Calcific tendinitis

Background

Shoulder anatomy

Shoulder anatomy, anterior.

Shoulder anatomy, posterior.

• Self-limiting disorder of calcium hydroxyapatite deposition within one or more tendons of the rotator cuff
  • Usually spontaneous, not necessarily caused by trauma or overuse
  • With time, the calcium undergoes painful resorption with subsequent tendon healing
• Middle-aged patients 30-50 years are most commonly affected (rarely seen in patients >70yrs), and women are moreso affected
• Adhesive capsulitis is most common complication
• Inflammatory reaction may exhibit warmth, swelling, or erythema that may mimic septic arthritis

Clinical Features

Precalcific phase

• Fibrocartilaginous metaplasia of the tendon, leading to chondrocyte formation
• Pain-free

Calcification phase

• Formative phase
  • Characterized by cell-mediated calcific deposits
  • +/- Shoulder pain
• Resting phase
  • Lacks inflammation or vascular infiltration
  • +/- pain
• Resorptive phase (1-2 wks)
  • Characterized by phagocytic resorption and vascular infiltration
  • Most painful phase; due to inflammation in the resorptive process, increase in intratendinous pressure, or subacromial impingement
    • Pain may be similar to rotator cuff tendinopathy; usually at rest, worse at night and with laying on affected side
    • Leakage of calcium crystals onto the bursa may lead to sudden dramatic pain
    • Any shoulder motion reproduces significant pain; shoulder impingement tests are usually positive
    • TTP over proximal humerus near tendinous insertion of rotator cuff; may also be near AC joint or deltoid

Post-calcific phase

• Calcific deposits have been resorbed; tendon returns to normal
• Variable levels of pain and shoulder dysfunction

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

Calcific tendinitis

• Imaging
  • Plain films will show calcification in the tendon(s) of the rotator cuff
    • Usually in the supraspinatus tendon, proximal to its insertion site on the greater tuberosity
    • Amount of calcification may not correlate with severity of symptoms
    • Note: calcification is not specific for calcific tendinitis (may occur in asymptomatic patients)
  • Ultrasound is sensitive for detecting calcifications
    • May show hyperechoic areas and posterior acoustic shadowing
    • Can simultaneously detect rotator cuff tears or bursitis

Management

• Nonoperative management is successful in most cases
  • NSAIDs, oral and topical
  • Physical therapy for rotator/glenohumeral strength and ROM
  • Stretch and strengthening
    • Avoid immobilization
      • Rest shoulder in abduction on back of a chair as soon as tolerable
      • Sleep with pillow beneath axilla
  • Subacromial corticosteroid injection

Disposition

• Primary care referral within 1wk
• If chronic, may consider ortho referral for extracorporeal shock wave therapy, ultrasound-guided lavage, or operative management

See Also

• Shoulder diagnoses
• Biceps Tendinitis