What is calcification tendinosis in the shoulder?

Calcific Tendinosis in the Shoulder

Calcific tendinosis of the shoulder is a common painful disorder characterized by calcium hydroxyapatite crystal deposits within the rotator cuff tendons, typically affecting individuals between 30 and 50 years of age. 1, 2

Definition and Pathophysiology

Calcific tendinosis (also called calcific tendinitis or calcifying tendinitis) is:

• A reactive process actively mediated by cells in a viable tendon environment
• Most commonly affects the rotator cuff tendons of the shoulder
• Characterized by single or multiple calcium deposits within the tendon tissue
• A condition that follows a natural evolutionary cycle with distinct phases

Evolutionary Stages

The condition progresses through several stages:

1. Precalcific stage: Initial cellular changes in the tendon
2. Calcific stage:
   • Formative phase: Active calcium deposit formation
   • Resting period: Stable, well-defined calcifications
   • Resorptive phase: Spontaneous breakdown of deposits
3. Postcalcific stage: Remodeling of normal tendon tissue

However, these stages don't always follow the typical sequence - some deposits may persist or lead to postcalcific tendinitis 1.

Clinical Presentation

Common symptoms include:

• Shoulder pain (may be acute or chronic)
• Pain exacerbation during certain movements
• Functional limitation of the shoulder
• In the resorptive phase: severe, acute pain due to inflammatory response
• Possible referred pain to the deltoid insertion

Diagnosis

Imaging Studies

Radiography is the recommended initial imaging modality 3:

• Standard shoulder radiographs should include:
  • Anterior-posterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view
• Radiographs can effectively demonstrate calcifications in tendons

Additional imaging when needed:

• Ultrasound (US): Shows calcifications and can assess for associated tendinopathy
• MRI: Helpful for evaluating soft tissue involvement and ruling out other pathologies

Differential Diagnosis

• Rotator cuff tears
• Subacromial impingement
• Adhesive capsulitis (frozen shoulder)
• Glenohumeral arthritis
• Acromioclavicular joint pathology

Treatment

Treatment should be based on the natural history of the disease, which shows a strong tendency toward self-healing through spontaneous resorption 1, 4.

Conservative Management (First-Line)

• Rest and activity modification
• NSAIDs for pain relief (e.g., ibuprofen 1.2-2.4g daily or naproxen 500mg twice daily) 5
• Physical therapy focusing on:
  • Pain control and protected range of motion (0-4 weeks)
  • Progressive strengthening exercises (4-8 weeks)
  • Functional exercises (8-12 weeks)

Intermediate Interventions

For persistent symptoms:

• Subacromial corticosteroid injections (limited to 2-3 injections, 4-6 weeks apart) 5
• Extracorporeal shock wave therapy (ESWT)
• Ultrasound-guided needling/lavage of the deposit

Surgical Management

Surgery should be considered only when conservative measures fail after 3-6 months 5, 1:

• Arthroscopic removal of calcium deposits is preferred
• In some cases, additional arthroscopic subacromial decompression may be indicated

Complications

• Persistent pain despite treatment
• Intramuscular migration of calcifications (rare but associated with increased pain) 6
• Tendon rupture (uncommon)

Prognosis

Most cases resolve spontaneously with conservative management. The timeline for resolution varies:

• Acute phase: Days to weeks
• Chronic phase: Months to years
• Some patients may experience persistent symptoms requiring more aggressive intervention

Follow-up Recommendations

Regular assessment at 2,6, and 12 weeks to evaluate:

• Pain levels
• Range of motion
• Functional improvement
• Response to treatment

Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment 5.