Calcific tendinitis of the shoulder

What is calcific tendinitis of the shoulder?

Calcific tendinitis of the shoulder is a very painful condition, where calcium deposits (calcium hydroxyapatite crystals) accumulate in tendons of the rotator cuff muscles. However, calcium tendinitis can happen in any muscle of the body. A rotator cuff is a group of four muscles that joins the upper arm with the shoulder to provide strength and stability to the shoulder joint. The deposition of calcium can happen either in a small spot or in the whole muscle. These calcium deposits create pressure and chemical irritation on the muscle and tendon, resulting in pain. Its exact cause is unknown, however patients with diabetes and hypothyroidism are more prone to get this condition.

Calcific tendinitis of the shoulder is one of the leading causes of shoulder pain after the frozen shoulder. It develops more commonly in people aged between 40-60 years. It is more common in women with sedentary lifestyles than heavy manual labourers. It could resolve by itself in 5-10 years and could be asymptomatic in 35% of the patients. The most common site of calcific tendinitis is supraspinatus tendon (63%) followed by infraspinatus and subscapularis tendons. 7 % cases of shoulder pain have calcific tendinitis as its prime aetiology. About 24-66% of patients have calcium deposits on both sides of the shoulder at a time.

 

What are the symptoms of calcific tendinitis of the shoulder?

The symptoms of calcific tendinitis could be either chemical (inflammatory) or mechanical. Patients usually present with severe disabling pain that occurred spontaneously. The pain is sometimes so severe that they could not sleep or use their arm for activities of daily living. The inflammation could lead to stiffness with severe limitation in range of motion of the shoulder and could be misdiagnosed as frozen shoulder. The pre-calcific and formative stages are less painful or sometimes painless with chalky calcium deposits. However, the resorptive phase is the most painful one where the lump becomes a paste due to inflammatory reaction. The calcium deposits could encroach into the sub acromial space and can lead to impingement symptoms with overhead activities. In later stages patients could present with weak rotator cuff muscles and muscle atrophy.

 

How is it diagnosed?

X-rays usually diagnose it, however in some cases MRI scan is used to assess the exact location, extent and rule out concomitant pathology. Ultrasound can be performed to assess the size of the deposits and to treat the problem with barbotage (needling & lavage) and steroid injection.

 

What happens if nothing is done?

Calcific tendinitis could resolve by itself, but it may take 5- 10 years. In some patients, it can progress to frozen shoulder, impingement syndrome that could damage the rotator cuff tendons.

  

How is it treated?

It can be treated both conservatively and surgically. 90% of the patients get better with non-operative management. Conservative treatment involves anti-inflammatory medications, steroid injections, physical therapy, therapeutic ultrasound and percutaneous needling and extracorporeal shockwave therapy.

Surgery is required only in 10 % of cases where conservative methods fail to provide relief.

Indications for surgery

  • Failure of non-surgical techniques
  • Resistance to non-surgical methods
  • Progressive Calcific tendinitis
  • Night pain
  • Interference with normal activities of daily life.
  • Associated other shoulder conditions

 

What are the non-operative treatments?

Non-operative treatment is the most beneficial treatment option for the patients with calcific tendinitis. It is helpful in relieving most of the symptoms. The non-operative treatment can be done by following ways-

  • Medications– It is the first line of treatment in calcific tendinitis.

Painkillers like paracetamol or codeine are given to relieve pain. Topical painkillers are given in the form of gel or cream that can stimulate nerve endings and reduce pain by blocking their supply to the brain.

Anti-inflammatory medicines such as aspirin or ibuprofen are prescribed to control swelling and pain. It is advisable to take these medicines with food as they can damage your stomach and kidneys.

  • Steroid injections– cortisone injections can be given to reduce inflammation in recommended doses. It could be a temporary solution for the condition and its effects may not last long.
  • Physical therapy– physical therapy under the supervision of a physiotherapist is advised to restore your range of motion with the relief of pain. It helps to maintain the strength of your shoulder and reduce the irritation triggered by calcium deposits. In its initial stage, physical therapy can improve the stiffness and can control pain to a great extent.
  • Therapeutic ultrasound- this painless procedure is used to break down calcium deposits with a high-frequency sound wave through a handheld device.
  • Percutaneous needling or needle barbotage- this procedure is a manual removal of the deposit through small holes made in the skin of affected area under local anaesthesia. Ultrasound is done in conjunction with this procedure to view the exact positions of the deposits while piercing.
  • Extracorporeal shock wave treatment (ESWT) – in ESWT, mechanical shocks are given to the affected site near the calcium deposits with the help of a small handheld device. These shocks help to break down the deposits. However, this procedure is painful and effective only when it is given in high frequency. However, this is still in experimental stage and not in widespread use.

 

What does the operation involve?

Only 10 % of cases of calcific tendinitis require surgery. The main purpose of the operation is to remove the calcium deposits from the affected tendon. The procedure is performed with a key hole (arthroscope) and the calcium deposits are removed from the tendon. Most patients need a subacromial decompression to increase the space between the rotator cuff tendons and acromion to reduce mechanical symptoms.

  • The operation is conducted as a day case under general/local anaesthesia, 2-3 small 1cm cuts are made a tiny camera (arthroscope) is inserted through the cut to locate the deposits and the deposit is removed with a surgical tool.
  • The skin is stitched with absorbable sutures and a sling is applied to shoulder for a week to support the joint. The surgical time is usually less than an hour and the majority of the patients go home the same day.

 

What happens after surgery?

  • The effect of local anaesthesia ends in 4- 10 hours after surgery. The patients are encouraged to take painkillers before they can experience pain usually for 48 hours. In this way, many patients do not report pain.
  • The patient is discharged on the same day and advised to take rest.
  • Before discharge, the patient is taught simple gentle exercises of the shoulder. These exercises can be started from the day one after the surgery. These exercises are important to reduce stiffness and pain and restore strength and normal range of motion of the shoulder and arm.
  • Light activities like using a keyboard or writing are allowed if they don’t cause excessive pain or discomfort.
  • The patient is reviewed again after 2 weeks for the check of wound and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • You could start a gentle range of movement (ROM) exercises as tolerated after surgery and progress to more strenuous activities (swimming, driving, lightweights in gym etc). This will be guided by your surgeon. Physical therapy plays an important role in returning back to the normal activities and its vital to work with the physiotherapists to get full function back in your shoulder.
  • Most patients report pain relief in 2-4 weeks after surgery, however this could be longer in some patients (large deposit, chronic problem and severe symptoms before surgery). It could take 3-6 months for full recovery.

 

Are there any risks?

  • Infection
  • Injury to nerves and blood vessels Recurrence
  • Injury to rotator cuff – might need repair that will prolong recovery
  • Shoulder stiffness (frozen shoulder)
  • Persistent pain in the shoulder

 

What are the results of the operation?

The outcome of surgery in calcific tendinitis iis successful in >90 % of the cases with relief of all symptoms in authors hands.

 

When can I return to driving and work?

When you are comfortable and in control of your shoulder, you could return back to work and driving. This usually is after 2-4weeks from surgery. The recovery could be prolonged in some patients based on the size of deposit, symptoms and associated pathology, and your surgeon can advise you more accurately.

Calcific tendinitis of shoulder

  1. 60 year old lady presented with painful shoulder (calcific tendinitis) despite steroid injection and physiotherapy. B. She had arthroscopic (Key hole surgery) removal of calcific deposit. The surgery restored function and movement back to her shoulder.

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