Calcifying Tendinitis Workup

Updated: Apr 14, 2020
  • Author: Anthony H Woodward, MD; Chief Editor: Herbert S Diamond, MD  more...
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Workup

Approach Considerations

The diagnosis of calcifying tendinitis is made from standard shoulder radiographs—anterior-posterior (AP), outlet, and axillary views. Laboratory studies are not required.

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Imaging Studies

Plain x-rays

Plain x-rays demonstrate calcific deposits. Routine shoulder views, true anteroposterior (AP) and lateral views, AP views with the shoulder in internal and external rotation, axillary views, and supraspinatus outlet views should be sufficient to demonstrate calcification in any rotator cuff tendon. The sensitivity of plain x-rays for detecting calcific deposits is 0.90 (when using ultrasonography as the standard).

The calcific deposit can be characterized radiologically as follows:

  • Location: Lateral or medial
  • Size: Large (>1.5 cm), medium, or small. Large deposits may be more likely to be symptomatic.
  • Morphology: Two systems have been proposed for classifying the morphology of calcific deposits: one by Gärtner and Heyer, [10]  another by the Société française d'arthroscopie (SFR: French Society of Arthroscopy). [4]

Gärtner and Heyer classify calcific deposits into the following three types:

  • Type I (formative phase): Dense calcifications with well-defined border; frequency, 37%; pain, mild
  • Type II (resting phase): Dense calcifications with Indefinite border; frequency, 32%; pain,  moderate to severe
  • Type III (resorptive phase): Translucent calcifications with indistinct border; frequency, 31: pain, severe

However, Kappa values for interobserver and intraobserver agreement indicate that the Gärtner and Heyer system is unreliable.{ref28 [4, 11, 12]        

The SFA classification comprises four types, with the appearance and frequency as follows [4] (French Society of Arthroscopy)

  • Type A: Dense, well defined, circumscribed calcifications; 17%
  • Type B: Dense, well defined, Segmented calcifications; 19%
  • Type C: Transparent and nonhomogeneous calcifications; 45%
  • Type D: Dystrophic deposit at tendon origin; 19%

 Magnetic resonance imaging (MRI)

MRI is not necessary to detect calcifying tendinitis, although its accuracy for finding calcification is more than 95%. It is most useful in cases of chronic calcifying tendinitis, which may be associated with rotator cuff tears, adhesive capsulitis or osteolysis of the tuberosity. [1]  

The calcific deposit causes decreased signal intensity on T1-weighted images. [13, 14]  If edema is present around the calcific deposit, as might occur in the resorptive phase, increased signal intensity around the calcific deposits may be present on T2-weighted images. [13] Do not misinterpret this increased area of signal intensity that is due to edema as a rotator cuff tear.

Ultrasonography

High-resolution ultrasonography (US) shows the presence of deposits and also defines their locations in the tendon, plus their size and texture. In the resting phase, the deposits appear hyperechoic and arc shaped, whereas they appear non-arc shaped (fragmented/punctate, cystic, nodular) in the resolving phase. These appearances can also be correlated with the symptomatic and asymptomatic phases of the disease. US examination during the nodular or cystic phase shows increased vascularity around the deposits. [1]

Ultrasonography does not expose the patient to radiation but accuracy of results depends heavily on the skill of the technologists and the interpreting radiologist. In experienced hands, ultrasonography is more sensitive than plain x-rays. [11, 15]

Computed tomography (CT)

CT has excellent resolution to detect calcium deposits. However, cost and radiation exposure limit its use. [15]

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