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1.
Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls.
Albano, D, Coppola, A, Gitto, S, Rapisarda, S, Messina, C, Sconfienza, LM
La Radiologia medica. 2021;(4):608-619
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Abstract
Rotator cuff calcific tendinopathy (RCCT) is a very common condition, characterized by calcium deposition over fibrocartilaginous metaplasia of tenocytes, mainly occurring in the supraspinatus tendon. RCCT has a typical imaging presentation: in most cases, calcific deposits appear as a dense opacity around the humeral head on conventional radiography, as hyperechoic foci with or without acoustic shadow at ultrasound and as a signal void at magnetic resonance imaging. However, radiologists have to keep in mind the possible unusual presentations of RCCT and the key imaging features to correctly differentiate RCCT from other RC conditions, such as calcific enthesopathy or RC tears. Other presentations of RCCT to be considered are intrabursal, intraosseous, and intramuscular migration of calcific deposits that may mimic infectious processes or malignancies. While intrabursal and intraosseous migration are quite common, intramuscular migration is an unusual evolution of RCCT. It is important also to know atypical regions affected by calcific tendinopathy as biceps brachii, pectoralis major, and deltoid tendons. Unusual presentations of RCCT may lead to diagnostic challenge and mistakes. The aim of this review is to illustrate the usual and unusual imaging findings of RCCT that radiologists should know to reach the correct diagnosis and to exclude other entities with the purpose of preventing further unnecessary imaging examinations or interventional procedures.
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2.
Tendons Involvement in Congenital Metabolic Disorders.
Abate, M, Salini, V, Andia, I
Advances in experimental medicine and biology. 2016;:117-22
Abstract
Congenital metabolic disorders are consequence of defects involving single genes that code for enzymes. Blocking metabolic pathways, the defect leads to the shortage of essential compounds, and/or to the accumulation of huge quantities of precursors, which interfere with normal functions. Only few of these diseases are characterized by a clinically significant tendon involvement.Heterozygous Familial Hypercholesterolaemia results from the inheritance of a mutant low-density lipoprotein receptor gene; patients show high cholesterol levels, precocious coronary artery disease, and may develop tendon xanthomata (mainly in Achilles tendon). The detection of xanthomata is important, because it allows an early diagnosis and treatment of the disorder. Cerebrotendinous Xanthomatosis is a rare genetic metabolic disorder of cholesterol and bile acid metabolism, characterized by accumulation of cholestanol in brain and tendons. Tendon abnormalities are similar to those reported in Heterozygous Familial Hypercholesterolaemia. Alkaptonuria is caused by a deficiency of the enzyme homogentisic acid oxidase. Due to the accumulation of the homogentisic acid, tendons and ligaments are characterized by a typical ochre/yellow pigmentation (ochronosis), with ensuing inflammation, calcification and rupture. In Congenital Hypergalactosemia an increased tendon collagen cross-linking by non-enzymatic galactosylation can be observed. Finally, Congenital Hypophosphatasia may be associated to deposition of hydroxyapatite crystals in rotator cuff, elbow, and Achilles tendons.
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3.
Injection therapies for Achilles tendinopathy.
