Ayyappan V Nair, Ajit Jangale MS, Murugesh Kurani Mahadev, Pramod
Kumar Mohan and Bollabathini Raju
- Indian Journal of Orthopaedic Surgery (IJOS) – 2022
LINK: chrome-extension://kdpelmjpfafjppnhbloffcjpeomlnpah/https://www.orthopaper.com/archives/2022/vol8issue1/PartH/8-1-107-681.pdf
Calcific tendinitis is a self‑limiting condition caused by deposition of calcium crystals in tendons, most commonly involving the shoulder. Calcium pyrophosphate dihydrate (CPPD) is a rare variant, and calcific deposits at the triceps insertion are uncommon. This case report describes a 35‑year‑old male with sequential CPPD involvement of the shoulder and elbow. The patient previously underwent arthroscopic debridement and rotator cuff repair for right shoulder calcific tendinitis. He presented with acute, severe right elbow pain and swelling without trauma. Examination revealed tenderness at the olecranon and restricted motion. Radiographs, MRI, and ultrasound showed homogeneous calcific deposits in the triceps tendon insertion with surrounding inflammation.
The patient underwent ultrasound‑guided needle aspiration and lavage under sedation and interscalene block. Synovial fluid analysis confirmed CPPD crystals. Post‑procedure, the patient was immobilized for one week, given NSAIDs and colchicine, and underwent physiotherapy. Pain improved from VAS 8/10 to 2/10, with full functional recovery at one‑year follow‑up.
This case highlights the rare sequential presentation of CPPD in the shoulder and elbow, underscores the importance of high suspicion for atypical calcific tendinitis, and demonstrates that ultrasound‑guided needling and lavage is an effective, minimally invasive treatment option with excellent outcomes
Introduction
Calcium pyrophosphate dihydrate (CPPD) or Pseudogout is a crystal arthropathy that consists of deposition of calcium pyrophosphate in joints and periarticular soft tissues [1]. Whenever the upper extremity is the site of inflammation (wrist, elbow, shoulder) in a first attack, there should be a strong suspicion for acute CPP crystal arthritis [2]. In contrast to the brief attacks of acute gouty arthritis that typically last for several days to one week, acute attacks of CPPD disease may last for weeks to months [2].
CPPD classically may present as acute, chronic, or asymptomatic CPPD [3]. The typical presentation consists of acute onset of pain without any history of trauma or event, or it may sometimes present as an incidental finding [4]. The mainstay of treatment is conservative [5], but in refractory cases, surgical management may be required [6].
The investigations include synovial fluid analysis, synovial biopsy, x-ray and blood investigations with inflammatory markers and ultrasonography, CT scan [7, 8].
In this case, the patient presented with all the classic symptoms and had a history of right shoulder calcific tendinitis. MRI homogenous calcific deposits were noted in the triceps and treated with ultrasound-guided needling and aspiration.
Case report
A right-handed 35-year-old male presented to OPD with acute, severe pain in the right elbow for four days. He had a history of right shoulder calcific tendinitis associated with rotator cuff tear and underwent arthroscopic debridement and rotator cuff repair.
The affected elbow was inflamed, in 90-degree flexion, and tender at olecranon. (Image 4).
The radiograph of the elbow demonstrated linear hyper-dense opacity near triceps insertion (Image 1). MRI and USG were advised, which showed homogeneous calcific depositions in the triceps tendon near insertion at olecranon with surrounding tissues inflammation (Image 3 and Image 4).
Procedure
Informed consent was taken, and after all investigations and fitness, the patient was posted. The patient was sedated and was given Inter scalene Block. Under aseptic precautions and USG guidance, two 18G needles were inserted into the lesion.
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International Journal of Orthopaedics Sciences
Through one needle, lavage was given with saline, and through another needle, calcific deposits were aspirated. USG confirmed completion of aspiration. The patient was advised for one week of rest, followed by elbow physiotherapy.
Image 2: Ultrasound showing echogenic lesions suggestive of calcification at triceps insertion.
Image 3: STIR images showing oedema of triceps tendon and effusion
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Image 4: Inflamed elbow posteriorly
Discussion
Calcific tendinitis of the elbow is uncommon. Calcium deposits around the elbow are generally secondary to massage, trauma or surgery, and endocrine disorders. Our patient previously presented with calcific tendinitis for the shoulder, which was surgically debrided and rotator cuff operated arthroscopically.
Diagnostic criteria for CPPD disease are based upon those initially proposed by Rosenthal, McCarty, and colleagues3, which highlight the importance of microscopy analysis of synovial fluid and tissue. In our case, we sent the tissues for analysis after the sonographic needling, and it positively showed birefringent crystals by compensated polarized light microscopy.
Tendon calcifications are important findings to diagnose CPPD. These appear as thin linear bands along the tendons’ length [9]. In a study by Yang et al., tendon calcification around the knee was never present without adjacent chondrocalcinosis and involved the gastrocnemius tendon in 28% and the quadriceps in 8.4% of x-rays [10]. Perreira et al. reviewed the prevalence and pattern of tendon calcification in patients with knee chondrocalcinosis and found involvement of Achilles, gastrocnemius, or quadriceps tendons in 21–25% of radiographs [11]. Less commonly observed was the involvement of the triceps tendon near the elbow, the rotator cuff, and the long head of the triceps at the shoulder [9].
Treatment may vary depending on symptoms, location, size, and nature of deposit [12]. In this case, the patient presented with severe pain and restriction of movements, so USGguided needle aspiration was performed. The patient presented with an 8/10 VAS score, and after the procedure, it was 2/10. His synovial fluid analysis showed CPPD crystals. The patient was immobilized for a week, and a course of NSAIDS and colchicine was given. From the 2nd week, he underwent physiotherapy. At the end of one year, the patient recovered completely.
Conclusion
High suspicion of unusual presentation of calcific tendinitis (with rare presentation and multiple sites involvement) gives more specific aetiology and better outcomes of calcific tendinitis. CPPD may present as calcific tendinitis in the shoulder. If any joint in the upper limb is involved as an acutely inflamed joint, it is prudent to exclude CPPD.
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