Abstract

Introduction: Acute calcific tendonitis at the pectoralis major insertion is rarely reported in the radiology literature, but not in the Orthopaedic literature. We present a case that illustrates the typical findings with discussion from a shoulder surgeon, and a senior radiologist.

Case Study: A 60-year-old woman was woken at night with sudden onset left shoulder and arm pain. She was otherwise systemically well. Her shoulder range of motion was globally restricted. Past medical history included previous spinal surgery and a hepatitis A infection within the last year.

Plain radiographs of the shoulder and humerus were unremarkable save for a small an anterior proximal humeral protuberance at the junction of proximal third and distal two-thirds of the humeral shaft. Blood tests were unremarkable. CT and MRI imaging showed a calcific tendon with associated cortical defect, and surrounding inflammation.

Because of the sinister red flag symptoms (night pain) and suggestion of cortical erosion with periosteal reaction, the differential diagnosis list included sarcoma. For this reason, it was referred to the local sarcoma service. This was reviewed by a senior radiologist. The diagnosis of calcific tendonitis of pectoralis major calcific tendonitis was made. The decision was made by the Sarcoma MDT to not biopsy the lesion but instead review clinically with interval scan and safety netting.

On six week clinic follow up the patient’s symptoms had improved. Because of the knowledge regarding this potential diagnosis, unnecessary invasive diagnostic procedures (CT biopsy) or surgeries were avoided. Repeat MRI at three month showed resolution of changes.

Conclusion: Both Orthopaedic surgeons within sarcoma services and wider members of the multidisciplinary team should be aware of this diagnosis. This would help to prevent over investigation of benign self-limiting pathologies.

Keywords: Calcific tendonitis; Osteosarcoma; Sarcoma; Pectoralis major