Calcific Tendonitis: Well, I Would Manage This Shoulder Pain

Shoulder and elbow structured oral examination question4

EXAMINER : This is a radiograph of a 63-year-old gentleman’s right shoulder. Proceed.

CANDIDATE : This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, wellmaintained subacromial space but the undersurface of the acromion is sclerotic suggesting possibility of him suffering from subacromial impingement. Can I see an axillary view please?

EXAMINER: Yes.

CANDIDATE : There are deposits of calcium in the supraspinatus tendon ...

EXAMINER : What is your opinion about his pain in the shoulder? CANDIDATE : Well, he could be struggling with calcific tendonitis.

EXAMINER : What do you want to do?

CANDIDATE : I would like to know the patient’s symptoms, examination findings, the treatments he had so far and his expectations.

EXAMINER : He is a keen golfer and gradually over the last 2 years he has developed the pain on over-head activities. He has not had any interventions so far. He wants to continue playing golf without pain. He has got positive impingement signs.

CANDIDATE : Well, I would inject his subacromial space with steroid today to relieve the bursitis secondary to the calcific tendonitis, which is causing impingement symptoms and review him in 8 weeks in clinic with repeat X-rays to assess the calcium deposits.

EXAMINER : Incidentally there is also another X-ray of his right shoulder which was performed 2 years ago when he started to have the pain, which shows the same calcium deposits. Does it change your plan?

CANDIDATE : ... Well, I would then book him now for arthroscopic excision of the calcium deposits.

EXAMINER : Will you perform any other procedures during the surgery?

CANDIDATE : I will consent him for arthroscopy and proceed ... so that I can assess the shoulder and perform the necessary at the time of the surgery.

Did he not start well? Did this candidate proceed well – with diagnosis and management plan? Did he pick up the clues by the examiners and correct himself? What will be your scoring for this candidate? Will you diagnose and manage this problem differently like the next candidate?

EXAMINER : This is a radiograph of a 63-year-old gentleman’s right shoulder. Proceed.

CANDIDATE : This plain AP radiograph shows normal glenohumeral joint and acromioclavicular joint, well-maintained subacromial space but the undersurface of the acromion is sclerotic suggesting possibility of him suffering from subacromial impingement. Can I see an axillary view please?

EXAMINER: Yes.

CANDIDATE : There are deposits of calcium in the supraspinatus tendon ...

EXAMINER : What is your opinion about his pain in the shoulder?

CANDIDATE : Looking at the radiographs, duration of his problem ...

(EXAMINER : 2 years) and his age I feel he has got degenerative calcification in his cuff and subacromial impingement.

** EXAMINER** : What do you want to do?

CANDIDATE : I would like to know the patient’s symptoms, examination findings, the treatments he had so far and his expectations.

EXAMINER : He is a keen golfer and gradually over the last 2 years he has developed the pain on over-head activities. He has not had any interventions so far. He wants to continue playing golf without pain. He has got positive impingement signs.

CANDIDATE : I want to know if he had any X-rays in the past and would like to assess the status of his cuff with an ultrasound scan.

EXAMINER : This is the X-ray taken 2 years ago – showing the same calcification. The ultrasound scan shows intact cuff.

CANDIDATE : Well I would inject the subacromial bursa today with steroid and review the patient in 8 weeks to see if the injection has helped his pain as a diagnostic test for impingement.

EXAMINER : He comes back in 8 weeks saying the pain was well controlled for 3 weeks and now the pain is back. What will you do?

CANDIDATE : This proves the pathology of subacromial impingement and I am going to talk to the patient about the subacromial decompression.

EXAMINER : Will you perform excision of the calcium deposits?

No, not necessarily. This degenerative calcification is a chronic one. It is not acute calcific tendonitis. Therefore I will perform only the subacromial decompression.

EXAMINER : Thank you.

This second candidate was much clearer about the pathology and management plan, which will be rewarded by a better score. He did not have to be prompted by the examiners regarding the calcium deposit which was there 2 years ago suggesting the degenerative calcification. The previous candidate failed to understand these prompting clues