Calcific tendonitis is a chronic condition that affects the soft tissues of the body. Tendons are soft tissue structures that connect muscles to bones. The condition mostly affects the shoulder, so chronic calcific shoulder tendinitis and calcific tendonitis are interchangeable in literature.
The painful disorder arises due to tendon degeneration followed by the accumulation of calcific deposits in the tendons.
The calcium deposits are predominantly found in the shoulder but can occur in any tendon. The incidence of the disease is low. Calcific tendinitis is usually diagnosed in individuals aged 40 to 60, with women being more affected than men.
A survey revealed a 2.7% incidence of tendinitis of the shoulder. Another study found calcific tendinopathy to be a major cause of shoulder pain, having a prevalence of 42.5% in patients with Subacromial pain syndrome (SAPS).
Calcific Tendonitis Vs. Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder is an acute disease of the shoulder that causes significant shoulder pain. Due to the similar nature of discomfort, people often confuse frozen shoulder and calcific tendinitis.
However, both disorders are separate entities with different underlying causes. Frozen shoulder arises from the thickening and tightening of the shoulder capsule (thus the name adhesive capsulitis), while shoulder calcific tendonitis occurs due to calcium deposits. The exact cause of this shoulder pathology (frozen shoulder) is unknown.
Both conditions can co-occur in a patient leading to unresolved, severe pain. Studies show that patients benefit from a combined treatment for frozen shoulder pain and calcific tendinopathy of the supraspinatus tendon.
Calcific Tendonitis And Subacromial Pain Syndrome
Subacromial pain syndrome is one of the most common causes of shoulder pain. The pain is more pronounced when carrying out shoulder activities above the head. As the shoulder is involved, many people consider subacromial pain syndrome to be the same as rotator cuff tendinitis of the shoulder.
However, the severe acute pain in SAPS frequently radiates to the neck region, differentiating it from calcific tendinitis of the shoulder. Symptoms arise due to subacromial impingement.
Stages Of Calcific Tendinitis
Clinicians and researchers have identified different stages for this painful shoulder condition.
Stages of tendonitis of the shoulder (calcific tendonitis) include the pre-calcific stage, formative and resting phases, restorative phase, and the post calcific stage.
Pre Calcific Stage
The initial stage is characterized by changes in the fibrocartilage of the tendon cells. Patients usually do not feel any pain during this stage.
As the name suggests, this is the stage of calcium deposition. Crystals of calcium deposit in the shoulder joint lead to severe pain and reduced range of motion. The stage is further divided into two phases.
In this phase, calcific deposits cause symptoms. You can identify the small calcific deposits in the shoulder tendon.
In between the formative and the restorative phase, there is a resting phase/stage. During this phase, there is no activity. The duration of the formative and resting phases is highly variable.
The body tries to clear the shoulder joint off the calcific deposit. Thus, the highlight of this phase is a lot of phagocytotic (macrophage) activity in the rotator cuff region.
The phase is also characterized by increased tendon pressure and oedema. Sometimes the calcium crystals extravasate into the neighbouring region, i.e., the subacromial bursa.
Post Calcific Stage
In the last stage, i.e., post calcific stage, remodelling of the rotator cuff tendons takes place. This remodelling is brought about by the granulation tissue and the fibroblasts, ultimately leading to the complete healing of the tendon. Patient symptoms also subside during this stage.
Signs And Symptoms
Calcific tendonitis is asymptomatic in a large number of cases. When present, the following symptoms are seen:
A lot of acute calcific tendinitis patients complain of severe pain in the shoulder. Severe shoulder pain is felt only in the upper limb and does not radiate to the neck or the elbow.
The pain is most pronounced when raising the arm above the head level. Pain is also felt you reach behind your back. The rotator cuff calcifications make overhead movements painful for the patient.
Decreased Range Of Motion
As severe pain is felt on moving the shoulder, many patients try to avoid movement. The sudden onset of pain on movement also significantly reduces the range of motion. This negatively impacts the quality of life.
