Rheumatology 2001; 40: 1316-1317
© 2001 British Society for Rheumatology
Letters to the Editor |
Calcific tendinitis mimicking acute sternoclavicular joint arthritis
Rheumatology Section, Hamad General Hospital, Doha, PO Box 3050, Qatar
SIR, Acute calcific tendinitis is a common disorder. It can affect almost any tendon and its insertion, and is most common around the shoulder [1]. Clinically, the patient presents with symptoms of pain, swelling, erythema and limitation of motion around the involved joint, mimicking acute monoarthritis [2]. Other than the shoulder, sites that may be involved include the hip, spine, elbow, wrists, knees, ankles and feet [2, 3]. We report a patient with acute calcific tendinitis of the sternal head of the sternocleidomastoid muscle mimicking acute arthritis of the sternoclavicular joint. This has not been reported before.
A previously healthy 69-yr-old male patient presented with pain, swelling and erythema of the inner upper right side of the chest of 3 days' duration. The pain started suddenly in the area of the right sternoclavicular joint, and was associated with redness and swelling of the area. He gave no history of fever, chills, trauma, recent drug ingestion or any similar attacks. Over the next 3 days the swelling and pain got worse, so that he could not sleep the night before he presented, and the erythema extended downwards.
Physical examination revealed an afebrile patient with swelling and erythema over the right sternoclavicular joint extending laterally to the midclavicular line and down to the manubriosternal junction. The sternoclavicular joint was exquisitely tender. Joint aspiration was attempted but no fluid was obtained. Laboratory investigation revealed a leucocyte count of 10 400/µl (70% neutrophils and 25% lymphocytes), a haemoglobin concentration of 15 g/dl and an erythrocyte sedimentation rate (ESR) of 10 mm/h. Concentrations of calcium, phosphorus and alkaline phosphatase, glucose, uric acid, serum urea nitrogen and creatinine were all normal. X-ray of the right sternoclavicular joint showed no obvious abnormalities in the bone. An initial diagnosis of septic arthritis was made and the patient was treated with intravenous cloxacillin. Computed tomography (CT) scanning was done the next day, and revealed soft-tissue swelling and calcification anterior to the right sternoclavicular joint (Fig. 1
).
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A diagnosis of calcific tendinitis of the sternal head of the sternocleidomastoid muscle was made. The antibiotic was discontinued and was replaced by tenoxicam intramuscularly at 20 mg daily. Within 48 h the swelling and redness had subsided considerably, with almost complete pain resolution on the third day. He was discharged on the fourth day on oral tenoxicam, with instructions to continue it for another week. A week after discharge, physical examination revealed minimal swelling of the area without redness or tenderness.
The presentation of acute calcific tendinitis is generally quite dramatic, the condition being characterized by rapid onset of severe pain accompanied by a restricted range of motion [3]. Local oedema and erythema may occur and, because of the inflammatory nature of the condition, the affected area is usually very tender.
The most common site for calcific tendinitis is the shoulder area. Certain unusual sites of calcific tendinitis are overlooked and underdiagnosed, such as the hand [2], wrist [4, 5] and neck [6]. In many of these cases an initial diagnosis of infection is usually entertained because of similarity in presentation, the fact that some of these cases may be associated with fever [2] and the unfamiliarity of the treating physician with this condition. One important aspect of the differentiation of acute calcific tendinitis from a septic process is that in the former the leucocyte count is normal and the ESR is usually normal [2].
Unusual locations of acute calcific tendinitis that have been reported include the peroneus longus muscle [7], the vastus lateralis muscle [8] and the insertion of the pectoralis major [9].
To our knowledge, this is the first reported case of acute calcific tendinitis involving the sternal head of the sternocleidomastoid muscle. In our patient the presentation was acute, with acute pain, oedema and erythema that extended beyond the anatomical limits of the tendon. This can be explained by the spillage of hydroxyapatite crystals (the crystals commonly associated with calcific tendinitis) into the surrounding soft tissue space [2], causing inflammation in the area with erythema and redness. The response to a non-steroidal anti-inflammatory drug (NSAID) was dramatic, with resolution of clinical findings within a week.
The diagnosis of calcific tendinitis is usually confirmed by radiographic evidence of calcification of the involved tendon [5]. CT scanning may play a role in the diagnosis of unusual cases [10]. In our patient, the simple X-ray did not show the calcification clearly because of the overlapping shadows of the lung and the ribs. Although it is not necessary for the diagnosis, magnetic resonance imaging usually shows the calcification and demonstrates the inflammation and oedema of the surrounding tissues [2].
The prognosis in acute calcific tendinitis is very good, with resolution of symptoms in 3 weeks in untreated patients and within 1 week in patients treated with NSAIDs [5].
This case demonstrates that increased awareness of the presentation of acute calcific tendinitis can lead to earlier diagnosis, avoidance of unnecessary intervention and rapid resolution of symptoms with proper therapy.
References
- Faure G, Daculsi G. Calcific tendinitis: a review. Ann Rheum Dis1983;42(Suppl.):49–53.
- Selby CL. Acute calcific tendinitis of the hand: an infrequently recognized and frequently misdiagnosed form of perarthritis. Arthritis Rheum1984;27:337–40.[Medline]
- Chow HY, Rech MP, Schills J, Calabrese LH. Acute calcific tendinitis of the hip. Case report with magnetic resonance imaging findings. Arthritis Rheum1997;40:974–7.[Medline]
- Dilly DF, Tonkin MA. Acute calcific tendinitis in the hand and wrist. J Hand Surg Br1991;16:215–6.[Medline]
- Wells NJ, Carr NJ. Is acute calcific tendinitis in the wrist unrecognized and under-reported? Can J Plast Surg1995;3:142–4.
- Sarkozi J, Fam AG. Acute calcific retropharyngeal tendinitis: an unusual cause of neck pain. Arthritis Rheum1984;27:708–10.[Medline]
- Cox D, Paterson FW. Acute calcific tendinitis of the peroneus longus. J Bone Joint Surg Br1991;73:342.[Medline]
- Ramon FA, Degryse HR, De Schopper AM, Van March EA. Calcific tendinitis of the vastus lateralis muscle. A report of three cases. Skeletal Radiol1991;20:21–3.[Medline]
- Ikeyawa S. Calcific tendinitis of the pectoralis major insertion: a report of two cases. Arch Orthop Trauma Surg1996;115:118–9.
- Archer BD, Friedman L, Stilgenbaur S, Bressler H. Symptomatic calcific tendinitis at unusual sites. Can Assoc Radiol J1992;43:203–7.[Medline]
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