Journal of Orthopaedic Surgery 2015;23(1):116-9
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons: a case report Kam-Lung Tung, Siu-Bon Woo
Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong
INTRODUCTION ABSTRACT We report on a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient had a positive coracoid impingement test for both shoulders. Radiology showed calcific deposits at the insertion of both subscapularis tendons, close to the lesser tuberosities and just posterior to the coracoid tips. The patient underwent sequential arthroscopic coracoplasty and removal of calcific deposits in the subscapularis tendons. The patient returned to work 6 weeks after each surgery. At 2 years, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence. Key words: arthroscopy; shoulder pain; tendinopathy
Calcific tendinitis is an uncommon shoulder disorder among adults.1 Arthroscopic removal of calcific deposits is needed when conservative treatment fails.2 We report a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient made a full recovery and returned to work after a course of rehabilitation. CASE REPORT In June 2011, a 36-year-old man presented with bilateral anterior shoulder pain, which was exacerbated on elevation and adduction of the arms. There was tenderness over both coracoid processes on palpation, but not at the acromioclavicular joints. Pain occurred during forward flexion and cross-arm adduction. The range of motion and power of the rotator cuff were normal bilaterally. Both shoulders
Address correspondence and reprint requests to: Kam-Lung Tung, Department of Orthopaedics and Traumatology, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong. Email: [email protected]
Vol. 23 No. 1, April 2015
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons 117
(a)
(b)
(c)
Figure 1 (a) Radiographs showing calcific foci anterior to the humeral heads, (b) computed tomography showing the calcific deposits at the insertion of both subscapularis tendons, and (c) magnetic resonance imaging showing hypointense lesions within the subscapularis tendons.
(a)
(b)
were positive for the coracoid impingement test, in which the shoulders were placed in a position of cross-arm adduction, forward elevation, and internal rotation to bring the lesser tuberosity in contact with the coracoid.3,4 Radiographs revealed calcifications anterior to the humeral heads close to the lesser tuberosities (Fig. 1a). Computed tomography confirmed calcific foci at the insertion of both subscapularis tendons, with bifocal lesions in the right shoulder (Fig. 1b). Magnetic resonance imaging (MRI) showed hypointense nodular thickening near the humeral insertion of the subscapularis tendons on both T1- and T2-weighted images (Fig. 1c). The calcific foci were close to the coracoid tip in both shoulders; the distance was only 5 mm in axial images and the coracohumeral distance was 7.5 mm in the right shoulder and 9.5 mm in the left shoulder. An acromial spur was noted in the right shoulder. Conservative treatment (physiotherapy and oral non-steroidal anti-inflammatory drugs) failed to resolve the symptoms, and sequential arthroscopic debridement of calcific tendinitis of the subscapularis tendons was performed (left shoulder first). The patient was placed in a beach chair position under general anaesthesia. The operating arm was held by a limb positioner (Spider Limb Positioner, Smith & Nephew, USA). A 30º arthroscope was used through the posterior portal. The rotator interval was opened using radiofrequency ablation (VAPR system, DePuy Mitek, USA) introduced through the anterior portal and the coracoid tip was exposed. Coracoplasty was performed using a 4.5-mm arthroscopic burr (Conmed Linvatec, USA). The adequacy was estimated by the space available
(c)
Figure 2 A 70º arthroscope is used through the posterior portal. The upper border of the subscapularis tendon is seen. (a) A shaver is introduced through the anterior portal after coracoplasty. (b) Calcific deposits are noted within the subscapularis tendon. (c) An oval calcific deposit is excavated close to the lesser tuberosity.
Journal of Orthopaedic Surgery
118 KL Tung et al.
between the coracoid tip and the anterior border of the subscapularis tendon using the diameter of the burr head as a gauge.5 As the calcific deposit was located near the lesser tuberosity, a 70º arthroscope was then used and a posterior directed force was applied to the humeral shaft to facilitate visualisation of the subscapularis insertion to the lesser tuberosity. The calcific lesion was localised by a spinal needle, which was introduced through the anterior portal and confirmed by fluoroscopy. A transverse incision in line with the fibre of the subscapularis tendon was made using radiofrequency, and the calcific deposit was curetted (Fig. 2). Histopathologic examination of the deposit revealed fibro-adipose tissue with chondroid metaplasia and amorphous eosinophilic acellular substance. Postoperatively, the patient was given an arm sling for 2 weeks and oral non-steroidal anti-inflammatory drugs. Radiographs confirmed complete removal of the calcific foci (Fig. 3). Range-of-motion and strengthening exercises were started. The patient returned to work after 6 weeks. Six months later, the right shoulder was treated surgically in the same manner. In addition, acromioplasty was performed using a 30º arthroscope through the anterolateral portal to visualise the insertion of the subscapularis tendon. Postoperative management was similar. At the 2-year follow-up, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence (Fig. 4). DISCUSSION Calcific tendinitis of the rotator cuff may be due to hypoxia of the tissue and most commonly involves the supraspinatus tendon, followed by infraspinatus, teres minor, and subscapularis.6 Surgical treatment is rarely needed when patients respond to conservative treatment.1,7,8 Arthroscopic debridement enables quick resolution of symptoms and rehabilitation. The use of a 70º arthroscope through the posterior portal provides an excellent aerial view of the subscapularis tendon and coracoid.5 The subacromial approach also provides equally good access to the subscapularis tendon.8 In most cases, calcium deposits can be removed without the need for repair of the subscapularis tendon.7,8 When there is a large
Figure 3 Complete removal of the calcific deposits in both shoulders.
