Calcifying / calcific tendonitis (CT)

Terminology is calcifying and not calcific due to the evolving nature of the condition, with a strong tendency to self limiting. It is not a degenerative process.

CT is a common idiopathic disorder of the shoulder in which a multifocal, cell-mediated calcification (calcium phosphate crystals) in a living tendon is usually followed by spontaneous phagocytic resorption. The tendon reconstitutes itself after resorption or surgical removal of the calcium deposit.

The pathogenesis is poorly understood with several different theories, but there appears to be an association between CT and endocrine disorders (diabetes, thyroid, oestrogen levels). It is more common in females than in males and most often occurs in the 4th and 5th decade. There is no difference between dominant and non-dominant side. Most commonly affected tendons are in order supraspinatus, infraspinatus, subscapularis.

Presentation

Depending on stage and extend of calcium deposit.

Uhthoff’s stages:

In the resorptive phase: acute severe constant pain with reluctance to move, and grossly limited passive and active range of movement (ROM).

In chronic calcifying tendinitis (when the normal healing cycle has been blocked), the presentation consists of mechanical signs of impingement.

The main diagnostic test is X-ray.

• Chronic: Painful Arc and Hawkins for impingement.
• Acute: Severe restricted ROM (active and passive).

Plain radiographs (X-ray). It must be noted that X-ray findings do not often correlate with symptoms.

Overview

• Optimise pain management
• Conservative management
• NSAIDs, PKs, rest, advice
• Consider CSI if pain problematic

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Conservative Management

90% heal/settle with conservative management (NSAID’s, PK’s, rest, ice, advice).
There is no clear evidence as to what is effective conservative management. Many treatments have been proposed but with varying effects. The available studies are limited and of poor quality.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

CSI for pain relief but no effects on calcium deposit.

Refer for surgical opinion (needle aspiration, arthroscopy with decompression and debridement) when spontaneous resolution and conservative management fails.

There is an intriguing link between CT and primary contracted shoulder. The pathological processes of both conditions are still largely unclear. Common features are intense pain, night pain, decreased ROM and natural history is towards self- limiting over time.

Farin, P.U., Rasanen H., Jaroma, H. and Harju, A., 1996. Rotator cuff calcifications: Treatment with ultrasound-guided percutaneous needle aspiration and lavage. Skeletal Radiology, 25 (6), 551-554.

Green, S., Buchbinder, R., and Hetrick, S.E. 2003. Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 2.Art. No.: CD004258. DOI: 10.1002/14651858.CD004258. Link Here (link correct as of 18/03/2024).

Hanchard, N., Cummins, J., and Jeffries, C. 2005. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of shoulder impingement syndrome. The Chartered Society of Physiotherapy, 1-101.

Hofstee, D.J., Gosens, T., Bonnet, M., and De Waal Malefijit, J. 2007. Calcifications in the cuff: take it or leave it? British Journal of Sports Medicine, 41 (11), 832-835. Link Here (link correct as of 18/03/2024).

Hughes, P.J., and Bolton-Maggs, B. 2002. Calcifying tendinitis. Current Orthopaedics, 16(5), 389-394. Link Here (link correct as of 18/03/2024).

Maugers, Y., Varin, S., Gouin, F., Huguet, D., Rodet, D., Nizard, J., N'Guyen, J.M., Guillot, P., Glemarec, J., Passutti, N., and Berthelot, J.M. 2009. Treatment of shoulder calcifications of the cuff: A controlled stufy. Joint Bone Spine, 76(4), 369-377. Link Here (link correct as of 18/03/2024).

Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Shoulder Pain. 2001. Physical Therapy, 81(10), pp. 1719-1730. Link Here (link correct as of 18/03/2024).

Riley, D.C., Kaufman, M., Ward, T.M., Acevedo, Y., Guerra, R., and Folorunsho, A. 2013. Emergency department diagnosis of supraspinatus tendon calcification and shoulder impingement syndrome using bedside ultrasonography. Clinical Ultrasound Journal, 5(1), 2-4.

Uhthoff, H.K., and Sarkar, K. 1989. Calcifying Tendinitis, Balliere's Clinical Rheumatology 3(3); 567-581. Link Here (link correct as of 18/03/2024).