Calcific Tendonitis

Calcific tendonitis refers to a build-up of calcium in the rotator cuff (calcific deposit). When calcium builds up in the tendon, it can cause a build-up of pressure in the tendon, as well as causing chemical irritation. This leads to pain. The pain can be highly intense. It is one of the worst pains in the shoulder (the other being Frozen Shoulder).

Calcific Tendonitis

Demographics

typically affects patients aged 30 to 60
more common in women

Anatomic Location

Supraspinatus tendon is most often involved

Risk factors

Commonly associated with endocrine disorders

diabetes
hypothyroidism

There are three stages of calcification

Precalcific (Before the formation of calcific deposits)

Clinically this stage is pain-free

Calcific

Subdivided into three phases

Formative phase
formation of calcific deposits
Resting phase
No inflammation
resorptive phase
Marked inflammation
clinically this phase is most painful

Postcalcific
Improvement of symptoms

In addition to the chemical irritation and pressure, the calcific (calcium) deposit reduces the space between the rotator cuff and the acromion. It affects the normal function of the rotator cuff. This can lead to subacromial impingement between the acromion and the calcium deposit in the rotator cuff when lifting the arm overhead.
The cause of the calcium build-up in the rotator cuff is not known. It tends to be more common in people between the ages of 30-60 years of age. It does eventually disappear spontaneously, but this can take between 5 to 10 years to resolve.
Calcific deposit in the rotator cuff of the shoulder.

Diagnosis

The calcific deposit can be seen on plain x-rays. However, an ultrasound scan is better to find small calcific deposits which can be missed on x-rays. Ultrasound also makes it possible to assess the size of the deposit in all directions. The clinician can also see the blood vessels around the calcific deposit.

Treatment

Treatment of calcific tendinitis involves:

1. Painkillers and anti-inflammatory medications
2. Physiotherapy – keeps your shoulder strong and flexible and reduce the irritation
3. Cortisone steroid injections – reduces inflammation and control the pain
4. Ultrasound-guided Barbotage – under ultrasound guidance, the calcific deposit is injected with a saltwater solution, and the calcium is also sucked out into a syringe. The area is then repeatedly washed.
5. Surgical excision

US Guided Barbotage

Ultrasound guided barbotage therapy is an outpatient treatment. A diagnostic ultrasound scan is performed firstly. The skin is then marked and sterilized and local anaesthetic is given. Using the ultrasound image, the needle is guided into the calcification under direct vision. The calcification will then be attempted to be aspirated/withdrawn. To encourage healing the calcification is punctured several times under local anaesthetic. Finally, the tendon is bathed in some more local anaesthetic.
There is a very small risk of introducing infection and if you are allergic you may react to the drugs. It can be a painful procedure, although with local anaesthetic most people tolerate the procedure. There is a 60-70% chance of significant or complete improvement in symptoms and return to activities. About one third of patients may not respond and may ultimately require surgery.

Can I drive afterwards?

You are advised to have somebody drive you home after the procedure as you may be in discomfort afterwards. You can return to driving the following day.

Surgery for Calcific Tendonitis

Surgery is required if the pain is not controlled with the methods above and/or the pain is severe, with night pain.
The goal of any surgery is to reduce the effects of impingement by increasing the amount of space between the acromion and the rotator cuff tendons, allowing for easier movement and less pain and inflammation. The calcium deposit is also debrided and released at the same time. The operation performed is Arthroscopic Subacromial Decompression & Excision of the Calcific Deposit.

Summary

• Calcific tendonitis is the calcification and tendon degeneration near the rotator cuff insertion, most commonly leading to shoulder pain with decreased range of motion.
• Diagnosis can be made radiographically with orthogonal radiographs of the shoulder showing calcium deposits overlying the rotator cuff insertion.
• Treatment is a course of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Arthroscopic decompression of the calcium deposit is indicated for patients with progressive symptoms having failed conservative measures.