What is calcific tendinosis of the rotator cuff?

Calcific Tendinosis of the Rotator Cuff: Definition and Management

Calcific tendinosis of the rotator cuff is a condition characterized by calcium hydroxyapatite deposits within the rotator cuff tendons, most commonly affecting the supraspinatus tendon, causing pain, inflammation, and functional limitation of the shoulder. 1

Pathophysiology and Prevalence

Calcific tendinosis is a common shoulder disorder with prevalence rates of up to 42.5% in patients with shoulder pain 1. It typically affects adults between 30-50 years of age, with the condition being more favorable to treatment in younger adults (30-40 years) 2.

The condition is characterized by:

• Hydroxyapatite crystal deposits within the rotator cuff tendons
• Most commonly affects the supraspinatus tendon
• Can be single or multiple deposits of varying sizes
• Considered a self-limiting disease in most cases, but can have a prolonged, disabling course in some patients 1

Clinical Presentation

Patients with calcific tendinosis typically present with:

• Activity-related shoulder pain 2
• Pain during specific phases of movement, particularly with overhead activities
• Decreased range of motion during abduction with external or internal rotation 3
• Focal weakness in the affected shoulder 3
• Pain that may be acute or chronic in nature

Diagnosis

Diagnosis is primarily based on imaging:

• Ultrasound is highly effective with reported 100% sensitivity in identifying calcific deposits 4
• MRI can confirm the diagnosis and rule out other pathologies
• X-rays can show the calcific deposits and help determine their size and morphology

Treatment Options

Treatment should follow a stepwise approach based on symptom severity and duration:

1. First-Line Conservative Management

• NSAIDs are strongly recommended as first-line treatment for pain control 4

  • Ibuprofen at 1.2g daily is considered the safest option
  • Can be increased to 2.4g daily if needed
  • Can be combined with acetaminophen (up to 4g daily) for inadequate relief

• Physical therapy focusing on:

  • Rotator cuff and scapular stabilizer strengthening
  • Re-establishing proper mechanics of the shoulder
  • Restoring range of motion 3
  • Eccentric strengthening exercises and proprioception training 4

2. Second-Line Interventions

For persistent symptoms despite initial conservative treatment:

• Ultrasound-guided percutaneous needling and lavage (barbotage):

  • Most effective for middle-sized calcifications (12-17mm) 2
  • More effective for softer calcifications 2
  • Often combined with corticosteroid injection into the subacromial bursa 1
  • Shows superior clinical outcomes after 1-2 years compared to other treatments 1

• Extracorporeal shock wave therapy (ESWT):

  • Alternative to barbotage
  • Less effective for larger calcific deposits 1
  • Safe but with mixed evidence of effectiveness 3

• Corticosteroid injections:

  • Can be effective for short-term pain relief
  • Limited to 2-3 injections with 4-6 weeks between injections 4
  • May provide temporary relief but doesn't necessarily address the underlying calcification

3. Surgical Management

For cases resistant to conservative and minimally invasive treatments:

• Surgical consultation should be considered if:

  • Pain persists despite 3-6 months of well-managed conservative treatment
  • Functional limitations significantly impact quality of life 4

• Surgical options include:

  • Arthroscopic removal of calcific deposits
  • Arthroscopic debridement
  • Bursectomy (open or arthroscopic) 4

Prognosis and Recovery

• About 90% of patients can be treated non-operatively 5
• Recovery timeline varies:
  • First weeks after barbotage: substantial reduction in symptoms
  • Around 3 months: symptoms may recur as corticosteroid effects diminish 1
  • 6 months to 1 year: substantial improvement in pain, shoulder function, and quality of life 1
  • Long-term (5 years): similar outcomes between different treatment modalities, suggesting a self-limiting course 1

Return to Activity Guidelines

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity
• Full range of motion compared to the uninjured side
• Strength symmetry >90% compared to the uninjured side
• Successful completion of functional tests 4

Important Considerations

• Calcific tendinosis differs from rotator cuff tears, which are more common in older adults and often require different management approaches 3
• Treatment success is highly dependent on the characteristics of the calcific deposits (size, consistency) and patient factors (age) 2
• Younger patients (30-40 years) with middle-sized (12-17mm), softer calcifications tend to have better outcomes with minimally invasive procedures 2