Calcific Tendinopathy of the Shoulder
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Search Strategy[edit | edit source]
Pubmed, Science Direct, Cochrane Library, Medline
"calcific tendonitis” “diagnosis” “treatment” “evaluation”
"calcific tendonitis of the shoulder" "calcific tendinitis examination"
Definition/Description[edit | edit source]
Calcific tendonitis, or "calcium hydroxyapatite crystal deposition disease”[1], refers to the deposition of calcium—predominantly hydroxyapatite—in a tendon, most often in those of the rotator cuff. May be secondary to a local decrease in oxygen tension resulting in fibrocartilaginous metaplasia and resulting calcification.[2]
File:Shoulder.jpg File:Shldr3.jpg
Epidemiology/Etiology[edit | edit source]
Etiology is still unclear.
- Hypovasculariation, but has been removed from both poorly and well-vascularized tissues.
- Compression
- Metabolic factors
- Mesodermal defects
- Local degenerative and proliferative changes
Unlikely Causes[1]:
- Infection and Trauma
- No abnormalities found in blood or urine analyses.
Calcific tendonitis occurs in 2.5%–7.5% of healthy shoulders in adults[2], and 39-62% of those being seen in medical centers for shoulder pain[1]. It's more commonly seen in women (70% of cases) and most frequently during the 5th decade of life, but has been seen in a 3 year-old and a 72 year-old.[2][1]. Right shoulder is more frequently affected but no evidence to support prediscposing factors.[1]
Common locations: [2]
- The supraspinatus tendon (80% of cases): critical zone - Most Common
- Infraspinatus tendon (15% of cases): lower 1/3
- subscapularis tendon (5%of cases): pre-insertional fibers
The consistency of the calcium deposit seems to be correlated with pain severity, not the size. [1]
- Asymptomatic: appear granular or cheesy, and have sharply defined, circumscribed borders.
- Symptomatic: enlarge, liquify, and have less well-defined borders.
"dry powder", "chalk-like", "semi-liquid toothpaste", "milky" and "creamy"
Characteristics/Clinical Presentation[edit | edit source]
Clinical presentation varies.[3]
Calcific tendonitis is a self-limiting condition.[2] Symptoms may last several days or become chronic; there is no clear prediction of disease course. Time required for symptoms to disappear is typically too long for patient’s QoL.[3]
The typical clinical manifestation is a sub-acute, low-grade shoulder pain that increases at night (50% of patients), with restricted range-of-motion.[2]
| Stages[1] | |
|---|---|
| Stage Name | Presentation |
| Chronic (Silent) Phase |
|
|
Acute Painful Phase |
|
|
Mechanical Phase |
|
Differential Diagnosis[edit | edit source]
Pathologies which present similiar to Calcific Tendonitis of the Shoulder:
- Subdeltoid Bursitis[4]
- Subacromial Impingement [4]
- Rotator Cuff Tears
- Adhesive Capsulitis [1]
- Gout [5]
Outcome Measures[edit | edit source]
Outcome measures to track treatment efficacy:
- VAS Pain scale[3]
- UCLA Shoulder Rating Scale[3]
- DASH Outcome Measure
- Radiology/MRI changes[6]
File:Shldr1.jpg File:Shldr2.jpg
Examination[edit | edit source]
As Calcific tendinitis is a soft tissue injury that can only be conclusively diagnosed via imaging, it is important to rule out other shoulder pathologies. In regards to imaging, a minimum of 2 views of the suspected tendon area to rule out avulsion fractures and rule in calcific tendinitis are required. It is recommend that the initial images include the anteroposterior view in neutral, internal, and external rotation[5]. Imaging will provide definitive proof of calcific buildup thru what appear to be “bone spurs”. An ultrasound image of the area is also advised, as this will rule out or rule in any differential diagnoses of soft tissue injuries such as a rotator cuff tear [7]. 20-46.4 % of all cases are bilateral in nature, so all images and examinations should be conducted in a bilateral fashion [8], [5]. Only 35% of cases are symptomatic, so bilateral imaging and examination can detect calcified deposits in an asymptomatic shoulder, if one side is already experiencing calcific tendinitis. This can help to guide treatment and decrease possible patient expenses and future visits.
Since imaging is the only way to diagnose calcific tendinitis, physical examinations will be seek to more-so rule out a condition than to rule in a condition. The examination findings are based on patient history and clinical findings. In regards to history, calcific tendinitis occurs most frequently in the fourth and fifth decades but has been reported in a 3 year old and as late as 72 year old [8], [1]. In most reports, females are more commonly affected than males. And regardless of handedness, the right side has a higher incidence of occurrence[1]. Several systemic diseases are associated with an increased risk of calcification, such as gout, hypercalcemia of any cause, and various rheumatic diseases[9], [5].
The chief patient complaints to expect in calcific tendinitis are:
1.) Night pain, causing loss of sleep (rule out cancer!)[9], [5], [10], [1]
2.) Constant dull ache[1].
3.) Pain increases considerably with AROM[1] (rule out fracture!).
4.) Decrease in ROM, or complaint of stiffness [8], [10], [1].
5.) Radiating pain up into the suboccipital region, or down into the fingers[9], [5], [1].
• Observation-check bilaterally for swelling, atrophy or scapular movement that will indicate compensation for decreased humeral movement.
• Palpation-attention to any swelling, temperature difference, point tenderness. Most specifically, the supraspinatus tendon, as it is the most commonly affected[5]. The infraspinatus, teres minor, subscapularis, and biceps tendons are also involved and follow in incidence in the aforementioned order[1].
• Neuro and cervical screen may indicated as N&T, or radiating pn may be present.
• AROM and PROM-pain and decreased ranges may be present in any, or all planes (depending on tendon(s) involved). Observe end feel, may be empty 2˚ to pain.
• MMT’s-may demonstrate decrease from contralateral side or be limited by pn.
Medical Management
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Physical Therapy Management
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Key Research[edit | edit source]
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Resources
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Clinical Bottom Line[edit | edit source]
Calcific tendinitis is a comparatively common disease with an incidence between 2.7 and 7.5% and minority of cases are symptomatic3. Its unknown etiology and impact on quality of life and function are just two reasons it requires further research. A thorough physical examination and patient history review can help to distinguish it from other pathologies of with a similar presentation. Current best evidence suggests that ……….
Recent Related Research (from Pubmed)[edit | edit source]
References[edit | edit source]
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- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 Wainner R S, Hasz M. Management of Acute Calcific Tendinitis of the Shoulder. JOSPT 1998; vol 27 (3): 231-237.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Serafini G, Sconfienza L, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial. Radiology [serial online]. July 2009;252(1):157-164. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 20, 2011.
- ↑ 3.0 3.1 3.2 3.3 3.4 Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.
- ↑ 4.0 4.1 Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons ... [Et Al.] [serial online]. July 1996;5(4):314-319.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627. Cite error: Invalid
<ref>tag; name "Gimblett" defined multiple times with different content - ↑ Takahashi M, Ogawa K. Calcific tendinitis of the rotator cuff showing a contracted state of abduction: a report of four cases. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons. January 1997;6(1):72-76.
- ↑ Rapp S M. With few advances in calcific tendinitis treatment, diagnosing it becomes critical. Orthopedics Today. 2008; 70.
- ↑ 8.0 8.1 8.2 Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.
- ↑ 9.0 9.1 9.2 Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.
- ↑ 10.0 10.1 Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.
