석회성건염 한양의대재활의학교실 이규훈

석회성건염 한양의대재활의학교실 이규훈

Definition Calcifying tendinitis Acute or chronically painful condition that is caused by inflammation around calcium deposits located in or around the tendons Vascularized, viable soft tissue Cyclic process Within the midsubstance of the tendon Dystrophic calcification

Classification Size : small, medium, large Degree and duration : acute, subacute, chronic Radiologic finding : localized, diffuse Clinical : dystrophic, reactive Appear : dry, powdery deposit soft, putty, or toothpaste deposit milky or creamy deposit

Sites of calcium deposition

Epidemiology Painless shoulder : 2.7% - 20% Painful shoulder : 6.8% in all age 35%-45% in 31-49 years Common site : supraspinatus tendon (82-90%) Women > men Laterality : Rt. > Lt. Bilaterality : 13-24% Occupation : 주부, 사무직노동자 A rotator cuff tear may coexist : 25% Spontaneous resolution : 9.3% after 3 years 27% after 10 years

Pathogenesis Degeneration Hypovascularity Decreased local oxygen tension Metabolic disorder Hereditary

Degenerative calcification Degenerative process Focal hyalinization, fibrillate, detach Necrosis Microspherolith, psammoma Aging : decreased vascularity

Reactive calcification

Clinical findings Begin wth subacute or chronic symptom Formative phase Pain or tenderness, referred pain Impingement No vascular and no cellular reactions Hard and well defined deposition

Clinical findings Progress to acute symptom Resorptive phase Acute pain Bursitis Vascular and cellular proliferaton -> increase intratendious pressure Fluffy and ill defined deposition

Clinical findings

Radiologic finidngs Radiograph Confirm and follow up Size : small, medium, large Localize vs diffuse Type A or I : homogeneous calcification and well defined limits Type B or II : heterogeneous calcification and well defined limits Type C or III : heterogeneous calcification and ill defined limits Type D : dystrophic calcification

Consistency of Rotator Cuff Calcifications: Observations on Plain Radiography, Sonography, Computed Tomography, and at Needle Treatment. FARIN, PEKKA Investigative Radiology. 31(5):300 304, May 1996. Figures 1A 1C. (A) Plain radiography of a rotator cuff calcification with a well defined periphery. (B) Corresponding axial computed tomography scan. The calcification is homogeneous with a density of 939 Hounsfield units. (C) Corresponding shows a rotator cuff calcification (arrows) with a clear acoustic shadow (arrowheads). The calcification proved to be hard at ultrasound guided needle treatment. 2

Consistency of Rotator Cuff Calcifications: Observations on Plain Radiography, Sonography, Computed Tomography, and at Needle Treatment. FARIN, PEKKA Investigative Radiology. 31(5):300 304, May 1996. Figures 2A 2C. (A) Plain radiography of a rotator cuff calcification with an ill defined periphery. (B) Corresponding axial computed tomography scan. The calcification (arrows) is nonhomogeneous with a density of 122 Hounsfield units. (C) Corresponding sonogram shows a rotator cuff calcification (arrows) with no acoustic shadow. The calcification proved to be soft (slurry calcification) at treatment. 3

Consistency of Rotator Cuff Calcifications: Observations on Plain Radiography, Sonography, Computed Tomography, and at Needle Treatment. FARIN, PEKKA Investigative Radiology. 31(5):300 304, May 1996. Figures 3A and 3B. (A) Reconstructed sagittal oblique computed tomography scan of a nonhomogeneous calcification (arrows). The density values from the upper part of the calcification are 120 to 130 Hounsfield units (HU), and the values from the lower part are 400 to 420 HU. (B) Corresponding transverse sonogram shows a hyperechoic mass (arrows) with mixed acoustic shadow. In the center part of the hyperechoic mass is an acoustic shadow (arrowheads). The other parts have no shadow. The upper part of the calcification proved to be soft and the center of the lower part was hard at needle treatment. 4

CONCLUSIONS: Ultrasound and CT were reliable in predicting the consistency of rotator-cuff calcifications. 9

Management Non operative NSAIDs Physiotherapy Physical modality Puncture aspiration/needling Radiotherapy Extracorporeal shock wave therapy Surgical treatment

Puncture aspiration/needling

Table 2. Mean visual analog scale (VAS) scores before and after percutaneous needle puncture treatment (±SD). VAS p With aspiration Without aspiration Time point, weeks (n=41) ( =40) Pretreatment 6.8±1.4 6.4±1.8 NS Posttreatment 1 6.8±2.3 6.5±2.1 NS 2 6.7±2.1 5.0±2.3* S 3 4.9±1.4* 4.7±2.3* NS 6 4.4±1.6* 4.5±1.9* NS 12 4.1±2.7* 4.3±2.5* NS 24 3.3±1.9* 3.4±1.6* NS 36 3.5±2.1* 3.6±2.4* NS *P<0.05 vs. pretreatment. NS=not significant; S=significant (P<0.05).

Pain : painless : VAS, 0 cm, mild : VAS, 1 4 cm moderate : VAS, 4 8 cm, severe : VAS, 8 10 cm High-resolution ultrasonography (HRUS) arc shaped : an echogenic arc with clear shadowing fragmented or punctate : at least 2 separated echogenic spots or plaques nodular : an echogenic nodule without shadowing cystic : a bold echogenic wall with an anechoic area, weak internal echoes Color Doppler ultrasonography (CDUS) grade 0 : no color flow signal grade 1 : <3 color spots grade 2 : 3 6 color spots grade 3 : >6 color spots

Arc shaped Fragmented shaped Nodular shaped Cystic shaped

Grade 0 Grade 1 Grade 2 Grade 3

Color Doppler ultrasonography of the rotator cuff is highly correlated to symptoms. Higher-grade CDUS signals usually indicate resorptive status. We recommend a combination of HRUS and CDUS for more accurate prediction of the formative or resorptive status of calcific plaques.

Biceps tendon Greater tuberosity Coronal plane Longitudinal plane