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Mr. Mark Falworth, Consultant Orthopaedic Shoulder & Elbow Surgeon, London, Watford, Stanmore, UK / Shoulder / Calcific Tendonitis

Calcific Tendonitis

Calcific tendonitis is an unusual condition in which calcium is deposited in the tendons of the rotator duff. Although it can affect any of the four tendons of the rotator cuff tendons, the supraspinatus is the tendon that is most commonly affected.

The natural history of calcific tendonitis is such that there are four distinct phases; the Pre-calcific Phase, the Formative Phase, the Resorptive Phase and finally the Repartive Phase. The clinical presentation of the condition is dependent on the phase of the disease process. In either the Pre-calcific or Formative Phase there is usually no pain and indeed the presence of the calcific deposit may cause no symptoms and may only be noted as an incidental finding following an X-ray or scan. Alternatively, once the calcific deposit is formed, the calcium may distort the tendon anatomy such that symptoms are caused by the altered anatomy of the affected tendon as opposed to the presence of the deposit itself. This can result in a dull pain which is made worse with the arm is taken up to, or beyond, shoulder height, such that it resembles the pain associated with subacromial impingement. The pain is often poorly localised and may be referred down the arm or into the neck. Night pain is also reported

Whilst some established calcific deposits slowly dissolve causing little in the way of symptoms, in some instances the clacium can cause significant pain. These lesions are believed to be in the Resorptive Phase. During this phase, the calcium dissolves and as it does, it swells such that it can cause extreme and unremitting pain. The pain can be so severe that those affected are often incapacitated by it and describe it as the worst pain they have ever experienced. Often, no shoulder movement is tolerated and the arm is held firmly against the chest. The pain is usually localised to a specific site of the shoulder and is of shorter duration than the chronic form, with symptoms often settling after 2-3 weeks, however if no intervention is pursued, discomfort can continue for many months.

The clinical course of this disease therefore usually follows a cycle. Recognition of this, and an accurate assessment as to where the patient is in the cycle, is helpful in establishing the correct treatment protocol.

Symptoms

  • Pain related to shoulder movement
  • Excruciating pain unrelated to movement that is believed to due to the ‘eruption’ of calcific material into the bursa during the Resorptive Phase.
  • Night pain
  • Clicking
  • Restricted movement secondary to the progressive thickening and scarring of the bursa.

Causes & Risk factors

The cause of calcific tendonitis is unclear and is still not completely known. It has been suggested that it may be secondary to tendon degeneration or possibly as a result of genetic influences or a cell mediated response.

Diagnosis

The diagnosis of calcific tendonitis is usually made with the help of radiological imaging including x-rays, ultrasound scans and MRI scans. However, as the severity of pain associated with a dissolving calcific deposit can be unlike any other shoulder condition, a clinical diagnosis can also be suspected in those patients presenting with unremitting pain.

Although x-rays are the imaging modality to investigate the shoulder, interestingly a calcific deposit that is undergoing resoption (dissolving) may not be easily seen on an x-ray and therefore ultrasound or MRI scans might also need to be arranged to confirm the diagnosis. These two latter techniques have the added advantage of giving information regarding the state of the affected tendon as sometimes this also needs addressing during any planned treatment.

Treatment

There are a number of treatments available for calcific tendonitis, each being chosen based on the clinical features of the condition. The options include;

  • Conservative treatment comprising of rest, activity modification and the use of anti-inflammatory medications. Although the condition is often self limiting, if no direct treatment is undertaken the symptoms may last for many months or perhaps years.
  • Injection treatments; the space between the rotator cuff and the acromion (the subacromial space) can be injected with local anaesthetic and Cortisol. The anti-inflammatory component of the injection can reduce swelling and pain and can be used in conjunction with physiotherapy to aid recovery. However, this will not deal directly with the calcific deposit.
  • Ultrasound guided needling (Barbotage); The calcific deposit is located with the use of ultrasound and then under local anaesthetic, the calcific deposit is broken up with a needle and then aspirated back into the syringe.
  • Extracorporeal shockwave therapy; shockwave therapy is a new treatment which is giving some promising results. It is a non-invasive method of trying to treat an established calcific deposit. Usually three sessions of treatment are undertaken with the aim that the acoustic waves cause fragmentation and resorption of the calcific deposit. High-energy shock waves are believed to result in the mechanical disintegration of the calcific deposit whereas low-energy shock waves have a role in providing pain relief.
  • Arthroscopic calcific debridement; Arthroscopic techniques often provide the best means with which to locate and remove the calcific deposit. The removal of the calcium can often be achieved by needling the deposit under direct vision however larger deposits may require more formal excision. The aim of the treatment is to always remove the calcium whilst not damaging the rotator cuff tendons. However, depending on the extent of any associated damage to the rotator cuff tendons, sometimes a subacromial decompression and even a rotator cuff repair may also be needed.