Working Diagnosis:
Acute calcific tendinopathy of the left hamstring origin.

Treatment:
The patient was treated successfully with ultrasound guided barbotage of calcium deposits and local glucocorticoid injection therapy.

Outcome:
The patient was able to return to baseline activity without weakness or pain after procedure. On three month follow-up, the patient had lasting relief.
Repeat XR of the pelvis on follow-up demonstrated interval resorption of the calcific density previously seen adjacent to the ischial tuberosity. Case Photo #3

Author's Comments:
Discussion
- Calcific tendinopathy is characterized by the deposition of calcium crystals in tendon. Subsequent tendon inflammation around the calcium deposits causes pain.
- Calcific tendinopathy is more commonly described in the rotator cuff and is rarely seen at the hamstring origin as seen in this case report.
- While a clear cause remains unknown, associations include female gender, fourth decade of life, endocrine disorders, & history of kidney stones. Trauma and overuse are not described as risk factors in literature.
- Clinical presentation of calcific tendinopathy is often the atraumatic insidious onset of pain. Plain films and ultrasound help with localization of the lesion for both diagnostic evaluation and treatment.
- First line treatment: is conservative management with NSAIDs and physical therapy. Studies of rotator cuff calcific tendinopathy indicate 50-70% of patients will have symptom resolution at 6 months with conservative management alone. Intractable pain at onset may warrant barbotage and/or glucocorticoid therapy as a first line approach.
- Second line treatment is extracorporeal shockwave therapy or ultrasound guided barbotage if conservative management fails.
- Third line treatment is surgery reserved for refractory cases.

Editor's Comments:
This case has many of the classic features of calcific tendinopathy but it involves a less common anatomic location than is normally described. Estimates of the prevalence of calcific tendinopathy in the general population are varied with some sources quoting an incidence of rotator cuff involvement in 2.7-22% of the population. It is most common in 30-50 year olds with a slightly higher prevalence in women than men (1). However, it has been described in children and adolescents in rare cases. It is more commonly seen in individuals with diabetes and hypothyroidism. It can also be a presenting manifestation of hydroxyapatite crystal deposit disease (HADD) (2). The pathogenesis of the condition is still unclear due to difficulty identifying the initial steps in the onset of this condition. Many theories have been proposed with the most commonly cited being degenerative calcification caused by a cycle of repetitive trauma, vascular ischemia in the tendon and necrosis of tenocytes leading to intracellular calcium deposition. The rotator cuff is the most common anatomic location (supraspinatus 80%, infraspinatus 15% and subscapularis 5% respective incidences) (2). The knee and the hip are the next most common anatomic areas affected (2). In rotator cuff disease, it has been noted to be bilateral in 10% of cases. It is also interesting to note that incidental calcification has been described as occurring in 2.5-20% asymptomatic individuals (2). In general the condition is thought to resolve spontaneously over the course of months. Treatments are essentially the same as with non-calcific tendinopathy: analgesics, physical therapy and injection therapies. Shock wave therapy has also been described as a treatment option for calcific tendinopathy. One additional therapy for this disorder that is unique to this entity, as was described in this case, is needle aspiration of the calcific deposits or barbotage. Although conservative therapy is usually successful, individuals with associated endocrine disorders have a more complicated prognosis that is typified by earlier onset of symptoms, longer natural history and a higher chance of surgical intervention (1).

References:
Oliva F, Via AG, Maffulli N. Physiopathology of intratendinous calcific deposition. BMC Medicine 2012, 10:95
El-Feky M, Bronson R. Calcific Tendonitis [online] Radiopaedia. https://radiopaedia.org/articles/calcific-tendonitis. Accessed September 28, 2020

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