Background: Chest pain is a frequent cause of emergency department consultations, often requiring exclusion of life threatening conditions. We present a rare case of calcific tendinopathy of the pectoralis major tendon mimicking a cardiac emergency.

Case Presentation: A 70 year old man presented with severe atraumatic left sided chest pain radiating to the shoulder and arm. Initial clinical and laboratory findings excluded cardiac and vascular causes. Computed tomography and ultrasound revealed pronounced calcification at the humeral insertion of the pectoralis major tendon. Conservative therapy was insufficient, while ultrasound guided percutaneous lavage with triamcinolone infiltration led to marked symptom resolution.

Conclusion: Calcific tendinopathy of the pectoralis major represents an extraordinarily rare cause of acute chest pain. Recognition of this condition is essential to avoid unnecessary cardiac work up and to provide targeted therapy.

Chest pain is one of the most common presenting complaints in the emergency department. After exclusion of acute coronary syndrome, pulmonary embolism, and aortic dissection, musculoskeletal causes are often considered. Calcific tendinopathy is usually localized in the rotator cuff, whereas involvement of the pectoralis major tendon is exceptionally rare. We report a case of acute calcific tendinopathy of the pectoralis major presenting as severe chest pain.

A 70‑year‑old man was referred to the emergency department by his primary care physician for refractory left‑sided atraumatic chest pain. Symptoms began acutely the prior evening without trigger and worsened overnight. Pain was sharp, persistent (VAS 10/10), and exacerbated by minimal left shoulder movement. Immobilizing the left arm provided slight relief. Pain radiated from the left chest to the entire shoulder, scapula, and arm.

Examination

On arrival the patient was afebrile; blood pressure was 145/97 mmHg (left) and 150/97 mmHg (right), pulse 92/min, and oxygen saturation 93% on room air. Cardiopulmonary examination was unremarkable, with palpable peripheral pulses. Marked tenderness was noted in the left pectoralis major and axillary region. Active and passive left shoulder movement was impossible due to pain. Strength was limited by pain, sensation remained intact, and the skin was normal.

Diagnostics

Electrocardiogram showed normal sinus rhythm without ischemic changes. Laboratory tests including CRP, leukocyte count, hs‑troponin, creatine kinase, and D‑dimer were all normal. Because of persistent severe pain despite analgesia, CT angiography was performed to exclude aortic dissection. Imaging instead revealed pronounced soft‑tissue calcification at the humeral insertion of the left pectoralis major tendon (Figure.1). Ultrasound confirmed the calcification at the insertion site with adjacent inflammatory reaction (Figure.2).

Figure 1: Chest CT: Faint soft- tissue calcification (arrow) at the humeral insertion oft he left pectoralis major muscle

Ultrasound imaging confirmed the location oft the described calcifications at the insertion site oft he left pectoralis muscle (Figure.2). 

Figure 2: Ultrasound left shoulder: Large calcification in the left ventral region, closely associated with the long head of the biceps tendon (2), most likely at the insertion site of the pectoralis major muscle with adjacent inflammatory reaction (1) in cross-section

The diagnosis of acute calcific tendinopathy oft he left pectoralis major muscle was established.

Therapy and Course

The patient was hospitalized for pain management and initially treated with opioids, non‑steroidal anti‑inflammatory drugs, and paracetamol. After five days without sufficient improvement, a 7‑day course of oral prednisolone (30 mg/day) was initiated but proved ineffective. Subsequently, ultrasound‑guided percutaneous lavage (barbotage) combined with local triamcinolone infiltration was performed, resulting in rapid clinical improvement and complete resolution of symptoms.

Calcific tendinopathy (synonyms: calcific tendinitis, periarthritis, tendinosis) is characterized by calcium hydroxyapatite crystal deposition within tendons. While most prevalent in the rotator cuff tendons (3-10% population prevalence [2]), 50% of calcifications remain asymptomatic. Among patients with shoulder pain, 7-17

Written informed consent for publication was obtained from the patient.

The authors declare no potential conflict of interest.