The exact cause of the disease has not yet been established. However, it is known to develop in three distinct stages: the pre-calcific, the calcific, and the post-calcific stage. The pre-calcific stage consists of microscopic degenerative changes within the tendon and is usually asymptomatic. The calcific stage, during which patients most often seek medical attention, includes three separate phases. In the formative phase, cells deposit calcium within the tendon mass, while the subsequent resting phase appears to be relatively free of cellular or inflammatory activity. In the resorptive phase, however, new blood vessels form within the normally avascular tendon (a process known as neovascularization), and through these vessels, cells such as phagocytes gather to break down the calcium deposits. This represents the most painful clinical stage of the disease process. Finally, the post-calcific stage follows.
Patients presenting with calcific tendinitis of the shoulder may report shoulder pain without any preceding traumatic event, a sensation of catching, audible clicks, or reduced motion and strength of the joint. On examination by an orthopedic surgeon, reduced range of motion of the shoulder and decreased strength of the rotator cuff are the most prominent clinical findings. These are often accompanied by altered coordination of shoulder and scapular movement (scapulothoracic dyskinesis) as the patient tries to compensate for pain-related restriction of shoulder motion.
The most appropriate diagnostic tool for calcific tendinitis is plain radiographs, which can reveal the location, density, size, and outline of calcium deposits within the rotator cuff. They are also useful for monitoring the progression of deposits over time. Shoulder ultrasound, in the hands of a skilled physician, can also be valuable both for identifying calcifications and for guiding needle-based therapies such as decompression, barbotage, or even simple injections. Finally, MRI may be used in selected, persistent cases where the presence of other shoulder pathologies, such as rotator cuff tears, is suspected.
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Treatment of calcific tendinitis of the shoulder includes both conservative and interventional methods, with the former often providing long-term symptom relief. Initial management for all phases of the disease focuses on pain relief using paracetamol and nonsteroidal anti-inflammatory drugs, followed by physiotherapy. In cases of severe, persistent symptoms, corticosteroid injections into the subacromial space can be beneficial. Complete symptom resolution may take up to six months, with success rates reaching around 60–70% of patients.Treatment of calcific tendinitis of the shoulder includes both conservative and interventional methods, with the former often providing long-term symptom relief. Initial management for all phases of the disease focuses on pain relief using paracetamol and nonsteroidal anti-inflammatory drugs, followed by physiotherapy. In cases of severe, persistent symptoms, corticosteroid injections into the subacromial space can be beneficial. Complete symptom resolution may take up to six months, with success rates reaching around 60–70% of patients.
In stubborn cases, extracorporeal shock wave therapy (ESWT) can be used as an adjunct, especially during the formative and resting phases. However, its effectiveness and the frequency of side effects are dose-dependent. The higher the energy delivered to the calcification, the more effective the method is in fragmenting the deposit and promoting its resorption, thereby improving functional outcomes. However, higher energy also increases the likelihood of treatment-related pain or local reactions (redness, inflammation, bruising) afterward. Another method used in combination with medication and physiotherapy during the resorptive phase is ultrasound-guided needle lavage or barbotage. In the first technique, two needles are inserted under ultrasound guidance to create a closed irrigation system through which saline and local anesthetic are introduced via one needle, while an attempt is made to aspirate the calcium deposit through the other. In the second, a single needle is used to break up the deposit, followed by injection of local anesthetic and corticosteroid for pain relief.
When conservative management fails and symptoms persist, significantly impairing daily life, surgical treatment is considered, either arthroscopic or mini-open. This approach involves removal of the calcium deposits as well as decompression of the rotator cuff tendons as they pass beneath the acromion, and, when necessary, repair of associated tears. Surgery has been shown to provide short-term pain relief, but patients should be informed that the recovery period is usually longer, particularly if additional procedures on the rotator cuff are performed. They should also be aware that, although shoulder function generally improves with surgery, some degree of residual stiffness may persist.
Calcific tendinitis is a common shoulder disorder that can cause significant pain and disability, particularly during the resorptive phase of calcium deposits. Although the disease may sometimes recur or leave residual stiffness in the long term, conservative treatment is generally effective in relieving pain and restoring function for most patients. When conservative measures fail, surgical options remain available.
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