What is calcific tendinosis?

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Calcific Tendinosis: Definition, Diagnosis, and Management

Calcific tendinosis is a condition characterized by the deposition of calcium hydroxyapatite crystals within tendons, causing pain, inflammation, and functional limitations. It is one of the three main types of crystal-induced arthropathies (CiAs), specifically classified as basic calcium phosphate deposition (BCPD) 1.

Pathophysiology and Clinical Presentation

  • Calcific tendinosis involves abnormal deposition of hydroxyapatite crystals in tendons, leading to secondary inflammation 2
  • Most commonly affects the rotator cuff tendons (particularly supraspinatus), but can occur in any tendon of the body 2, 3
  • Clinical presentation typically includes:
    • Localized pain that worsens with activity or prolonged use of the affected tendon
    • Tenderness over the affected tendon on palpation
    • Restricted range of motion
    • Possible muscle guarding and crepitus 4

Diagnostic Approach

Imaging Modalities

Different imaging techniques have varying utility in diagnosing calcific tendinosis:

  1. Radiography (X-ray):

    • First-line imaging modality
    • Can identify calcium deposits in tendons
    • Limited in evaluating soft tissue involvement 1

  2. Ultrasound:

    • Excellent for detecting calcifications
    • Can assess tendon integrity and surrounding soft tissue
    • Allows dynamic evaluation
    • Shows characteristic features of tophi 1, 4

  3. MRI:

    • Provides detailed evaluation of soft tissues
    • Can detect associated inflammation and edema
    • Less sensitive than ultrasound or CT for detecting calcifications 1, 5

  4. CT/Dual-Energy CT:

    • Highly sensitive for detecting calcifications
    • Can characterize cortical bone abnormalities
    • Useful for detecting complications like intraosseous extension 1, 5

Disease Stages and Imaging Correlation

Calcific tendinosis progresses through different phases, each with distinct imaging findings 2, 6:

  1. Formative phase: Asymptomatic calcium deposition
  2. Resting phase: Stable calcifications with minimal symptoms
  3. Resorptive phase:
    • Most symptomatic stage
    • Calcium becomes soft and unstable
    • Potential for migration to adjacent tissues
  4. Post-calcific phase: Healing after resorption

Complications and Migration Patterns

Calcific tendinosis can lead to several complications:

  • Migration patterns of calcium deposits can include 2:

    • Bursal migration
    • Intraosseous migration
    • Muscular migration
    • Other less common migration sites

  • Intraosseous extension is a rare but significant complication that can cause severe pain 5

  • Chronic cases may lead to persistent pain and functional limitations 7

Management Approaches

Non-Pharmacological Management

  • Physical therapy with eccentric strengthening exercises 4
  • Deep transverse friction massage to reduce pain 4
  • Relative rest and activity modification 4
  • Extracorporeal Shock Wave Therapy (ESWT) for chronic cases 4

Pharmacological Management

  • NSAIDs as first-line medication for pain and inflammation 4
  • Acetaminophen as an alternative analgesic 4
  • Corticosteroid injections (limited to 2-3 injections, 4-6 weeks apart) 4
  • Ultrasound-guided aspiration and percutaneous irrigation in symptomatic cases 5

Surgical Management

  • Considered if pain persists despite 3-6 months of conservative treatment 4
  • Options include:
    • Arthroscopic removal of calcification
    • Possible subacromial decompression
    • Excision of abnormal tendon tissue
    • Longitudinal tenotomies 4

Prognosis

  • Over 90% of cases have a good prognosis with appropriate conservative management 4
  • Even with optimal management, resolution typically requires 3-6 months 4
  • Some cases may have a complicated course (10-30% of patients) 6

Monitoring and Follow-up

  • Pain and function should be reassessed every 4-6 weeks 4
  • Treatment plan should be adjusted if no improvement after 8-12 weeks 4
  • Imaging (ultrasound or radiography) should be used to monitor changes in calcification size 4

Understanding the natural history and progression of calcific tendinosis is crucial for appropriate management and preventing unnecessary interventions. Multimodality imaging plays a key role in diagnosis, monitoring, and guiding therapeutic interventions.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Rotator Cuff Injury Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Research

[Calcific tendinitis].

Radiologie (Heidelberg, Germany), 2024

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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