Calcific tendonitis is a disease marked by the deposition of calcium crystals. It is most commonly seen in the rotator cuff, with limited studies in other body parts. The following case report describes a 63-year-old woman with calcific tendonitis of the gluteus medius tendon. She was successfully treated with ultrasound-guided needle lavage and steroid injection after conservative treatment failure.
A 63-year-old woman presented with persistent left hip pain for several months. She had previously been diagnosed as having trochanteric bursitis of the right hip and her pain had been mildly alleviated with a steroid injection into the bursa. She reported left hip pain with activities of daily living, which aggravated to moderate pain with prolonged periods of sitting and, more specifically, with walking and standing. The patient denied any concurrent back pain, radiating symptoms, or previous injury to this hip.
On evaluation of the left hip, she had normal range of motion of flexion, extension, and internal and external rotation compared bilaterally. The patient was tender to palpation over the greater trochanter. She reported increased pain with a hip scouring maneuver and active contraction of the gluteus medius. Anterior, posterior, and lateral projection radiographs (Figure 1) showed mild osteoarthritis of the left hip and a gluteus medius tendon calcific deposition. Differential diagnosis included labrum tear, calcific tendonitis, snapping hip, bursitis, osteoarthritis, and lumbar radiculopathy.
Calcific tendonitis of the left hip (arrow) seen on the anterior posterior view.
The patient completed 2 months of conservative treatments including noninvasive procedures such as manual therapy, core and gluteus stability, proprioception, and nonsteroidal anti-inflammatory drugs. However, her pain and limited range of motion persisted, indicating that the conservative measures had failed.
An intra-articular steroid injection was administered into the hip joint. This injection into the joint was used as a diagnostic tool. If it provided significant pain relief, then the pain was a result of the osteoarthritis in the joint. If it did not provide pain relief, then the pain resulted from the calcific deposition outside the joint. The injection only provided mild pain relief, indicating that her pain was stemming from the calcific tendonitis. She was subsequently referred for an ultrasound-guided needle lavage and steroid injection.
The patient's left hip was evaluated visually with a B-Mode Ultrasound using a GE LOGIQ e (GE Healthcare, Milwaukee, WI) with a C 1–5 RS linear array ultrasound transducer (GE Healthcare) identifying the calcification of 2.21 × 2.06 × 1.75 cm in size in the gluteus medius tendon (Figure 2). After the area was prepared in a sterile manner, it was anesthetized with 1% lidocaine. A 21-gauge needle was used to enter the calcification, repeatedly aspirate, and subsequently lavage it. The area was repeatedly trephinated to stimulate a healing response by breaking down the remaining calcification and increasing blood flow to the area, and a corticosteroid injection of 40 mg triamcinolone acetonide injectable suspension was injected deep into the gluteus medius.
Ultrasound image of calcific tendonitis in the gluteus medius (small arrow). The calcification is located between the superficial and deep field of view (large arrow).
One week after the procedure, the patient reported a significant decrease in pain. At her 6-week follow-up visit, the patient reported being pain free on the left greater trochanter. She denied pain with a hip scouring maneuver and active contraction of the gluteus medius, and had normal range of motion. The patient was pain free and there were no recurrences of the calcific tendonitis 1 year after the lavage per the patient's report.
Calcific tendonitis is a pathological deposition of calcium hydroxyapatite crystals in a periarticular muscle attachment such as a tendon, soft tissue, or ligament near the bone attachment.1,2 Calcific tendonitis of the hip has been reported mainly on the gluteus medius tendon,3–5 its undersurface, the bursa between the gluteus medius, and the rectus femoris2,6 and gluteus maximus.6,7 Calcific tendonitis most commonly affects the rotator cuff muscles, particularly the supraspinatus, but it has also been reported in the hip, knee, foot, wrist, elbow, and neck.3,8 The incidence of calcific tendonitis is reported to be 7% in people between 30 and 60 years of age with shoulder pain.1,9 In those with hip pain, the incidence has been reported to be approximately 5.4%.10 Although the incidence of trochanteric bursitis is only 5.6 per 1,000 patients,11 the incidence of calcific tendonitis in this population is 12% to 40% higher for unknown reasons.4,10 Calcific tendonitis is not always symptomatic and may resolve spontaneously.6 Because of the low incidence of calcific tendonitis in the hip, there is limited research on the treatments for this area and most of the available data focuses on calcific tendonitis of the shoulder.
The exact pathogenesis of calcific tendonitis is unknown,2 but it is usually accompanied by pain, inflammation, tenderness, and limited range of motion.2 There are three phases of calcific tendonitis: pre-calcific, calcific, and post-calcific. The tendon undergoes fibrocartilaginous transformation during the pre-calcific phase. The calcific phase is then subdivided into three additional phases: formative, resorptive, and reparative.1 As the calcification forms, it enlarges and has a chalk-like appearance. Calcific deposits enter a resting period during the formative stage, possibly causing mechanical symptoms and an inflammatory reaction to the deposit. The resorptive phase is the painful stage due to macrophages and multilinear giant cells absorbing the deposit and possibly leaking into the bursal space, thereby increasing the pressure in the area and causing pain. Finally, fibroblasts restore the normal tendon collagen pattern during the reparative phase, and the tendon then moves into the post-calcific stage.1 The current patient most likely experienced pain during the calcific formative phase.
