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CASE REPORT
Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 90-93

Calcifying Tendinitis of Subscapular Tendon Presenting as Frozen Shoulder: A Rare Case report


Department of Orthopaedics, Aarupadai Veedu Medical College and Hospital, Pondicherry, India

Date of Web Publication19-Jan-2015

Correspondence Address:
Raghavendra Beshaj
Department of Orthopaedics, Arupadai Veedu Medical College and Hospital, Pondicherry - 607 402
India
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DOI: 10.4103/1319-6308.149546

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  Abstract 

We present an unusual case of chronic diffuse calcifying tendonitis involving the subscapularis tendon with a clinical presentation similar to frozen shoulder in a 58-year-old right hand dominant female. The patient was treated with arthroscopic removal of the calcific deposits. Patient had drastic improvement in the pain score postoperatively; range of movement was near normal with weakness in internal rotation. Now at one year follow up all the movements of shoulder are in good range and of same power as the opposite shoulder except for weak internal rotation.

  Abstract in Arabic 

التهاب الأوتار التكلسي تحت الكتف حيث يظهر كالكتف المتجمد- تفرير حالة نادرة
هذه حالة غير عادية من حالات التهاب الأوتار التكلسي الحادة المنتشرة التي تشمل أوتار تحت الكتف التي تظهر سريريا مشابهة للكتف المتجمد في اليد اليمني لسيدة تبلغ من العمر 58 عاما. عولجت المريضة بالمنظار لإزالة الرواسب المتجمدة وفد استجابت للعلاج حيث خفت درجة الألم بعد العملية، وصارت الحركة أقرب إلى العادية مع ضعف في حركة الدوران الداخلية. وبعد المتابعة لمدة عام أصبحت حركة الكتف وقوته في مستوى جيد كما هو الحال في الكتف المقابل ما عدا ضعف حركة الدوران الداخلية




Keywords: Calcifying tendinitis, frozen shoulder, shoulder, subscapularis tendon


How to cite this article:
Beshaj R, Kumar I A. Calcifying Tendinitis of Subscapular Tendon Presenting as Frozen Shoulder: A Rare Case report. Saudi J Sports Med 2015;15:90-3

How to cite this URL:
Beshaj R, Kumar I A. Calcifying Tendinitis of Subscapular Tendon Presenting as Frozen Shoulder: A Rare Case report. Saudi J Sports Med [serial online] 2015 [cited 2019 Jul 19];15:90-3. Available from: http://www.sjosm.org/text.asp?2015/15/1/90/149546


  Introduction Top


The term 'calcifying tendinitis' was first coined by De Seze and Welfling. [1] It is a common disorder of the rotator cuff and accounts for approximately 10% of all consultations for painful shoulder. It affects women more often than men; its peak incidence is in the fifth decade. [2] The most common site of occurrence is within the supraspinatus tendon and it rarely affects the subscapularis tendon. [3]

Frozen shoulder is a painful, debilitating disorder reportedly affecting 2-5% of the general adult population [4] and 10-20% of people with diabetes. [5] Primary frozen shoulder is classically described as having three stages, with stage I involving pain, stage II pain and restricted movement, and finally stage III, involving painless restriction. [6] Most cases resolve over the course of 18-30 months. However, a minority of patients have a protracted course with ongoing restriction. [7]

We hereby share with you an unusual case of chronic diffuse calcifying tendonitis involving the subscapularis tendon with a clinical presentation similar to frozen shoulder.


  Case report Top


A 58-year-old right hand dominant lady presented with 6 months duration of left shoulder pain and restriction of movements. Problem was insidious in onset and progressively restriction of movements was predominant than the pain. She is not a known diabetic or hypertensive and no known cardiac ailments. She did have regular physiotherapy for near 3 months with little improvement and also has had one shot of intra-articular steroid injection by her own physician.

Clinically she had forward flexion of 30 degrees, abduction of 20-30 degrees. No external rotation and internal rotation was up to her trochanteric level only. [Figure 1] and [Figure 2]. It was difficult to assess her impingement and her cuff strength was intact clinically. The X-ray of the shoulder anteroposterior view alone was done [Figure 3], which was normal and no magnetic resonance imaging (MRI) scan was taken. On the basis of these findings, we made a diagnosis of peri-arthritis shoulder or frozen shoulder. Patient was advised to have arthroscopic capsular release.
Figure 1: Shoulder movement abduction preoperatively

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Figure 2: Shoulder movement internal rotation preoperatively

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Figure 3: Preoperative shoulder anterioposterior view

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Patient was given regional block and general anaesthesia for the operative procedure. She was positioned on her right lateral position and standard posterior portal was made. Intraoperatively severe capsular tightness was noted. Middle glenohumeral ligament was found to be very tight and was released. Sub scapular tendon was found completely calcified, which was unusual [Figure 4] and release was necessary to have full range of external rotation.
Figure 4: Arthroscopic image showing tight mghl and calcifiedsubscapularis tendon

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The calcific deposits were of a hard chalky texture, and the arthroscopic shaver was used to excise the deposit [Figure 5]. The remaining tendon was sutured. Both anterior and posterior capsular lease was performed and an epidural catheter was inserted for post-operative pain relief. At the end of the procedure, a thorough washout of both the glenohumeral joint and subacromial space was done, and this is necessary to prevent leaving behind any calcium fragments. For post-operative pain a single dose of local anaesthetic was given through the epidural catheter on day 1, following which catheter was removed. Two days of intramuscular analgesic was given followed by oral nonsteroidal anti-inflammatory analgesics for 5 days.
Figure 5: Arthroscopic image showing removal of calcific deposit using arthroscopic shaver

