Calcific Tendonitis

The true etiology of the disease has yet to be established. However, we do know that it develops in three distinct stages: the precalific, the calcific and the postcalcific. The precalcific stage consists of the development of microscopic, degenerative changes within the tendon and is most of the times pain-free. The calcific stage, which is when most patients seek medical advice, consists of three phases. During the formative phase, cells deposit calcium within the tendon’s substance, while the subsequent resting phase appears to be relatively free of cellular or inflammatory activity. During the resorptive phase, however, new blood vessels are formed (neoangiogenesis) within the normally avascular tendon and, by way of them, cells destined to dissolve the calcium deposits (phagocytes) accumulate. This is clinically the most painful phase of the disease process. Finally, the postcalcific stage begins. 

Patients presenting with calcific tendonitis may complain of shoulder pain without any distinct previous traumatic event, catching, “clicking” or decreased shoulder motion and strength. When examined by an orthopedic surgeon, the decrease in shoulder range of motion and rotator cuff strength are the most predominant signs, often accompanied by a disturbance in the coordinated movement the shoulder and scapula (scapular dyskinesia) as the patient tries to compensate for decreased shoulder mobility due to pain. 

The gold standard for the diagnosis of calcific tendonitis are plain radiographs. These can help identify the location, density, size and delineation of the calcific deposits within the rotator cuff tendons. They are also used to monitor how the deposits progress over time. Ultrasound of the shoulder, in the hands of an adequately trained physician, can also help both in the diagnosis of the calcific deposits as well as for needle guidance when delivering treatments such as decompression, barbotage or even simple injections. Finally, magnetic resonance imaging (MRI) can also be used in select, refractory cases where the presence of concomitant shoulder pathology, such as rotator cuff tears, is investigated. 

 The treatment of calcific tendonitis of the shoulder consists of both non-operative as well as operative measures, with the former being most the time successful in alleviating patient symptoms for prolonged periods of time. The first line of treatment for all phases of the disease involves pain relief with a combination of non-steroidal inflammatory drugs (NSAIDs) and paracetamol, followed by physical therapy. In severe or refractory symptoms, steroid injections in the subacromial space can also be helpful. Symptom resolution can take up to six months but is achievable in 60-70% of patients.  

As an adjunct to the aforementioned modalities in persistent cases, extracorporeal shock-wave therapy has also been used to treat the disease in the formative and resting phases mostly. It should be noted that its efficacy along with its side-effect profile are dose dependent, i.e. the higher the energy administered to the lesion, the more effective this method is in fragmenting it and assisting in its resorption, allowing for better functional outcomes. However, higher energy may as well mean more pain during the procedure or local reaction (redness, inflammation, bruising) thereafter. Another method used in conjunction with pharmacological and physical therapy in refractory cases during the resorptive phase of the disease is ultrasound-guided needle lavage or barbotage. In the former, two needles are inserted under ultrasound guidance near the lesion to create a flow system through which saline and local anesthetic are administered through ne needle, while the calcific deposit is attempted to be aspirated through the other. In the latter, a single needle is used to break up the deposit followed by the administration of local anesthetic and corticosteroid for pain relief. 

When attempts at conservative management are met with failure and symptoms persist, disabling patients in their daily lives, surgical management can be undertaken through arthroscopic or mini-open approaches. These entail the removal of the calcific deposit as well as decompression of the rotator cuff tendons under the acromion and/or repair of concomitant rotator cuff tears. In the short term, surgical management has been found to be effective in pain relief, although patients should expect a longer recovery period, especially when additional procedures have to carried out at the same time. Patients are also advised that shoulder function will get better with surgery but may be left with some residual stiffness in the joint. 

Calcific tendonitis is a common shoulder disease which can be the cause of severe pain and disability, especially during the resorptive phase of the calcific deposits. Although in some cases the disease may recur or leave some form of shoulder stiffness in the long term, conservative treatment is mostly effective in relieving pain and restoring function in the majority of patients. Should this, however, fail, surgical options are also available.