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Imaging Quiz: Elbow Pain in a Cyclist

Marvin Moe Bell, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 5 - MAY 97


Diagnosis

Return to case presentation.

[FIGURE 2] The radiographs of the patient's left elbow (figure 2) showed a rounded, fluffy calcification at the biceps insertion to the radius. The patient declined nonsteroidal anti-inflammatory medication, but agreed to use heat and avoid bicycling temporarily. Over the following 6 weeks, pain resolved, and range of motion gradually improved.

On reexamination at 6 weeks, the elbow was nontender, and pronation was possible to 90°. Repeat x-ray showed nearly complete resolution of the calcification. During the visit, the patient noted that his mountain bike seat was roughly 6 inches above his handlebars. He tended to ride with his left elbow fully extended and in pronation to reach the handlebar. He often used his right arm to change gears and to handle his water bottles. The patient was instructed to raise the handlebar a couple of inches and to change arm positions more frequently while riding. There was no recurrence of pain at a 3-month follow-up.

Discussion

Calcific tendinitis is a painful condition associated with the deposition of calcium hydroxyapatite crystals in tendons. The condition affects both sexes and is most common between the ages of 40 and 70 (1). The cause remains unknown, but a popular theory suggests calcium deposition into inflamed or ischemic areas. On the basis of histologic studies, Urthoff et al (2) challenged this theory and postulated that tendinous tissue evolves into fibrocartilage, which then calcifies by an active, cell-mediated process.

Calcifications are seen in up to 3% of all adults (3), and the shoulder is the most common site. More than half of these cases involve the insertion of the supraspinatus tendon (1). Calcific tendinitis is less common at other sites but has been found near almost every joint, including the hips, knees, wrists, elbows, hands, and feet (1,3,4). On x-ray, calcifications may appear granular, hazy, or plaque-like and may not be visible if superimposed over bone.

A literature search revealed only a single case report describing calcific tendinitis of the biceps insertion at the radius (5). That case differed from the present instance in that supination rather than pronation was limited. In addition, symptoms failed to resolve after a course of anti-inflammatory medication and 4 months of observation. The patient's symptoms disappeared following surgical excision of the calcified portion of the tendon.

Faure and Daculsi (6), in their review of calcific tendinitis, state that both symptoms and deposits often spontaneously disappear; they suggest, therefore, that physicians and patients "should generally abstain from interfering." The favorable outcome in the present case certainly supports such conservative initial therapy; rest, heat, and modification of biking posture helped resolve the calcific tendinitis of the patient described here. When a patient's condition occurs with a new activity or with overuse, modification of the activity is an important part of treatment.

References

  1. Resnick D, Niwayama G: Diagnosis of Bone and Joint Disorders. Philadelphia, WB Saunders, 120211, pp 1575-1597
  2. Urthoff HK, Sakar K, Maynard JA: Calcifying tendinitis: a new concept of its pathogenesis. Clin Ortho 1976;118(Jul-Aug):164-168
  3. Holt PD, Keats TE: Calcific tendinitis: review and unusual manifestations. Contemp Diag Radiol 1996;19(15):1-5
  4. Eisenberg RL: Clinical Imaging: An Atlas of Differential Diagnosis, ed 2. Gaithersburg, MD, Aspen Publishers, 1992, p 686
  5. Murase T, Tsuyuguchi Y, Hidaka N, et al: Calcific tendinitis at the biceps insertion causing rotatory limitation of the forearm: a case report. J Hand Surg 1994;19(2):266-268
  6. Faure G, Daculsi G: Calcified tendinitis: a review. Ann Rheum Dis 120213;42(suppl):49-53

Dr Bell is an associate director of the Scottsdale Memorial Family Practice Residency in Scottsdale, Arizona. Address correspondence to Marvin Moe Bell, MD, 7301 E Second St, Suite 210, Scottsdale, AZ 85251.


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