Kearney, RS, Parsons, N, Metcalfe, D, Costa, ML
The Cochrane database of systematic reviews. 2015;(5):CD010960
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Abstract
BACKGROUND Achilles tendinopathy is a common condition, often with significant functional consequences. As a wide range of injection treatments are available, a review of randomised trials evaluating injection therapies to help inform treatment decisions is warranted. OBJECTIVES To assess the effects (benefits and harms) of injection therapies for people with Achilles tendinopathy. SEARCH METHODS We searched the following databases up to 20 April 2015: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and SPORTDiscus. We also searched trial registers (29 May 2014) and reference lists of articles to identify additional studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials evaluating injection therapies in adults with an investigator-reported diagnosis of Achilles tendinopathy. We accepted comparison arms of placebo (sham) or no injection control, or other active treatment (such as physiotherapy, pharmaceuticals or surgery). Our primary outcomes were function, using measures such as the VISA-A (Victorian Institute of Sport Assessment-Achilles questionnaire), and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies. We assessed treatment effects using mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables and risk ratios (RRs) and 95% CIs for dichotomous variables. For follow-up data, we defined short-term as up to six weeks, medium-term as up to three months and longer-term as data beyond three months. We performed meta-analysis where appropriate. MAIN RESULTS We included 18 studies (732 participants). Seven trials exclusively studied athletic populations. The mean ages of the participants in the individual trials ranged from 20 years to 50 years. Fifteen trials compared an injection therapy with a placebo injection or no injection control, four trials compared an injection therapy with active treatment, and one compared two different concentrations of the same injection. Thus no trials compared different injection therapies. Two studies had three trial arms and we included them twice in two different categories. Within these categories, we further subdivided injection therapies by mode of action (injury-causing versus direct repair agents).The risk of bias was unclear (due to poor reporting) or high in six trials published between 1987 and 1994. Improved methodology and reporting for the subsequent trials published between 2004 and 2013 meant that these were at less risk of bias.Given the very low quality evidence available from each of four small trials comparing different combinations of injection therapy versus active treatment and the single trial comparing two doses of one injection therapy, only the results of the first comparison (injection therapy versus control) are presented.There is low quality evidence of a lack of significant or clinically important differences in VISA-A scores (0 to 100: best function) between injection therapy and control groups at six weeks (MD 0.79, 95% CI -4.56 to 6.14; 200 participants, five trials), three months (MD -0.94, 95% CI -6.34 to 4.46; 189 participants, five trials) or between six and 12 months (MD 0.14, 95% CI -6.54 to 6.82; 132 participants, three trials). Very low quality evidence from 13 trials showed little difference between the two groups in adverse events (14/243 versus 12/206; RR 0.97, 95% CI 0.50 to 1.89), most of which were minor and short-lasting. The only major adverse event in the injection therapy group was an Achilles tendon rupture, which happened in a trial testing corticosteroid injections. There was very low quality evidence in favour of the injection therapy group in short-term (under three months) pain (219 participants, seven trials) and in the return to sports (335 participants, seven trials). There was very low quality evidence indicating little difference between groups in patient satisfaction with treatment (152 participants, four trials). There was insufficient evidence to conclude on subgroup differences based on mode of action given that only two trials tested injury-causing agents and the clear heterogeneity of the other 13 trials, which tested seven different therapies that act directly on the repair pathway. AUTHORS' CONCLUSIONS There is insufficient evidence from randomised controlled trials to draw conclusions on the use, or to support the routine use, of injection therapies for treating Achilles tendinopathy. This review has highlighted a need for definitive research in the area of injection therapies for Achilles tendinopathy, including in older non-athletic populations. This review has shown that there is a consensus in the literature that placebo-controlled trials are considered the most appropriate trial design.
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4.
Nonpharmacologic and pharmacologic management of CPP crystal arthritis and BCP arthropathy and periarticular syndromes.
Rosenthal, AK, Ryan, LM
Rheumatic diseases clinics of North America. 2014;(2):343-56
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Abstract
Calcium crystal arthritis is often unrecognized, poorly managed, and few effective therapies are available. The most common types of calcium crystals causing musculoskeletal syndromes are calcium pyrophosphate (CPP) and basic calcium phosphate (BCP). Associated syndromes have different clinical presentations and divergent management strategies. Acute CPP arthritis is treated similarly to acute gouty arthritis, whereas chronic CPP and BCP arthropathy may respond to strategies used for osteoarthritis. Calcific tendonitis is treated with a variety of interventions designed to dissolve BCP crystals. A better understanding of the causes and larger well-planned trials of current therapies will lead to improved care.
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Occurrence of tendon pathologies in metabolic disorders.