Some calcific tendonitis patients have also reported shoulder tenderness, pain, and reduced mobility.
Sleep Disturbance From Pain due to calcific tendonitis
The worst aspect of calcific tendonitis is nocturnal pain. Night pain arising from calcific tendinopathy disrupts sleep, harming the patient’s work efficiency and rest.
Causes And Risk Factors of Calcific Tendonitis
Calcium Deposit In The Rotator Cuff
Calcific tendonitis may affect any joint, but the rotator cuff tendon is most commonly affected. It develops due to tendon degeneration and accumulation of calcium deposits in the shoulder joint; therefore, it is a degenerative calcification disorder. The calcium forms crystals in the rotator cuff tendons (shoulder tendon), leading to calcific tendinitis of the shoulder.
The rotator cuff refers to a group of shoulder muscles and tendons that play the crucial role of connecting the shoulder to the upper arm. Calcium hydroxyapatite crystals most frequently get deposited into the following tendons of the rotator cuff:
- supraspinatus tendon
- infraspinatus tendon
Rotator cuff tendonitis is a condition different from calcific tendonitis. The former is a condition of inflammation and damage of the shoulder bursa, while calcific tendonitis shows symptoms by filling calcium deposits in the rotator cuff tendons.
It is believed that the calcium deposit process can stem from multiple factors, such as abnormal thyroid activity, diabetes, and a genetic predisposition to the disease. Women aged 30-60 years are more prone to develop calcific tendonitis.
Calcifying tendinitis can affect players and musicians as well. Drummers have been known to develop calcific tendonitis due to hectic shoulder activities. Studies have also found golfers falling prey to lateral epicondylitis and calcific tendinitis.
Diagnosis of calcific tendonitis
Your doctor will take your complete medical history and take help from radiographic imaging such as X-rays and ultrasounds. The physician will perform a physical exam to find the underlying cause for the persistent shoulder pain.
An X-ray image is good at appreciating large calcium deposits, whereas ultrasound guidance is required to detect the small calcium deposit group. Calcific tendonitis diagnosed with radiographic imaging allows the doctor to plan a better treatment strategy.
Calcific tendonitis is generally a self-limiting condition. Treatment is required in cases of refractory calcific tendinitis. You can take help from the following treatment options.
Home Management Of Calcific Tendonitis
Rest And Ice
Rest allows your rotator cuff tendons and muscles to heal. This allows better healing and removal of calcific material in the soft tissues. Ice or cold application aids in reducing inflammation.
You can immobilize your arm with a sling to avoid abrupt and excessive forces. This protects the joint from pain and discomfort. You should not make your arm completely immobile as it may add to problems. A sling is to protect uncontrolled movements but patients are advised to keep the arm slightly mobile.
The pendulum exercise is a rehabilitation exercise advised to shoulder pathology patients. This at-home exercise significantly improves mobility and alleviates pain.
Physical therapy is widely gaining popularity as an effective non-surgical alternative for tendonitis of the shoulder. A case study concluded that conservative strategies such as physical therapy and exercise help reduce pain from calcium deposition.
Sports physical therapy is employed when dealing with players (golfers mostly). It improves blood circulation of the shoulder and amps up the removal of calcium deposits.
Different painkiller medications are advised to manage pain during the painful stages. Depending on the severity of the pain, NSAIDs and steroid injections are suggested. Most patients stop taking analgesics during the restorative phase.
Steroid injections are administered into the painful, swollen joints to manage symptoms. Like other inflammatory conditions, corticosteroid injections can help lower joint inflammation. According to doctors, a steroid injection in the joint can relieve pain for long periods, but the treatment modality is reserved for severe cases only.
