Calcifications within tendon substance

[Linh]

Hi Steve,

When you see calcifications within the, for example, mid Achilles tendon substance, do you call it calcific tendinosis or dystrophic calcification- ossification? Does it make a difference if there is pain located there?

Same with supraspinatus, with acute excruciating pain with soft calcification, I will not hesitate to call it calcific tendinosis. But when there is hard calcification with no pain, is that calc degenerative in nature, especially in elderly patients?

Best regards,
Linh

[Stephen Bird]

Hi Linh,

Great discussion point,

I only use the words “calcific tendinosis” when it is painful and it is hydroxyapatite deposition we are looking at.

Hydroxyapatite is a bone salt so by definition must enter the tendon via the enthesis and hence is located adjacent to the enthesis.

Dystrophic calcification is different. It represents areas of tenocyte exhaustion from overload injury in the past where calcification has been laid down as part of the recovery. It is usually not immediately adjacent to the enthesis and often looks “stranded” in the mid tendon. It is not acutely painful like hydroxyapatite and is chronic in nature so you may see it has not changed if you have old images on the PACS system.
Dystrophic calcification will usually also be more dense on a plain radiograph compared to hydroxyapatite and it is also good to know that monosodium rate (gout crystals) are less dense again.

Hydroxyapatite is more dynamic in nature due to a process of active deposition (migration) and resorption where as dystrophic calcification is more stable in nature over time.

Hydroxyapatite is also less attentive to the ultrasound beam than dystrophic calcification so you can often ” see through ” calcific tendinosis.

There are certainly cases where I ponder if I should use the term calcific tendinosis (hydroxyapatite) or the words dystrophic calcification, but if you use the methodology I have described I feel like I get it right most of the time.

You need to take into account the location, patient presentation symptoms, radiographic appearance, through transmission and chronology.

Steve

[Linh]

Nice explanations, I will put these tips into practice. Thank you Steve.

[Stephen Bird]

I think I will make a webinar lesson on echogenic things inside tendons !

Steve

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