What is calcific tendonitis?Calcific tendonitis (shoulder calcification, shoulder pain) is a condition situated in the area within the tendons of the rotator cuff, particularly around the supraspinatus tendon. It is caused by insufficient blood supply to the rotator cuff, leading to reactive calcium deposits on the tendon insertions.
How does calcific tendonitis progress?
One can distinguish four stages in the course of this disease:
1. Phase of cellular changes:
During this phase, the tendon tissue is transformed into fibrocartilage. Patients usually do not feel pain at this stage, or if they do, very little.
2. Calcification stage:
Parts of the cartilage tissue die and calcium deposits are formed. This condition is visible through ultrasound examination and later by means of an X-ray. When the shoulder tendon bulges considerably, an acromion tightness can be a consequence when lifting the arm overhead. This means that all the tendons that slide under the acromion, in particular the supraspinatus tendon and the subacromial bursa, become irritated and this may lead to the painful condition of subacromial impingement syndrome.
3. Resorptive stage:
During this stage, the calcium deposit is resorbed, accompanied by a severe and often extremely painful inflammatatory response. When single calcium deposits reach the subacromial bursa, this may cause an inflammation of the bursa (subacromial bursitis).
4. Postcalcific stage:
Once the calcium deposit is resorbed, a relapse is extremely rare.
Not every calcific tendonitis undergoes each stage, the shoulder can pause at any one. As a rule, calcific tendonitis is not very painful; some patients do not experience any discomfort at all. The patient may experience episodes of acute pain due to the tendonitis progressing in stages.
The symptoms of patients suffering from calcific tendonitis can vary considerably as it depends on the size of the calcium deposit and the stage of the disease.
Possible symptoms of calcific tendonitis :
• Pain on the affected side when lying in the lateral position
• Pain under pressure or strain
• Pain when working whilst lifting the arms overhead
• Sudden spontaneous shoulder pain
• Pseudoparalytic shoulder (very limited range of arm motion)
Causes of calcific tendonitis
Calcific tendonitis (shoulder calcification) is caused by restricted blood flow in the rotator cuff. This leads to a localised rise of pressure in the tendon tissue and thus to a lack of oxygen.
Why can neck pain result from calcific tendonitis?
When calcium deposits lock the joint, irritate the tendon insertions and cause pain, the patient tends to adopt a protective posture, which can lead to a frozen shoulder. This condition is a painful restriction of the gleno-humeral mobility due to a bursitis and an inflammation of the shoulder joint capsule, resulting in a thickening, followed by a shrinking of the shoulder joint capsule. The patient has a tendency to stop using the shoulder, which fosters a further shrinking of the capsule.
Normally the arm can be lifted through the shoulder joint up to an abduction angle of 90°. The remaining 90°, up to a full gleno-humeral abduction of 180° (overhead lifting), are performed through sliding movements of the shoulder blade on the thorax (see film). When the shoulder joint capsule shrinks as a result of the inflammation, the patient adopts a protective posture to minimise pain, and the arm no longer moves via the gleno-humeral joint but via the sliding movement of the shoulder blade only. This leads to an overstrain of the neck muscles, as they are responsible for the movement of the shoulder blade. The muscles become so tense, that the whole neck and upper back hurt, which often makes the patients believe that their actual problem is not shoulder calcification but muscular strain.
Like a pebble that pinches in a tight shoe and pierces the sock, the calcium deposit causes damages in the tendon tissue. As a result, the tendon becomes brittle, cracked, loses its mechanical resistance and eventually tears.
If therapy is begun too late, the damage is often irreparable, with the tendon tearing even after stitching.
How is the diagnosis made?
Existing calcium deposits of a calcific tendonitis can be seen on an X-ray or ultrasonically. Magnetic resonance imaging (MRI) is not an option as it cannot clearly visualise calcium deposits.
What is the treatment of Calcific tendonitis?
In cases of an acute subacromial bursitis implicating severe pain, the arm can be put into a shoulder orthosis (bandage) for a short time to give relief to the patient. Anti-inflammatory painkilling medication and the application of ice (cryotherapy) can reduce pain and inflammatory processes. The injection of a light anaesthetic into the area brings quick relief.
As soon as pain is alleviated, physiotherapy should begin in order to relieve the shoulder tendons and to preserve the shoulder joint's mobility. With recurrent pain, the use of shockwave therapy may be successful. Shock waves are repeatedly applied to the calcified area, triggering biological processes which then break down the calcium deposit.
If the above mentioned conservative treatments fail to bring relief, if the patient is experiencing persistent pain or if the calcium deposit is larger than 0.39 square inch and of a hard consistency, surgery to remove the deposit may be necessary. Often the calcifying tendonitis of the shoulder heals spontaneously and the majority of people do not need surgery, but sometimes it is inevitable that deposits will need to be removed. In this case the surgeon broadens the subacromial space, usually through minimally invasive arthroscopic surgery. During the arthroscopy a diagnosis of further lesions can be made (e.g. arthritis, torn rotator cuff) and it may be possible to treat them also during the intervention.
After the surgery, the shoulder should be rested for approximately three weeks. Physiotherapy will then help to preserve the shoulder's mobility.
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