Working Diagnosis:
Calcific Subcoracoid Bursitis/ Hydroxyapatite deposition disease (HADD)

Treatment:
Calcific barbotage procedure with subcoracoid bursa corticosteroid injection was performed Case Photo #5 . Approximately 2cc of calcium was aspirated Case Photo #6 .

Outcome:
The procedure completely resolved the patient's pain and improved her range of motion. She was able to return to work shortly after the procedure. At one week follow up, she had returned to exercising without shoulder pain.

Author's Comments:
Hydroxyapatite deposition disease (HADD), or calcific subcoracoid bursitis is characterized by periarticular and intra-articular deposition of calcium hydroxyapatite crystals. The etiology remains uncertain, but it is believed to accumulate in damaged tissue secondary to trauma via fibrocartilaginous metaplasia. This often occurs in tendons, with the supraspinatus being the most common site. Bursal involvement is rare.

The stages of this condition include:
Precalcific: no pain.
Formative and Resting stages: pain is absent or mild. Calcification is round to ovoid and well defined on imaging.
Resorptive: acute pain and functionally limiting. Calcification is ill-defined with comet tail-like appearance on radiographs.

Ultrasound appearance varies by stage as well. If hardened, it will reveal a hyperechoic rim with a strong posterior acoustic shadowing. If the calcium accumulation is still in a softer stage, it will appear homogenous and hyperechoic. Fluid appears as a hyperechoic rim with anechoic or hypoechoic core. MRI will display a hypointense signal in the accumulation with hyperintense signal surrounding if fluid has collected.

Treatment of HADD includes rest, ice, anti-inflammatories, corticosteroid injection, or calcific barbotage which ultimately helped our patient improve.

Editor's Comments:
HADD, as above, is due to calcium hydroxyapatite deposition into and around joints of the body and can be an asymptomatic, incidental finding on imaging. It has a higher prevalence in middle aged women, and the shoulder, particularly the rotator cuff tendons, is the most commonly affected region.

During the precalcific phase, fibrocartilaginous transformation occurs, which sets up the calcium deposition process in the formative phase. There are usually no symptoms during the resting phase, but the inflammatory reaction that occurs during the resorptive phase can lead to acute pain and limited functional range of motion of the affected joint. Scar tissue then replaces the calcified area in the postcalcific phase. Imaging may reveal an area of well-defined (formative phase) or ill-defined (resorptive phase) calcification within the rotator cuff tendinous insertions around the shoulder joint with or without associated bursal inflammation.

Extracorporeal shockwave therapy (ESWT) is one treatment modality used for calcific tendinitis. Ultrasound-guided barbotage is another effective treatment and includes needling to break down the calcified deposit into smaller pieces, as well as a lavage procedure to withdraw the broken down fragments. It can be paired with a corticosteroid injection into the affected bursa to allow further pain relief. Studies have revealed a high success rate with ultrasound-guided barbotage in regards to functional improvement and lack of a need for further interventions, but there exist no head-to-head comparisons between the ESWT and barbotage procedures.

References:
Garcia GM, McCord GC, Kumar R. Hydroxyapatite crystal deposition disease. Semin Musculoskelet Radiol. 2003;7(3):187-193.

Gatt DL, Charalambous CP. Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients. Arthroscopy. 2014;30(9):1166-1172.

Hongsmatip P, Cheng KY, Kim C, Lawrence DA, Rivera R, Smitaman E. Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies. Eur J Radiol. 2019;120:108653.

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