How is calcification in the subacromial bursa identified and treated?

Identification and Treatment of Calcification in the Subacromial Bursa

Subacromial bursa calcifications are best identified using ultrasound or MRI, with ultrasound being the preferred initial imaging modality due to its high sensitivity for detecting calcifications and ability to guide therapeutic interventions. 1

Diagnostic Approach

Initial Imaging

• Plain Radiography:
  • First-line imaging modality that may show calcifications in the subacromial region 2
  • Limited ability to differentiate soft tissue calcifications and determine exact location 2
  • May show sclerosis, spur formation of acromion, or calcific tendinosis 2

Advanced Imaging

• Ultrasound:

  • Preferred for evaluating subacromial bursa calcifications 1
  • Advantages:
    • Non-invasive and cost-effective 1
    • Can distinguish calcifications from other pathologies 1
    • Allows real-time visualization for guided interventions 3
    • Can detect fragmentation of calcifications (associated with symptomatic cases) 3
    • Can identify power Doppler signal (strongly associated with pain) 3
    • Can visualize widening of the subacromial-subdeltoid bursa 3

• MRI:

  • Highly sensitive (95%) and specific (95%) for rotator cuff pathology 2
  • Superior for evaluating soft tissue structures and surrounding anatomy 1
  • Can detect associated tendon degeneration and partial tears 2
  • Useful when ultrasound findings are inconclusive 1

Diagnostic Features

Key Findings on Imaging

1. Calcification Characteristics:

   • Size: Larger calcifications are more likely to be symptomatic 3
   • Morphology: Fragmented calcifications correlate with pain 3
   • Location: Precise location within the bursa vs. adjacent tendons 4

2. Associated Findings:

   • Power Doppler signal: Present in symptomatic cases, absent in asymptomatic ones 3
   • Subacromial-subdeltoid bursa widening: Associated with pain 3
   • Migration of calcium deposits from tendons into the bursa (rare complication) 4

Treatment Options

Conservative Management

1. Relative Rest:

   • Reduce activities that aggravate symptoms 2
   • Avoid complete immobilization to prevent muscle atrophy 2

2. Physical Therapy:

   • Eccentric exercises and stretching 2
   • Tensile loading to stimulate collagen production 2

3. Non-invasive Modalities:

   • Intensive pulsed ultrasound therapy has shown effectiveness in calcific bursitis 5
   • Iontophoresis may be beneficial as part of a comprehensive approach 5

Interventional Procedures

1. Ultrasound-Guided Percutaneous Lavage (UGPL):

   • Effective for calcific tendinitis with bursal involvement 6
   • Success factors:
     • Creating communication between calcification and subacromial bursa 6
     • Calcium extraction during the procedure 6

2. Corticosteroid Injections:

   • Intrabursal steroid injection after UGPL improves outcomes at 3 months 6
   • More effective than rilonacept (IL-1 inhibitor) for subacromial bursitis 7
   • Presence of bursal widening before injection correlates with better outcomes 3

Monitoring and Follow-up

• Assessment at 3 months post-treatment is essential for management strategy 6
• Clinical improvement correlates with radiological disappearance of calcifications 6
• Follow-up imaging (ultrasound) to monitor calcification resorption 3

Clinical Pearls and Pitfalls

• Calcifications may be asymptomatic in approximately 50% of cases 3
• The presence of power Doppler signal and bursal widening strongly correlates with symptomatic calcifications 3
• Migration of calcium deposits from tendons into the bursa is a rare complication that causes intense acute pain 4
• Creating communication between calcification and bursa during UGPL significantly improves outcomes 6

By following this systematic approach to diagnosis and treatment, clinicians can effectively manage calcifications in the subacromial bursa and improve patient outcomes.