Percutaneous Needling (Ultrasound Guided Lavage)
Percutaneous needling is a safe and effective treatment for tendonitis of the shoulder. It involves inserting fine (single or double needles) into the affected site and irrigating the region to remove calcium deposits. All this procedure is done under ultrasound guidance; therefore, the process is known as ultrasound guided needle lavage. Studies show that ultrasound guided needle lavage significantly improves shoulder function and reduces persistent pain.
Many clinicians believe that shock wave therapy should be the first line of treatment for refractory calcific tendonitis. It involves delivering shock waves to the body to achieve different purposes. This treatment method is famous for breaking down calcified kidney stones. Thus, shock wave therapy can also be potent in removing calcium deposits in the rotator cuff.
The most commonly used shockwave therapies for calcific tendinopathy include radial shockwave therapy and extracorporeal shock wave therapy.
Radial Shock Wave Therapy
Radial shock wave therapy enhances the cell mediated process of healing in the body. According to a randomized clinical study, radial shock wave therapy is completely safe and very effective in managing calcific tendonitis symptoms. Study participants noted improvement in shoulder function and a reduction in pain 4 weeks after the procedure.
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave treatment is a major treatment modality for calcifying tendinitis of the shoulder. According to a randomized clinical study, high and low extracorporeal shockwave therapy reduce the symptoms, i.e., alleviates pain and improves range of motion.
According to a review, high-energy extracorporeal shockwave therapy alleviates pain and can lead to a complete resolution of calcium deposits (in the rotator cuff insertion).
Arthroscopic decompression for calcific tendonitis involves removing the calcific deposits. This releases the pressure off the joint and lowers symptoms.
Subacromial decompression involves smoothing the bone spurs that cause subacromial impingement. The procedure is not very effective for treating calcific tendonitis. According to studies, calcific deposit debridement alone is the better surgical option.
However, most recently a study highlighted the efficacy of arthroscopic treatment and subacromial decompression for calcific tendonitis. The 2023 study concluded that arthroscopic treatment and subacromial decompression without calcific debridement can lead to complete resolution of symptoms.
Frequently Asked Questions
How do you treat calcific tendonitis?
There are multiple ways of treating calcific tendonitis. The simplest domestic treatment involves taking rest, applying ice and using a sling to limit pressure. Rehab exercises can also provide significant relief. You can take help from painkiller medications (NSAIDs and steroids). Non-interventional treatments include physical therapy and shock wave therapy. Radial and extracorporeal shockwaves are pretty effective in treating shoulder tendonitis. Ultrasound guided needle irrigation of the rotator cuff removes calcium hydroxyapatite crystals. Modern research suggests that arthroscopic surgery and subacromial decompression without calcific debridement can lead to complete resolution of the disease.
What triggers calcific tendonitis?
There are multiple factors that can trigger calcific tendonitis including old age, overuse/repetitive strain to the shoulder, hormonal imbalance, trauma/injury. The disease has a genetic predisposition too.
What makes calcific tendonitis worse?
Continuous hectic activity can make your condition worse. As calcific tendonitis is characterized by calcium deposition and inflammation. Overuse even after the beginning of symptoms can increase the inflammation leading to worsening of the disorder.
How long does it take to recover from calcific tendonitis?
Calcific tendonitis is generally a self-limiting and resorbing disease. In the vast majority of cases, symptoms subside within 1 to 6 weeks. However, in some people complete resorption of the calcium deposition may take several months.
What are the three stages of calcific tendonitis?
The three stages of calcific tendonitis are pre calcific, calcific and post calcific stage. No evident symptoms are seen during the pre calcific stage. Calcific stage is divided into formative and restorative phases. Symptoms arise during this stage. Post calcific stage is characterised by clearance of the calcific deposits (that occurred during calcific stage). Patients start to resume normal pain free life during this stage.
Can Calcific Tendonitis Go Away On Its Own? Is It Permanent?
In around 90% of the cases, calcific tendinitis resorbs on its own and does not require any intervention. However, in some cases the calcification becomes permanent and requires surgical intervention for pain relief.