Abate, M, Schiavone, C, Salini, V, Andia, I
Rheumatology (Oxford, England). 2013;(4):599-608
Abstract
This article reviews the pathogenetic role of metabolic disorders, which are of paramount relevance to the progression of tendon damage. In diabetes, the prevalence of rheumatological diseases is high, mainly because of the deleterious effects of advanced glycation end products that deteriorate the biological and mechanical functions of tendons and ligaments. In heterozygous familial hypercholesterolaemia, most patients develop Achilles xanthomatosis, a marker of high risk for cardiovascular disease caused by cholesterol deposition in the tendons. Tendon degeneration has also been observed in non-familial hypercholesterolaemia. Monosodium urate crystal deposition in soft tissues is a hallmark of chronic gouty arthritis. In this group of diseases, the mobilization of cholesterol and uric acid crystals is presumably followed by low-grade inflammation, which is responsible for tendon degeneration. Adiposity may contribute to tendon disorders via two different mechanisms: increased weight on the load-bearing tendons and systemic dysmetabolic factors that trigger subclinical persistent inflammation. Finally, tendon abnormalities have been observed in some rare congenital metabolism disorders such as alkaptonuria.
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Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.
Coombes, BK, Bisset, L, Vicenzino, B
Lancet (London, England). 2010;(9754):1751-67
Abstract
BACKGROUND Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. METHODS We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported. FINDINGS 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise. INTERPRETATION Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy. FUNDING None.
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Acute calcific periarthritis of the hand and wrist: a series and review of the literature.
Doumas, C, Vazirani, RM, Clifford, PD, Owens, P
Emergency radiology. 2007;(4):199-203
Abstract
This article presents three patients with acute calcific periarthritis (ACP) of the hand and wrist. ACP is an unusual, painful, monoarticular, periarticular inflammatory process associated with juxtaarticular deposits of amorphous calcium hydroxyapatite. ACP is a distinct clinical subset of hydroxyapatite deposition disease. ACP has a high rate of misdiagnosis because of its rare occurrence and its clinical resemblance to other entities. Clinical presentation may simulate infection, and the associated periarticular calcifications may be mistaken for gout, pseudogout, or other entities. One third of patients with ACP provide a history of antecedent trauma. Treatment is conservative. Patients typically will have a reduction in symptoms within 4-7 days after the acute onset of pain. Radiographically, the periarticular mineralization usually resolves or markedly decreases within 2-3 weeks, although on occasion, some calcifications may remain visible for months. Failure to recognize and correlate the typical clinical and radiographic presentation of this disease may lead to unnecessary diagnostic tests, invasive procedures, and inappropriate medication.
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Crystal deposition disease of the shoulder (including calcific tendonitis and milwaukee shoulder syndrome).
Halverson, PB
Current rheumatology reports. 2003;(3):244-7
Abstract
Calcific tendinitis of the shoulder is a dynamic process. Osteopontin is present in cells surrounding tendon calcifications. Resorption is probably mediated by cathepsin K-containing multinucleated giant cells. Rotator cuff tears are associated with an inflammatory response based on the presence of interleukin-1 and a proliferative synovitis. Metalloproteinases are found in the synovial fluids of patients with rotator cuff tears. Some patients with large rotator cuff tears progress to a severe destructive arthropathy characterized by large joint effusions, which are noninflammatory but contain basic calcium phosphate crystals. These crystals stimulate metalloproteinase production in vitro and also suppress metalloproteinase inhibitor production. Mutations in the ank gene result in decreased extracellular inorganic pyrophosphate in murine progressive ankylosis, and increased extracellular inorganic pyrophosphate in some cases of familial chondrocalcinosis.
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Common conditions of the achilles tendon.
Mazzone, MF, McCue, T
American family physician. 2002;(9):1805-10
Abstract
The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Aging and increased activity (particularly velocity sports) increase the chance of injury to the Achilles tendon. Although conditions of the Achilles tendon are occurring with increasing frequency because the aging U.S. population is remaining active, the diagnosis is missed in about one fourth of cases. Injury onset can be gradual or sudden, and the course of healing is often lengthy. A thorough history and specific physical examination are essential to make the appropriate diagnosis and facilitate a specific treatment plan. The mainstay of treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and nonsteroidal anti-inflammatory drugs, but physical therapy, orthoties, and surgery may be necessary in recalcitrant cases. In patients with tendon rupture, casting or surgery is required. Appropriate treatment often leads to full recovery.