Although there is no gold standard imaging to diagnose calcific tendonitis, plain radiographs are the most practical modality to do so because they are cost-effective and allow for easy visualization of a well-defined homogeneous calcific contour. Computed tomography and magnetic resonance imaging may be helpful in evaluating the lesion and ruling out other conditions. Diagnostic ultrasound provides real-time imaging, which is beneficial for a therapeutic procedure. The deposit will be seen as a hyperechoic focus with or without posterior acoustic shadowing.1,2,5,8
Conservative treatment for calcific tendonitis (eg, nonsteroidal anti-inflammatory drugs, physical therapy, and rest) has been the choice of treatment for calcific tendonitis due to its self-limiting character. A study reported that 27% of patients continued to have shoulder pain after conservative treatment for the shoulder.12 In the case series by Park et al.,8 20 of the 30 hips responded to a 2-week course of nonsteroidal anti-inflammatory drugs, whereas 50% of those had a decrease in crystal deposit size. Although most cases of calcific tendonitis are treated conservatively, some seek more aggressive procedures once conservative treatment has failed. More aggressive procedures include steroid injections, extracorporeal shock wave therapy, acupuncture, and surgery.6 Needle aspiration lavage is another more aggressive treatment that has been recently studied.
A newer and minimally invasive procedure to treat calcific tendonitis, ultrasound-guided needle lavage has become a popular treatment option because it is effective and inexpensive.12,13 A 2-year longitudinal study evaluated the short- and long-term effects on the effectiveness of ultrasound-guided needle lavage for calcific tendonitis of the rotator cuff and concluded that it was a valid alternative as a first choice treatment because it decreased pain and calcification size in most patients.14 A systematic review on diagnostic ultrasound lavages of the rotator cuff concluded the need for more high quality randomized control trials regarding ultrasound-guided needle lavage to determine its true efficacy.12 There were few case reports2,8,13,15 regarding ultrasound-guided needle lavage of the hip, all with good outcomes and patients reporting no symptoms within 6 months. This case study supports previous research for ultrasound-guided needle lavage as a minimally invasive procedure for patients with persistent hip pain stemming from a calcification deposit.
Further randomized controlled trials regarding the efficacy and long-term outcomes of ultrasound-guided needle lavage and steroid injection for calcific tendonitis of the hip should be conducted. These randomized controlled trials should focus on patients who have experienced a failure of conservative treatment and are still symptomatic.
Calcific tendonitis of the gluteus medius is an uncommon pathological process, but should remain in the differential diagnosis of those with lateral hip pain because it is easily identified on radiographs. Ultrasound-guided needle lavage and steroid injections are effective treatments in patients with painful calcific tendonitis of the hip after conservative treatment has failed.
- Siegal DS, Wu JS, Newman JS, Del Cura JL, Hochman MG. Calcific tendinitis: a pictorial review. Can Assoss Rad J. 2009;60:263–272. doi:10.1016/j.carj.2009.06.008 [CrossRef]
- Hong MJ, Kim YD, Park JK, Kang TU. Successful treatment of rectus femoris calcification with ultrasound-guided injection: a case report. Korean J Pain. 2015;28:52–56. doi:10.3344/kjp.2015.28.1.52 [CrossRef]
- Lin W, Liu CY, Tang CL, Hsu CH. Acupuncture and small needle scalpel therapy in the treatment of calcifying tendonitis of the gluteus medius: a case report. Acupunct Med. 2012;30:142–143. doi:10.1136/acupmed-2012-010149 [CrossRef]
- Connell DA, Bass C, Skyes CJ, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003;13:1339–1347.
- Sakai T, Shimaoka Y, Sugimoto M, Koizumi T. Acute calcific tendinitis of the gluteus medius: a case report with serial magnetic resonance imaging findings. J Orthop Sci. 2004;9:404–407. doi:10.1007/s00776-004-0799-y [CrossRef]
- Oh KJ, Yoon JR, Shin DS, Yang JH. Extracorporeal shock wave therapy for calcific tendinitis at unusual sites around the hip. Orthopedics. 2012;33:769.
- Thomason HC 3rd, Bos GD, Renner JB. Calcifying tendinitis of the gluteus maximus. Am J Orthop (Belle Mead NJ). 2011;30:757–758.
- Park SM, Baek JH, Ko YB, Lee HJ, Park KJ, Ha YC. Management of acute calcific tendinitis around the hip joint. Am J Sports Med. 2014;42:2659–2665. doi:10.1177/0363546514545857 [CrossRef]
- Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD. Sports-related muscle injury in the lower extremity. Clin J Sports Med. 2006;25:803–842. doi:10.1016/j.csm.2006.06.011 [CrossRef]
- Yang JH, Oh KJ. Endoscopic treatment of calcific tendinitis of the rectus femoris in a patient with intractable pain. J Orthop Sci. 2013;18:1046–1049. doi:10.1007/s00776-012-0250-8 [CrossRef]
- Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21:447–453. doi:10.1097/JSM.0b013e318221299c [CrossRef]
- Cooper G, Lutz GE, Adler RS. Ultrasound-guided aspiration of symptomatic rotator cuff calcific tendonitis. Am J Phys Med Rehab. 2005:84:81. doi:10.1097/01.PHM.0000150821.55552.2C [CrossRef]
- Vignesh KN, McDowall A, Simunovic N, Bhandari M, Choudur HN. Efficacy of ultrasound-guided percutaneous needle treatment of calcific tendinitis. AJR Am J Roent. 2015:204:148–152. doi:10.2214/AJR.13.11935 [CrossRef]
- Castillo-González FD, Ramos-Álvarez JJ, Rodríguez-Fabián G, Gonzáles-Pérez J, Calderón-Montero J. Treatment of the calcific tendinopathy of the rotator cuff by ultrasound-guided percutaneous needle lavage: two years prospective study. Muscles Ligaments Tendons J. 2014;4:220–225.
- Pierannunzii L, Tramontana T, Gallazzi M. Case report: calcific tendinitis of the rectus femoris: a rare cause of snapping hip. Clin Orthop Relat Res. 2010:468:2814–2818.. doi:10.1007/s11999-009-1208-9 [CrossRef]