Calcific Tendonitis of the Shoulder

Calcific Tendonitis Classification

There are several classifications of calcific tendonitis (see table 1). The classification used varies between practitioners and can be associated with the duration of clinical symptoms, degree of calcium invasion, association with or without endocrine disease, size, and morphology of the calcium deposit. For example, Neer’s classification divides pain and calcium deposit progress.  

Table 1: Classification of calcific tendonitis^(2-4).

Clinical Presentation

Calcific Tendonitis Diagnosis

Treatment

Conservative management
The primary treatment of calcific tendonitis is conservative, with a 30 to 80% success rate^(6,7). Nonsurgical treatment would include addressing the pain by taking oral painkillers and non-steroidal anti-inflammatory medication. While taking the medication, physiotherapy treatment can begin. Physiotherapy aims to create "space" in the glenohumeral joint. The calcium deposit takes up space either in or around the tendon. Manual therapy techniques assist in mobilizing the joint and soft tissue structures. Clinicians can prescribe gentle glenohumeral capsule, and rotator cuff muscle stretches to create space for the tendon to move within the subacromial space. Patients can start active assisted stretches in their home exercise program. The intention is to improve and maintain the range of motion and maximize functional levels. 

Subacromial steroid injection is performed by specialists when pain levels are severe. Another treatment done by orthopedic surgeons is needle aspiration and irrigation⁽⁷⁾. Extra-corporeal shockwave therapy is a more recent treatment choice⁽⁷⁾. This therapy utilizes acoustic waves to induce fragmentation of the crystals. Furthermore, clinicians may use ultrasound-guided barbotage, where under ultrasound guidance, they inject the calcific deposit with a saline solution and then remove the calcium into a syringe. The area is then repeatedly washed out⁽⁶⁾. 

Surgical management
Clinicians may recommend surgery when conservative options fail to manage pain intensity⁽⁷⁾. Surgery intends to reduce the effects of impingement and is typically arthroscopic, where surgeons make two or three mini-incisions around the shoulder joint. Through these key-hole incisions, they insert a camera and other surgical instruments to remove the calcium from the tendon under magnified vision. In its acute form, the calcium is paste-like, and surgeons can easily remove it with a fine needle. However, in its chronic presentation, the calcium tends to be more "stuck" and is not removed with as much ease. Depending on the size and location of the calcium deposit, the tendon is sometimes damaged when removing the deposit, requiring a complete surgical rotator cuff repair.

Post-surgery, there should be a dramatic relief of pain. Due to the phases of healing, a typical recovery in regaining range of motion and muscle power should be three to five months. This is influenced by how much of the calcific deposit occupied the tendon and thus affected when removing the calcium deposit.

The first phase of post-operative physiotherapy is to reduce the pain by managing swelling and inflammation around the glenohumeral joint. Electrotherapy, cryotherapy (ice application), and manual therapy are key modalities in the early healing phase. Once the pain and inflammation have settled, the next goal is to regain full shoulder range of motion. The physiotherapist should include accessory and physiological mobilization of the scapula and glenohumeral joints. Clinicians can include passive and active stretches to improve ROM. A home exercise program should include applying ice, gentle stretches, and introducing stability and strength exercises as the patient progresses through the tendon healing phases.

Conclusion

Calcific tendonitis is not a diagnosis that anyone would choose. However, several successful conservative and surgical solutions are available. Physiotherapy is a key part of either journey. The patient needs to wear their "patience cap" as there are no shortcuts to manage this complex diagnosis. Clinicians need to prioritize pain management to reduce the disuse consequences. Furthermore, they should manage the patient’s expectations and provide clear advice on recovery timelines and treatment options. 

References

1. J Shoulder Elb 2020 Dec; 23 (4):  210 – 216
2. Clin Orthop. 1961; 20:  61 – 72
3. R I Med J.  1953; 36:  512 – 516
4. Neer CS II, editor. Shoulder Reconstruction. PA:  WB Saunders; 1990. 421 – 485
5. Br J Sports Med 2008. 42: 628 - 635
6. Acta Biomed 2018; 89, 1: 186-196
7. J Orthop Traumatol. 2016 Mar; 17(1): 7–14