Calcific Tendinopathy of the Shoulder

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Original Editors

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Search Strategy

Pubmed, Science Direct, Cochrane Library, Medline

"calcific tendonitis” “diagnosis” “treatment” “evaluation”

"calcific tendonitis of the shoulder" "calcific tendinitis examination"

Definition/Description

Calcific tendonitis, or "calcium hydroxyapatite crystal deposition disease”, 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.

File:Shoulder.jpg Siegal D, Wu J, Newman J, Del Cura J, Hochman M. Calcific tendinitis: a pictorial review. Canadian Association Of Radiologists Journal [serial online]. December 2009;60(5):263-272.

Images: Left- 

Epidemiology/Etiology

Etiology is still unclear.

Possible Causes:

• Hypovasculariation, but has been removed from both poorly and well-vascularized tissues.
• Compression 
• Metabolic factors
• Mesodermal defects   
• Local degenerative and proliferative changes

Unlikely Causes:

• Infection and Trauma
• No abnormalities found in blood or urine analyses.

Calcific tendonitis occurs in 2.5%–7.5% of healthy shoulders in adults, and 39-62% of those being seen in medical centers for shoulder pain. 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.. Right shoulder is more frequently affected but no evidence to support prediscposing factors.

Common locations: 

• 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.  

• 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

Clinical presentation varies.

Calcific tendonitis is a self-limiting condition. 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.

The typical clinical manifestation is a sub-acute, low-grade shoulder pain that increases at night (50% of patients), with restricted range-of-motion.

Stages
Stage Name	Presentation
Chronic (Silent)  Phase	Presence of the calcific deposit  is asymptomatic and may be so for years.
Acute Painful Phase	Severe pain, disability, and frequently nocturnal discomfort.
Mechanical Phase	Tendon impingement being a prominent finding Pain of less severe nature than the acute phase

Differential Diagnosis

 Pathologies which present similiar to Calcific Tendonitis of the Shoulder:

• Subdeltoid Bursitis
• Subacromial Impingement 
• Rotator Cuff Tears
  
• Adhesive Capsulitis 
• Gout 

Outcome Measures

Outcome measures to track treatment efficacy:

• VAS Pain scale
• UCLA Shoulder Rating Scale
  
• DASH Outcome Measure
  
• Radiology/MRI changes

Images: 

Examination

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. 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 .  20-46.4 % of all cases are bilateral in nature, so all images and examinations should be conducted in a bilateral fashion ^, . 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 ^, . In most reports, females are more commonly affected than males. And regardless of handedness, the right side has a higher incidence of occurrence. Several systemic diseases are associated with an increased risk of calcification, such as gout, hypercalcemia of any cause, and various rheumatic diseases, .

The chief patient complaints to expect in calcific tendinitis are:
1.) Night pain, causing loss of sleep (rule out cancer!)^, , , 
2.) Constant dull ache.
3.) Pain increases considerably with AROM (rule out fracture!).
4.) Decrease in ROM, or complaint of stiffness ^, , .
5.) Radiating pain up into the suboccipital region, or down into the fingers, , .

• 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. The infraspinatus, teres minor, subscapularis, and biceps tendons are also involved and follow in incidence in the aforementioned order.

• 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

Most current medical treatment approaches for calcifying tendonitis involve removal or downsizing of the calcium deposit(s). This is usually accomplished excision or surgery, or by attempting to activate the body’s natural calcium resorption processes. First line treatments, especially in primary care offices, are most often non-steroidal anti-inflammatory drugs, or possibly local steroid injections. These treatments are done with the goal of decreasing pain and inflammation, but there is little evidence that they promote resorption of the calcium deposits. In fact, some researchers believe steroid drugs may actually inhibit the resorption process (Uhthoff).

Needle aspiration of medium to large (>1.5cm) calcium deposits is easily administered in the outpatient setting, and has evidence showing positive outcomes up to 2 years post treatment. The procedure is done under local anesthesia, with ultrasound guidance. Two needles pierce the deposit; one to evacuate the toothpast-like calcium, and one to flush the shell with saline. Evidence shows that this process is most effective when the disease is in the acute phase, and the calcium within the deposit is viscous enough to be aspirated by a large bore needle. Once progressed to the chronic stage, the calcium in the deposit is too solid in consistency to be aspirated, thereby limiting the effectiveness of the treatment.

Arthroscopic excision of the deposit is argued by some to be the best treatment option for patients in the chronic stage of calcific tendonitis. This procedure has an advantage over needle aspiration in that it can remove hardened deposits that can’t be drawn through a needle bore. Performing any surgical procedure local to the affected tendon, like any acute injury, will stimulate the body’s calcium resorption system, which will help rid the tendon of any further deposits left behind after surgery. There is currently debate among surgeons concerning acromioplasty during procedures for deposit excision. Some believe that symptoms caused by calcific tendonitis is independent from rotator cuff impingement, and therefore the procedure doesn’t need to be performed if a type III acromion is not observed. (Neer, Uhthoff) Others have demonstrated that even with small diffuse deposits, pain is not relieved from excision alone, and relief only comes after subsequent acromioplasty. (Resch)

Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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 only help to distinguish it from other pathologies of  with a similar presentation as imaging is the only definitive diagnosis. Since the condition will often present as a number of other pathologies, treating calcific tendinititis with traditional therapy, based on a wrongly hypothisized pathology will result on little to no improvement of symptoms. If this situation presents in the clinic, imaging must be ordered to rule out calcific tendinitis. Current best evidence suggests that shockwave therapy has benefits to reabsorption of the calcific deposit. Impairment based therapy is still believed to be of greatest benefit thru increasing blood flow to allow the bodys natural reabsorptive processes to work.

Recent Related Research (from Pubmed)

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References

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