of having infection or neoplastic disease. Conclusion. Calcific tendinitis is a self-limiting condition. It is important to recognize the imaging features of this condition to avoid unnecessary investigation and surgery. Received: 2 May 2000 Revision requested: 8 June 2000 Revision received: 31 July 2000 Accepted: 8 August 2000     

Acute coccydynia related to precoccygeal calcific tendinitis

Symptomatic deposits of calcium hydroxyapatite have been reported in various sites other than the shoulders or hips. Sudden-onset coccydynia can lead to the discovery of calcific deposition in the precoccygeal region. We present the case of precoccygeal calcific tendinitis in a patient with acute coccydynia.     

Bone scintigraphic findings in patellar tendonitis

Three patients with the signs and symptoms of patellar tendonitis were studied with technetium-99m utilizing the triple phase technique. The scans demonstrated characteristic abnormal radiotracer localization at the inferior pole of the patella or tibial tuberosity on early and delayed images. The regional patellar anatomy likely explains the bone scintigraphic findings in patellar tendonitis.     

Spontaneous calcific cerebral embolus

Spontaneous calcific cerebral embolus is a rare complication of calcific vascular disease such as calcified aortic plaques, and calcific aortic and mitral stenosis. Fewer than 10 case reports are described in the literature. Cerebral ischaemic symptoms may provide the indication for surgical replacement, even in the absence of valvular insufficiency or stenotic symptoms. We report a case of stroke in a young man with a known bicuspid calcific aortic valve.     

MR arthrography in calcific tendinitis of the shoulder: diagnostic performance and pitfalls

The purpose was to assess the diagnostic performance of MR arthrography to diagnose calcific tendinitis of the shoulder and to assess the reasons for diagnostic errors. Standard MR arthrograms of 22 patients with calcific tendinitis and 61 controls were retrospectively analyzed by two independent and blinded radiologists. All cases were consecutively collected from a database. Conventional radiographs were available in all cases serving as gold standard. The supraspinatus was involved in 16, the infraspinatus in four and the subscapularis in two patients. All diagnostic errors were analyzed by two additional readers. Reader 1 correctly detected 12 of the 22 shoulders with and 42 of the 61 shoulders without calcific tendinitis (sensitivity 0.55, specificity 0.66). The corresponding values for reader 2 were 13 of 22 and 40 of 61 cases (sensitivity 0.59, specificity 0.69). Inter-rater agreement (kappa-value) was 0.42. Small size of the calcific deposits and isointensity compared to the surrounding tissue were the most important reasons for false negative results. Normal hypointense areas within the supraspinatus tendon substance and attachment were the main reason for false positive results. In conclusion, MR arthrography is insufficient in the diagnosis of calcific tendinitis. Normal hypointense parts of the rotator cuff may mimic calcific deposits and calcifications may not be detected when they are isointense compared to the rotator cuff. Therefore, MR imaging should not be interpreted without corresponding radiographs.     

Acute retropharyngeal calcific tendinitis: a case report with unusual location of calcification

Retropharyngeal calcific tendinitis is an inflammatory process caused by calcium hydroxyapatite crystal deposition in the longus colli tendon of the prevertebral space, and it may mimic a retropharyngeal infection or abscess. The diagnosis of retropharyngeal calcific tendinitis will be made radiologically by the detection of calcifications anterior to C1–C3 and prevertebral soft tissue swelling. We present a case of acute retropharyngeal calcific tendinitis with an unusual location of calcification anterior to the C5–C6 disc.     

Acute neck pain due to tendonitis of the longus colli: CT and MRI findings

Summary Calcific retropharyngeal tendonitis is an under-recognized cause of acute cervical pain produced by inflammation of the longus colli muscle. Although the clinical presentation may mimic more serious disorders, the diagnosis can be established radiographically by identification of prevertebral soft tissue calcification and swelling. Six patients with typical signs and symptoms of retropharyngeal tendonitis are presented. All were evaluated with plain films, four with CT and one with MRI. The pathognomonic finding of amorphous calcification anterior to C1-2 with associated asymmetric soft tissue swelling was clearly demonstrated by CT. Diffuse swelling of the longus colli muscle was shown as prominent high signal in the prevertebral region by T2 weighted MRI.