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Post operatively on day 1, patient was able to do forward flexion to 90 0 , abduction to 60 0 and external rotation of 20 0 and was able to do active assisted shoulder mobilization. The patient wore a sling for one week. Pain-free passive range of motion exercise started immediately from day 1 after surgery. After one week, active range of motion exercise was permitted. She continued physiotherapy on outpatient basis and on the 10 th post-operative day she had forward flexion of 160 0 and abduction of 90 0 with very minimal pain and external rotation was 20 0 -30 0 although she had poor internal rotation [Figure 6] and [Figure 7]. Patient had drastic improvement in the pain postoperatively; range of movement was near normal with weakness in internal rotation after 6 weeks following surgery. Now at one year follow-up all the movements of shoulder are in good range and of same power as the opposite shoulder except for weak internal rotation.
Figure 6: Shoulder movement abduction on 10th post operative day

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Figure 7: Shoulder movement flexion on 10th post operative day

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  Discussion Top


Although calcific tendonitis most frequently occurs in the supraspinatus tendon, it can also involve more than 1 tendon. [8] However, the frequency of the calcific tendinitis in the subscapularis tendon is low. [3],[9],[10] Regarding association between frozen shoulder and calcifying tendinitis, we could not find much in the literature except for a case series by Chen et al., which stated, "calcifying tendinitis can lead to acute pain resulting in frozen shoulder syndrome". They reported 32 cases in which frozen shoulder was associated with calcific tendinitis of the supraspinatus tendon. [11]

The first case of operative removal of calcific deposit was carried out by Harrington and Codman in 1902. Since then, favorable results have been reported by numerous authors with a subjective improvement of 82% and 71% achieving excellent objective results following open excision of the calcium deposit via a deltoid split approach combined with an acromioplasty. [12],[13],[14] Neer recommended excision of the calcifying tendon as 'a quarter orange' without the need for complementary suturing. [15] Porcellini et al., reported that the number and size of residual calcified deposits were negatively correlated with postoperative results, suggesting a preference for complete removal. [16] Furthermore, Chen et al., have reported in their case series that arthroscopic brisement of the glenohumeral joint and making multiple punctures in the calcific spot to treat the frozen shoulder associated with calcific tendinitis of the supraspinatus yielded good results. [11] In our case, we removed the calcific deposit completely and the subscapularis tendon was repaired and at one year follow-up all the movements of shoulder are in good range and of same power as the opposite shoulder except for weak internal rotation.


  Conclusion Top


Calcifying tendonitis of subscapularis tendon is rare, but not uncommon. Calcifying tendonitis can rarely present as frozen shoulder and we should be aware of such a clinical condition. Patients who are resistant to conservative treatment and are having disabling symptoms for more than 6 months are candidates for surgical treatment. The calcified deposits should be removed completely during the surgery for good functional outcome.

 
  References Top

1.
de Seze S, Welfling J. Calcifying tendinitis. Rhumatologie 1970;22:45-50.  Back to cited text no. 1
[PUBMED]    
2.
Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: A survey of 12,122 cases. J Am Med Assoc 1941;116:2477-82.  Back to cited text no. 2
    
3.
Arrigoni P, Brady PC, Burkhart SS. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139. e1-3.  Back to cited text no. 3
    
4.
Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl 1969;119:1-59.  Back to cited text no. 4
    
5.
Miller MD, Wirth MA, Rockwood CA Jr. Thawing the frozen shoulder: The "patient" patient. Orthopedics 1996;19:849-53.  Back to cited text no. 5
    
6.
Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;4:193-6.  Back to cited text no. 6
[PUBMED]    
7.
Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am 1992;74:738-46.  Back to cited text no. 7
    
8.
Lippmann RK. Observations concerning the calcific cuff deposit. Clin Orthop 1961;20:49-60.  Back to cited text no. 8
[PUBMED]    
9.
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.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Chen SK, Chou PH, Lue YJ, Lu YM. Treatment for frozen shoulder combined with calcific tendinitis of the supraspinatus. Kaohsiung J Med Sci 2008;24:78-84.  Back to cited text no. 11
    
12.
Gazielly DF, Bruyere G, Gleyze PT. Open acromioplasty with excision of calcium deposits and tendon suture. In: Gazielly DF, Gleyze PT, editors. The cuff. Paris: Elsevier; 1997. p. 172-5.  Back to cited text no. 12
    
13.
Rochwerger A, Franceschi JP, Viton JM, Roux H, Mattei JP. Surgical management of calcific tendinitis of the shoulder: An analysis of 26 cases. Clin Rheumatol 1999;18:313-6.  Back to cited text no. 13
    
14.
Postel JM, Goutallier D, Lambotte JC, Duparc F. Treatment of chronic calcifying or post calcifying shoulder tendinitis by acromioplasty without excision of the calcification. In: Gazielly DF, Gleyze PT, editors. The cuff. Paris: Elsevier; 1997. p. 159-63.  Back to cited text no. 14
    
15.
Neer CS, Marberrey TA. Calcium deposits. In: Neer CS, editor. Shoulder reconstruction. Philadelphia: WB Saunders Co; 1990. p. 774-89.  Back to cited text no. 15
    
16.
Porcellini G, Paladini P, Campi F, Paganelli M. Arthroscopic treatment of calcifying tendinitis of the shoulder: Clinical and ultrasonographic follow-up findings at two to five years. J Shoulder Elbow Surg 2004;13:503-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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