Calcific tendinitis is characterized by the presence of calcium deposits, actually hydroxyapatite (crystalline calcium phosphate), in a tendon of the rotator cuff. It’s often asymptomatic and occurs in 3-20% of shoulders in the general population.
When symptomatic it has a variable presentation of shoulder pain. It may be aggravated by elevation of the arm above shoulder level or lying on the shoulder. Patients may also complain of stiffness, snapping, catching, or weakness. It is most commonly found in adults between the ages of 30-50 years. Women, especially housewives and clerical workers, are more commonly affected than men.
What puts me at risk for calcific tendinitis?
The cause of calcific tendinitis is not well understood. It is not believed to be caused by trauma or systemic disease and is rarely associated with rotator cuff tears.
What is the chronologic progression of calcific tendinitis?
Formative phase: fibrocartilagenous transformation of a portion of the rotator cuff tendon with subsequent calcification – with a dry and chalky appearance
Resting phase: mature-appearing deposits, minimal pain, possible mechanical symptoms
Resorptive phase: calcium deposit is resorbed by inflammatory reaction – deposits have the appearance of toothpaste and may leak into the subacromial bursa and may be extremely painful
Postcalcific phase: fibroblasts reconstitute the tendon after the calcium deposit has been resorbed and pain subsides
How is calcific tendinitis diagnosed?
Plain x-rays may demonstrate asymptomatic calcium deposits in the rotator cuff tendons. Symptoms often occur if the calcification deposit is larger than 1.5cm. Calcium deposits may also be seen on ultrasound and MRI.
How is calcific tendinitis treated?
Most patients seek treatment during the painful resorptive phase. Treatment during other phases, during which the calcium deposits are generally asymptomatic, should be directed at other possible pathological conditions of the shoulder. There are several treatment options used for calcific tendinitis. Non-operative management is the treatment of choice. Oral anti-inflammatory agents are often useful for pain relief. Physical therapy is often prescribed to maintain or regain shoulder range of motion and strength. Corticosteroids may be injected into the subacromial space to reduce inflammation and control pain. Treatment varies based on the clinical and radiographic stage of the calcification. In the resorptive phase needling, aspiration, and lavage may be successful in achieving pain relief. The calcium deposits are localized by ultrasound or fluoroscopy and are broken up by repeated puncturing with a needle and then the deposits, appearing toothpaste-like, are removed by injecting and aspirating saline with a syringe. In the formative or resting phases another treatment option used to break up the deposits is extracorporeal shock wave therapy (ECSW).
Surgical treatment of calcific tendinitis with shoulder arthroscopy may be indicated if symptoms progress, pain is constant and interfering with activities of daily living, or there is a failure to improve with conservative management. The calcium deposits are localized and removed from the rotator cuff tendons with an arthroscopic shaver or through a longitudinal incision in the tendon. The rotator cuff may require repair after a thorough debridement. An acromioplasty is often performed during the arthroscopy to increase the amount of space between the acromion and rotator cuff tendons. This allows for easier shoulder movement which prevents impingment and subsequent pain and inflammation.
What is the prognosis after calcific tendinitis?
Early, aggressive physical therapy is started on the first postoperative day to regain shoulder range of motion and prevent stiffness. If an extensive debridement is performed with rotator cuff repair the postoperative rehabilitation program will be similar to that after a rotator cuff repair. Pain relief after debridement of the calcium deposits is usually substantial. After arthroscopic debridement of calcium tendinitis 70% of patients are noted to be pain-free at 3 months postoperatively and 90% are pain-free at 4 years postoperatively. Calcification has been reported to recur in 16-18% of patients.
- Azar, Frederick M. Shoulder and Elbow Injuries: Calcific Tendinitis, Campbell’s Operative Orthopaedics, 10th Edition, 2003. 2352-2355.
- Woodward, Anthony H. Calcifying Tendinitis. EMedicine 2006.
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