Figure 4 Axial views of the shoulders showing no recurrence of calcific deposits at 2 years.
defect in the upper subscapularis tendon, repair of the tendon to the native bone bed is needed.1 In our patient, prophylactic coracoplasty before removal of calcific deposits from the subscapularis tendons was performed, as the coracoid impingement test for each shoulder was positive and the distance between the coracoid tip and the calcific foci was only 5 mm. The mean coracohumeral distance should be 11 mm in asymptomatic patients and ≤5.5 mm in symptomatic patients.9 DISCLOSURE No conflicts of interest were declared by the authors.
Vol. 23 No. 1, April 2015
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons 119
REFERENCES 1. Arriogoni P, Brady PC, Burkhart SS. Calcific tendinitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139. 2. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8:183–8. 3. Okoro T, Reddy VR, Pimpelnarkar A. Coracoid impingement syndrome: a literature review. Curr Rev Musculoskelet Med 2009;2:51–5. 4. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 2006;22:521–7. 5. Lo IK, Burkhart SS. Arthroscopic coracoplasty through the rotator interval. Arthroscopy 2003;19:667–71. 6. Uhthoff HK, Löhr JF. Calcifying tendinitis. In: Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: Saunders; 1998:989–1008. 7. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Denaro V. Arthroscopic management of calcific tendinitis of the subscapularis tendon. Knee Surg Sports Traumatol Arthrosc 2007;15:1482–5. 8. Ifesanya A, Scheibel M. Arthroscopic treatment of calcifying tendonitis of subscapularis and supraspinatus tendon: a case report. Knee Surg Sports Traumatol Arthrosc 2007;15:1473–7. 9. Friedman RJ, Bonutti PM, Genez B. Cine magnetic resonance imaging of the subcoracoid region. Orthopedics 1998;21:545– 8.
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons: a case report Kam-Lung Tung, Siu-Bon Woo
Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong
INTRODUCTION ABSTRACT We report on a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient had a positive coracoid impingement test for both shoulders. Radiology showed calcific deposits at the insertion of both subscapularis tendons, close to the lesser tuberosities and just posterior to the coracoid tips. The patient underwent sequential arthroscopic coracoplasty and removal of calcific deposits in the subscapularis tendons. The patient returned to work 6 weeks after each surgery. At 2 years, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence. Key words: arthroscopy; shoulder pain; tendinopathy
Calcific tendinitis is an uncommon shoulder disorder among adults.1 Arthroscopic removal of calcific deposits is needed when conservative treatment fails.2 We report a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient made a full recovery and returned to work after a course of rehabilitation. CASE REPORT In June 2011, a 36-year-old man presented with bilateral anterior shoulder pain, which was exacerbated on elevation and adduction of the arms. There was tenderness over both coracoid processes on palpation, but not at the acromioclavicular joints. Pain occurred during forward flexion and cross-arm adduction. The range of motion and power of the rotator cuff were normal bilaterally. Both shoulders
Address correspondence and reprint requests to: Kam-Lung Tung, Department of Orthopaedics and Traumatology, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong. Email: [email protected]
Vol. 23 No. 1, April 2015
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons 117
(a)
(b)
(c)
Figure 1 (a) Radiographs showing calcific foci anterior to the humeral heads, (b) computed tomography showing the calcific deposits at the insertion of both subscapularis tendons, and (c) magnetic resonance imaging showing hypointense lesions within the subscapularis tendons.
