Calcific tendinopathy of the rotator cuff is a common cause of shoulder pain. Inflammation of the rotator cuff tendons may be complicated by adjacent bone erosion and subsequent migration of calcific deposits within the bone resulting in marrow inflammation. Bone marrow involvement is not readily visible using X-ray and ultrasound (US) and further testing is necessary. Magnetic resonance imaging (MRI) is a highly sensitive technique that can detect a focal bone T1 and T2-weighted hypointensity with bone marrow edema-like signal and cortical erosion. These findings can mislead the radiologist by suggesting an infectious or neoplastic lesion, often requiring further evaluation with computed tomography (CT) and biopsy. We report two cases of patients with shoulder pain in which different radiological approaches were used with pathological confirmation in one of them. In the first case, MRI revealed significant bone involvement in the head of the humerus and cortical erosion of the greater tuberosity. A CT examination and a biopsy was necessary for a final diagnosis of inflammatory bone reaction from intraosseous migration of tendinous calcifications. In the second case, similar MRI findings prompted re-evaluation of imaging to make a diagnosis of intraosseous migration of tendinous calcifications, obviating the need to perform CT and biopsy. We illustrate MRI signs of this complication that we think would allow to narrow the differential diagnosis potentially avoiding biopsy and additional CT examinations.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Flemming DJ, Murphey MD, Shekitka KM, Temple HT, Jelinek JJ, Kransdorf MJ. Osseous involvement in calcific tendinitis: a retrospective review of 50 cases. AJR. 2003;181:965–72.
Suzuki K, Potts A, Anakwenze O, Singh A. Calcific tendinitis of rotator cuff: management options. J Am Acad Orthop Surg. 2014;22:707–17.
Merolla G, Singh S, Bhat MG, Porcellini G. Complications of calcific tendinitis of the shoulder: a concise review. J Orthop Traumatol. 2015;16:175–83.
Pereira Bruno PG, Chang EY, Resnick DL, Pathria MN. Intramuscular migration of calcium hydroxyapatite crystal deposits involving the rotator cuff tendons of the shoulder: report of 11 patients. Skelet Radiol. 2016;45:97–103.
Sola WC Jr, Drake GN, Ramos CH, Gomes A, Gartsman GM. Calcific tendinitis of the rotator cuff associated with intraosseous loculation: two case reports. J Shoulder Elb Surg. 2009;18:e6–8.
Porcellini G, Paladini P, Campi F, Pegreffi F. Osteolytic lesion of greater tuberosity in calcific tendinitis of the shoulder. J Shoulder Elb Surg. 2009;18:210–5.
Malghem J, Omoumi P, Lecouvet F, Vande BB. Intraosseous migration of tendinous calcifications: cortical erosions, subcortical migration and extensive intramedullary diffusion: a SIMS series. Skelet Radiol. 2015;44:1403–12.
Merolla G, Singh S, Paladini P, Porcellini G. Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment. J Orthop Traumatol. 2016;17:7–14.
ElShewy MT. Calcific tendinitis of the rotator cuff. World J Orthop. 2016;7(1):55–60.
Messina C, Sconfienza LM. Ultrasound-guided percutaneous irrigation of calcific tendinopathy. Semin Musculoskelet Radiol. 2016;20(5):409–13.
Seyahi A, Demirhan M. Arthroscopic removal of intraosseous and intratendinous deposits in calcifying tendinitis of the rotator cuff. Arthroscopy. 2009;25:2176–83.
Klontzas ME, Vassalou EE, Karantanas AH. Calcific Tendinopathy of the shoulder with intraosseous extension: outcomes of ultrasound-guided percutaneous irrigation. Skelet Radiol. 2017;46:201–2018.
Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12122 shoulders. JAMA. 1941;116:2477–82.
Bosworth BM. Examination of the shoulder for calcium deposits: technique of fluoroscopy and spot film roentenography. J Bone Joint Surg. 1941;23:567–77.
Welfling J, Kahn MF, Desroy M, Paolaggi JB, de Sèze S. Calcifications of the shoulder; the disease of multiple tendinous calcifications. Rev Rhum Mal Osteoartic. 1965;32(6):325–34.
DePalma AF, Kruper JS. Long term study of shoulder joints afflicted and treated for calcific tendinitis. Clin Orthop. 1961;20:61–72.
Codman EA. The shoulder. Boston: Thomas Todd; 1934.
Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg. 1997;5:183–91.
Hackett L, Millar NL, Lam P, Murrell GAC. Are the symptoms of Calcific tendinitis due to neoinnervation and/or neovascularization? J Bone Joint Surg Am. 2016;98:186–92.
Gärtner J, Heyer A. Calcific tendinitis of the shoulder. Orthopade. 1995;24(3):284–302.
Molé D, Kempf JF, Gleyze P, Rio B, Bonnomet F, Walch G. Results of endoscopic treatment of non-broken tendinopathies of the rotator cuff, 2: calcifications of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot. 1993;79:532–41.
Farin PU. Consistency of rotator cuff calcifications: observations on plain radiography, sonography, computed tomography, and at needle treatment. Investig Radiol. 1996;31:300–4.
Newberg AH. Soft tissue calcification and ossification. Imaging Arthritis Metab Bone Dis. 2009;39:681–96.
The authors acknowledge Dr. N. Agarwal, Radiology Department of S. Maria Hospital, Rovereto, for collaboration in text translation, Dr. G. Gordan and Dr. E. Bragantini, Pathological Anatomy Department, S. Chiara Hospital, Trento for the images in Fig. 2.
Conflict of interest
The Authors declare that they have no conflict of interest.
About this article
Cite this article
Marinetti, A., Sessa, M., Falzone, A. et al. Intraosseous migration of tendinous calcifications: two case reports. Skeletal Radiol 47, 131–136 (2018). https://doi.org/10.1007/s00256-017-2769-4
- Calcific tendinopathy of rotator cuff
- Intraosseous migration