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Case report
Subscapularis myositis: An uncommon complication in calcific tendinopathy. A case study
Miositis del subescapular. Una evolución infrecuente en la tendinopatía calcificada. Estudio de un caso
Javier José Mateos Rodrígueza,
Corresponding author
jjmateosr@gmail.com

Corresponding author.
, Javier Fernández Jarab, David Castro Corredora, Begoña Gutiérrez San Joséb
a Rheumatology Service, General University Hospital of Ciudad Real, Ciudad Real, Spain
b Radiodiagnosis Service, Jiménez Díaz Foundation University Hospital, Madrid, Spain
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with functional limitation and a diagnosis of subscapular calcific tendinopathy by ultrasound &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; It started with a high intensity pain in the right shoulder&#44; with limited mobility&#46; On physical examination she presented pain that can be localized with the fingertip in the right greater tuberosity&#44; impossibility of abduction and of anterior and posterior antepulsion&#44; with positive Jobe and Neer provocation maneuvers&#46; Given the history of calcific tendinopathy&#44; calcium resorption was suspected&#44; an ultrasound scan was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and C&#41; and a magnetic resonance imaging &#40;MRI&#41; was requested&#46; Severe myositis in the subscapular muscle was observed in the MRI&#44; with images of migrated calcifications inside &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#44; in the context of the subscapular calcific tendinopathy&#46; The study was completed with a computed tomography &#40;CT&#41; for confirmation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C and D&#41;&#46; The patient received analgesic and anti-inflammatory treatment&#44; and an ultrasound-guided infiltration with betamethasone was performed&#46; After 6 months&#44; with the patient asymptomatic&#44; a control MRI was performed&#44; which was normal &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>E and F&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Intratendinous deposition of hydroxyapatite crystals is a disease widely described in the literature&#46; Louwerens et al&#46; report a prevalence of 7&#46;8&#37; in asymptomatic patients and of 42&#46;8&#37; in patients with clinical symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Uhthoff and Loehr there are 4 different phases&#58; precalcification&#44; formation&#44; resting and resorption&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the resorption phase&#44; the deposited calcium can migrate towards the subacromial bursa or to the bone surface of the humerus&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> being exceptional the migration towards the myotendinous junction&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinically&#44; it is usually a patient with long-standing chronic omalgia who presents an atraumatic hyperalgic syndrome with great functional limitation of two weeks of evolution&#44; with subsequent progressive improvement in most cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Focusing on the migration to the myotendinous junction&#44; there is hardly any literature on this complication&#46; In total we have found 21 cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#8211;8</span></a> being a series of 11 patients obtained after a 7-year follow-up in different centers&#44; published by Pereira et al&#46; in 2016&#44; the most extensive&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A distinctive characteristic of our patient is the affected muscle&#46; Of the cases that we know&#44; only in 2 of them the affected muscle is the subscapularis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding the diagnosis&#44; a history of calcific tendinopathy and a plain X-ray can guide us&#46; However&#44; to evaluate the migration towards the myotendinous junction we need more specific tests such as ultrasound&#44; computed tomography or MRI&#44; which allow us to visualize a more exact location of the deposits&#46; Becciolini et al&#46; comment on the usefulness of ultrasound for the localization of the deposits&#44; especially taking into account the cost-benefit&#44; in addition to the help of Power-Doppler to identify the secondary myositis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Pereira et al&#46; refer that MRI is the most suitable method for the evaluation of muscle involvement&#44; with which we can objectify the muscle edema secondary to the inflammatory response&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Its low frequency can make us confuse it with other entities&#44; so we must take it into account within the differential diagnosis with tumors&#44; infections&#44; and denervations&#44; among others&#46; Mileto et al&#46;&#44; present a differential diagnosis with the Parsonage-Turner syndrome&#44; in which the negative electromyography study and the absence of edema on the MRI at the level of other muscles innervated by the brachial plexus&#44; ruled out such diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Finally&#44; of the 21 cases that we have collected in the bibliographic references&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#8211;8</span></a> 14 had a subsequent follow-up&#44; of these&#44; 8 were successfully non-surgically treated and 6 underwent surgery due to poor clinical evolution&#46; In 2 of the patients with nonsurgical treatment&#44; ultrasound-guided puncture and calcium lavage were successfully performed&#44; so we could consider it a good alternative to arthroscopy in patients with poor evolution&#44; due to the lower risk it entails and the less associated damage in the rest of the structures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Intramuscular migration of hydroxyapatite is a very infrequent entity&#44; probably related to its underdiagnosis&#46; Future studies and research are necessary to determine the imaging test of choice&#44; especially in terms of the corresponding cost-benefit&#44; although according to the articles published so far&#44; ultrasound and MRI could currently be the most accurate&#46; Finally&#44; regarding the treatment&#44; we suggest that ultrasound-guided puncture can be very useful&#44; especially in those patients with a torpid evolution&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Calcific tendinopathy of the shoulder is characterised by the deposit of hydroxyapatite crystals in one or more tendons of the shoulder&#46; Within the processes that occur in this disorder&#44; there is the resorption phase&#44; in which the deposits could migrate towards adjacent structures&#46; A very rare complication is the migration towards the myotendinous junction of the corresponding tendon&#44; which causes a significant muscular inflammatory reaction that can be seen in specific complementary tests&#46; A clinical case is presented of a subscapular calcific tendinopathy&#44; with subsequent migration to the myotendinous junction&#44; causing myositis of the same&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tendinopat&#237;a calcificada del hombro se caracteriza por el dep&#243;sito de cristales de hidroxiapatita en uno o varios tendones del hombro&#46; Dentro de los procesos que ocurren en esta entidad est&#225; la fase de reabsorci&#243;n&#44; en la que los dep&#243;sitos podr&#237;an migrar hacia estructuras adyacentes&#46; Una muy rara complicaci&#243;n es la migraci&#243;n hacia la uni&#243;n miotendinosa del tend&#243;n correspondiente&#44; la cual provoca una importante reacci&#243;n inflamatoria muscular que puede objetivarse en pruebas complementarias espec&#237;ficas&#46; Presentamos un caso cl&#237;nico de una tendinopat&#237;a calcificante del subescapular&#44; con posterior migraci&#243;n hacia la uni&#243;n miotendinosa causando una miositis del mismo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mateos Rodr&#237;guez JJ&#44; Fern&#225;ndez Jara J&#44; Castro Corredor D&#44; Guti&#233;rrez San Jos&#233; B&#46; Miositis del subescapular&#46; Una evoluci&#243;n infrecuente en la tendinopat&#237;a calcificada&#46; Estudio de un caso&#46; Rev Colomb Reumatol&#46; 2021&#59;28&#58;218&#8211;220&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Ultrasound scan taken 2 years ago&#46; Arrow&#58; calcification in the subscapularis near the insertion of the tendon&#59; &#40;B&#41; Ultrasound taken in the acute moment&#46; Arrow&#58; the same location as in A&#44; with some residual millimetric calcifications&#59; &#40;C&#41; ultrasound in the acute moment&#46; Asterisk&#58; intramuscular coarse calcification&#44; calcium in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> images A&#8211;D&#46;</p>"
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                            0 => "B&#46;P&#46;G&#46; Pereira"
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                          "etal" => false
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                            0 => "J&#46;K&#46; Louwerens"
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                            2 => "R&#46;P&#46; van Hove"
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                          "etal" => false
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                      "titulo" => "Intramuscular calci&#64257;cation of the subscapularis muscle&#58; a case report"
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Article information
ISSN: 24444405
Original language: English
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2024 January 49 24 73
2023 December 58 22 80
2023 November 45 27 72
2023 October 67 51 118
2023 September 41 39 80
2023 August 32 24 56
2023 July 50 20 70
2023 June 59 35 94
2023 May 62 34 96
2023 April 50 31 81
2023 March 59 10 69
2023 February 34 5 39
2023 January 64 7 71
2022 December 37 5 42
2022 November 20 10 30
2022 October 26 7 33
2022 September 26 13 39
2022 August 30 13 43
2022 July 16 7 23
2022 June 29 4 33
2022 May 52 5 57
2022 April 13 5 18
2022 March 1 2 3
2021 August 0 4 4
2021 July 0 5 5
2021 June 0 3 3
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