(a)
(b)
were positive for the coracoid impingement test, in which the shoulders were placed in a position of cross-arm adduction, forward elevation, and internal rotation to bring the lesser tuberosity in contact with the coracoid.3,4 Radiographs revealed calcifications anterior to the humeral heads close to the lesser tuberosities (Fig. 1a). Computed tomography confirmed calcific foci at the insertion of both subscapularis tendons, with bifocal lesions in the right shoulder (Fig. 1b). Magnetic resonance imaging (MRI) showed hypointense nodular thickening near the humeral insertion of the subscapularis tendons on both T1- and T2-weighted images (Fig. 1c). The calcific foci were close to the coracoid tip in both shoulders; the distance was only 5 mm in axial images and the coracohumeral distance was 7.5 mm in the right shoulder and 9.5 mm in the left shoulder. An acromial spur was noted in the right shoulder. Conservative treatment (physiotherapy and oral non-steroidal anti-inflammatory drugs) failed to resolve the symptoms, and sequential arthroscopic debridement of calcific tendinitis of the subscapularis tendons was performed (left shoulder first). The patient was placed in a beach chair position under general anaesthesia. The operating arm was held by a limb positioner (Spider Limb Positioner, Smith & Nephew, USA). A 30º arthroscope was used through the posterior portal. The rotator interval was opened using radiofrequency ablation (VAPR system, DePuy Mitek, USA) introduced through the anterior portal and the coracoid tip was exposed. Coracoplasty was performed using a 4.5-mm arthroscopic burr (Conmed Linvatec, USA). The adequacy was estimated by the space available
(c)
Figure 2 A 70º arthroscope is used through the posterior portal. The upper border of the subscapularis tendon is seen. (a) A shaver is introduced through the anterior portal after coracoplasty. (b) Calcific deposits are noted within the subscapularis tendon. (c) An oval calcific deposit is excavated close to the lesser tuberosity.
Journal of Orthopaedic Surgery
118 KL Tung et al.
between the coracoid tip and the anterior border of the subscapularis tendon using the diameter of the burr head as a gauge.5 As the calcific deposit was located near the lesser tuberosity, a 70º arthroscope was then used and a posterior directed force was applied to the humeral shaft to facilitate visualisation of the subscapularis insertion to the lesser tuberosity. The calcific lesion was localised by a spinal needle, which was introduced through the anterior portal and confirmed by fluoroscopy. A transverse incision in line with the fibre of the subscapularis tendon was made using radiofrequency, and the calcific deposit was curetted (Fig. 2). Histopathologic examination of the deposit revealed fibro-adipose tissue with chondroid metaplasia and amorphous eosinophilic acellular substance. Postoperatively, the patient was given an arm sling for 2 weeks and oral non-steroidal anti-inflammatory drugs. Radiographs confirmed complete removal of the calcific foci (Fig. 3). Range-of-motion and strengthening exercises were started. The patient returned to work after 6 weeks. Six months later, the right shoulder was treated surgically in the same manner. In addition, acromioplasty was performed using a 30º arthroscope through the anterolateral portal to visualise the insertion of the subscapularis tendon. Postoperative management was similar. At the 2-year follow-up, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence (Fig. 4). DISCUSSION Calcific tendinitis of the rotator cuff may be due to hypoxia of the tissue and most commonly involves the supraspinatus tendon, followed by infraspinatus, teres minor, and subscapularis.6 Surgical treatment is rarely needed when patients respond to conservative treatment.1,7,8 Arthroscopic debridement enables quick resolution of symptoms and rehabilitation. The use of a 70º arthroscope through the posterior portal provides an excellent aerial view of the subscapularis tendon and coracoid.5 The subacromial approach also provides equally good access to the subscapularis tendon.8 In most cases, calcium deposits can be removed without the need for repair of the subscapularis tendon.7,8 When there is a large
Figure 3 Complete removal of the calcific deposits in both shoulders.
Figure 4 Axial views of the shoulders showing no recurrence of calcific deposits at 2 years.
defect in the upper subscapularis tendon, repair of the tendon to the native bone bed is needed.1 In our patient, prophylactic coracoplasty before removal of calcific deposits from the subscapularis tendons was performed, as the coracoid impingement test for each shoulder was positive and the distance between the coracoid tip and the calcific foci was only 5 mm. The mean coracohumeral distance should be 11 mm in asymptomatic patients and ≤5.5 mm in symptomatic patients.9 DISCLOSURE No conflicts of interest were declared by the authors.
Vol. 23 No. 1, April 2015
Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons 119
REFERENCES 1. Arriogoni P, Brady PC, Burkhart SS. Calcific tendinitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139. 2. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8:183–8. 3. Okoro T, Reddy VR, Pimpelnarkar A. Coracoid impingement syndrome: a literature review. Curr Rev Musculoskelet Med 2009;2:51–5. 4. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 2006;22:521–7. 5. Lo IK, Burkhart SS. Arthroscopic coracoplasty through the rotator interval. Arthroscopy 2003;19:667–71. 6. Uhthoff HK, Löhr JF. Calcifying tendinitis. In: Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: Saunders; 1998:989–1008. 7. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Denaro V. Arthroscopic management of calcific tendinitis of the subscapularis tendon. Knee Surg Sports Traumatol Arthrosc 2007;15:1482–5. 8. Ifesanya A, Scheibel M. Arthroscopic treatment of calcifying tendonitis of subscapularis and supraspinatus tendon: a case report. Knee Surg Sports Traumatol Arthrosc 2007;15:1473–7. 9. Friedman RJ, Bonutti PM, Genez B. Cine magnetic resonance imaging of the subcoracoid region. Orthopedics 1998;21:545– 8.
