Calcific tendonitis (CT), or calcific tendinopathy, is a painful condition involving calcium deposits in the tendons. Even though calcific tendonitis can occur in any joint, it usually occurs in the shoulder with calcium deposits in the rotator cuff tendons. CT can be a disabling condition due to the pain and limited range of motion. However, there are many non-surgical treatments to improve the condition, followed by physical therapy rehab.
The figure above shows a normal shoulder on the right (with labeled structures) and a shoulder with calcific tendonitis on the left. The calcific (calcium) deposits are in the supraspinatus tendon and the subacromial bursa, just above the tendon. The calcium deposits can sometimes affect the shoulder bursa, which will be discussed later in this article.
Causes of shoulder calcific tendonitis
Shoulder CT is caused by deposits of calcium hydroxyapatite crystals inside the tendons of the shoulder's rotator cuff muscles.
The exact reason the crystals deposit into the tendons has yet to be discovered. Extensive studies by numerous scientists have proposed different theories. Some of these theories include degeneration (wear and tear), repetitive (cumulative) trauma, genetics, or hypoxia (lack of oxygen).
There are three stages of calcific tendonitis, including the pre-calcific, calcific, and post-calcific.
- Pre-calcific stage involves cellular changes that predispose the tissues to form calcium deposits.
- Calcific stage is when calcium comes out of the cells, and forms calcium deposits in the tendons. This is the most painful stage.
- Post-calcific stage is a painless stage is which the calcium deposit is replaced with normal tendon.
The main symptom
The main symptom is shoulder pain, usually associated with decreased range of motion. The pain can be severe and disabling, making it difficult for the person to perform the activities of daily living. Frequently, the pain occurs first thing in the morning and can be in the front or back of the shoulder.
Who does calcific tendonitis affect?
CT occurs in 3–10% of the population, with half of these people developing symptoms. It is most commonly seen in people 30–60 years old, rare in people over 70 years old, and 10–25% of the time it occurs bilaterally (both shoulders).
CT is more common in women, who are affected twice as often as men. Workers in certain occupations, including desk workers, tailors, cashiers, and assembly line workers, are more likely to develop CT.
How calcific tendonitis is diagnosed?
The main way to diagnose CT involves plain X-rays. Unlike other tendonitis that cannot be seen on plain X-rays, the calcium deposits are visible since they are radiopaque, meaning the X-ray beams do not go through them, just like bones.
Diagnostic ultrasound can also be useful to diagnose CT.
If a detailed study is needed, a computed tomography (CAT or CT) scan or magnetic resonance imaging (MRI) test can be done. Both produce three-dimensional images of the bones, muscles, tendons, ligaments, nerves, and cartilage.
The bursa are the fluid-filled sacs throughout the body that cushion the bones, tendons, and muscles near the joints. A rare complication can occur when the calcium crystals that deposit in the rotator cuff tendon migrate into the different bursa of the shoulder.
6 possible treatment options
- Non-steroidal anti-inflammatory medications. These are usually the first line of treatment. They can be taken by prescription or a high enough dose of over-the-counter (OTC) tablets. Caution should be taken since there is a risk of gastrointestinal side effects, such as ulcers and gastritis.
- Sling. A sling should be used for support and pain reduction.
- Steroid injections. These are a common treatment choice since they are inexpensive, simple to perform, and have minimal complications.
- Extracorporeal shock wave therapy (ESWT). This method uses a specially designed machine to create pressure pulses (shock waves) guided by ultrasound or X-rays. These shock waves can break up the calcium deposits.
- Ultrasound-guided barbotage. This is a non-surgical procedure that can be done in the office. One or two needles are used to approach the calcified areas. Sterile saline is pushed through a needle to break up the calcium deposits. Then, either the same or a 2nd needle is used to draw out the broken pieces of calcium. After that, there is an injection of a steroid with a numbing anesthetic.
- Surgical procedures. Approximately 10% of calcific tendonitis cases will not respond to conservative treatment and require surgery.
There are two types of surgery — arthroscopic and open surgery:
- Arthroscopic involves using a small incision and a scope to surgically remove the calcific deposits. Nowadays, this is the gold standard for surgical treatment of CT.
- Open surgery is rarely done; it involves making a larger incision as an entrance point for the surgical instruments to remove the calcific deposits.
Physical therapy and at-home rehab
Since calcific tendonitis leads to a restricted range of motion, passive physical therapy that increases shoulder range of motion should be started immediately. Passive means the physical therapist uses their strength to move the shoulder.
In addition, physical therapy can include modalities such as ice, heat, ultrasound, and electrical stimulation.
Physical therapy can focus on strengthening the shoulder's muscles and supporting muscles after the range of motion has improved, once the pain is gone. This can be after conservative treatment, a procedure, or surgery.
Once a physical therapist explains the appropriate at-home instructions, they can be done at home or in a health club, including active range of motion exercises and strengthening.
In conclusion, calcific tendonitis can be a painful and disabling condition. However, it can be diagnosed and treated quickly. Injections and arthroscopic surgery can be effective treatments, especially when followed by physical therapy and home rehab.
Do I have calcific tendonitis or frozen shoulder?
Both conditions present with shoulder pain and limited range of motion. Calcific tendonitis frequently occurs with pain in the morning, while frozen shoulder with pain at night. To know which one you have imaging studies such as X-rays, CAT scans, and MRIs need to be done.
Is calcific tendonitis a form of arthritis?
No. Calcific tendonitis and arthritis are different. In calcific tendonitis the tendons are affected with the calcium crystal deposits, while in arthritis the synovial lining of the joints are attacked by our own bodies.
Can calcific tendonitis come back?
Like most diseases, the condition may return. When shoulder pain returns we suggest a follow-up visit with your medical provider.
Will calcific tendonitis resolve (go away) on its own?
Yes, it can go away on its own, but we do recommend seeking medical care.
Calcific tendonitis (CT) occurs when calcium hydroxyapatite crystals deposit in the shoulder's rotator cuff tendons.
The main symptoms of calcific tendonitis are pain, especially in the morning, and limited range of motion.
The exact reason the crystals deposit in the tendons is unknown, but several postulated theories include degeneration, cumulative trauma, genetics, or lack of oxygen.
The most common way to diagnose CT is plain X-rays since calcium deposits are radiopaque and do not allow the passage of light, like the bones. Other tests include ultrasound, CAT, and MRI scans.
Physical therapy and home rehab can help to reduce pain and improve range of motion.
- Orthopedic Research and Reviews. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment.
- Joints. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment.
- Journal of Ultrasound. Migration of calcium deposits into subacromial–subdeltoid bursa and into humeral head as a rare complication of calcifying tendinitis: sonography and imaging.
- National Library of Medicine. Ultrasound-Guided Barbotage.
- National Library of Medicine. Calcific Tendinitis of the Rotator Cuff: A Review.