Intraosseous migration of tendinous calcifications: cortical erosions, subcortical migration and extensive intramedullary diffusion, a SIMS series

Abstract

Calcium hydroxyapatite crystal deposition is a common disorder, which sometimes causes acute pain as calcifications dissolve and migrate into adjacent soft tissue. Intraosseous calcium penetration has also been described. We illustrate the appearance of these lesions using a series of 35 cases compiled by members of the French Society of Musculoskeletal Imaging (Société d'Imagerie Musculo-Squelettique, SIMS). The first group in our series (7 cases) involved calcification-related cortical erosions of the humeral and femoral diaphyses, in particular at the pectoralis major and gluteus maximus insertions. A second group (28 cases) involved the presence of calcium material in subcortical areas. The most common site was the greater tubercle of the humerus, accompanying a calcifying tendinopathy of the supraspinatus. In addition, an extensive intramedullary diffusion of calcium deposits was observed in four of these cases, associated with cortical erosion in one case and subcortical lesions in three cases. Cortical erosions and intraosseous migration of calcifications associated with calcific tendinitis may be confused with neoplasm or infection. It is important to recognize atypical presentations of hydroxyapatite deposition to avoid unnecessary investigation or surgery.

Ultrasound Appearance of the Migration of Tendon Calcifications

“…Although US has intrinsic limits for the evaluation of bone, it can assess surface erosions and lytic areas of the outer cortex as focal discontinuities confirmed in two orthogonal planes . Depiction of continuity between the tendinous calcification and the intraosseous component is mandatory to establish the diagnosis (Figure ) . Doppler imaging may show pericalcific hyperemia (Figure ) and also the level of erosion in the acute phase (Figure ).…”

“…Magnetic resonance imaging can easily show an intramedullary edema as a poorly defined area of a signal anomaly, hypointense in T1‐weighted and hyperintense in fat‐suppressed T2‐weighted or short‐tau inversion recovery sequences. The edema correlates with the pain severity . Intratendinous and intraosseous migration is rare (Figure ).…”

“…Computed tomography (CT) is superior in comparison to ultrasound (US) in showing deep‐tendon calcifications; it is also superior to radiographs in cases of superposition of adjacent bones to spatially localize the calcification . Magnetic resonance imaging (MRI) has well‐known limitations in assessing intratendinous calcifications; nevertheless, it is the only technique to assess bone edema in intraosseous calcium migration . Ultrasound has been shown to be an excellent imaging modality for the evaluation of CTe: it can show calcifications inside most of the appendicular tendons and accurately follow the different stages of CTe .…”

Intramuscular migration of calcific tendinopathy in the rotator cuff: ultrasound appearance and a review of the literature

“…In the shoulder, usually the calcification moves to the sub-bursal space or inside the subacromion-subdeltoid bursa, a condition that can be very painful, with an acute onset. Rarely, calcification may migrate to the bones, typically the humeral head, causing erosion [1,7,8].…”

“…These could be helpful in case of osseous involvement. CT is the best modality to evaluate erosion and demonstrate calcification and its consistency [1,2,7,8].…”