AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Painter described calcification in the shoulder in 1907. Codman established that the calcification was within the tendons of the rotator cuff. Calcifying tendinitis of the shoulder is characterized by the presence of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff.¹ This article addresses only calcifying tendinitis as it occurs in the shoulder. (See also the eMedicine article Rotator Cuff Disease.)

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Tendinitis.

Problem

Even supraspinatus tendons that are macroscopically normal contain minute amounts of calcium deposits. Degenerative tendons that have ruptured contain more calcium deposits, but it is not always in the form of calcium phosphate. The increase in calcium deposits is due to degenerative calcification.² In contrast, the calcium in tendons with radiographically visible calcification is in the form of crystalline hydroxyapatite. Calcifying tendinitis is a different condition from that of degenerative tendons in which there is a small increase in calcium content.

The diagnosis of calcifying tendinitis is made from imaging studies or from direct inspection of the affected tendon. Therefore, it is a description of a morphologic status. This condition may be an incidental finding in an asymptomatic shoulder, or it may be the cause of shoulder pain.³ However, calcification may be found in a painful shoulder and yet not be the cause of pain. Indeed, considering that calcific deposits are found in 3-20% of painless shoulders and 7% of painful shoulders, the calcific deposit may not be the cause of shoulder pain in many cases.

Frequency

The incidence of rotator cuff calcification without shoulder symptoms in the general population is 3-20% according to different reports. The highest incidence is in adults aged 30-50 years.⁴ The incidence of symptomatic calcifying tendinitis appears to have declined in the last 20-30 years.

The supraspinatus tendon is affected most often. Calcification is observed with decreasing frequency in the infraspinatus, teres minor, and subscapularis tendons. More than one tendon may be involved. Women are affected slightly more frequently than are men (housewives and clerical workers account for most cases), and the right shoulder is affected slightly more often than the left is. Both shoulders can have or develop calcific deposits in 13-47% of subjects, and the calcific deposit usually is described as being approximately 1-2 cm proximal to the tendon insertion on the greater tuberosity.

Etiology

The cause of calcifying tendinitis is not known. It is generally agreed that it is not caused by trauma, and it is rarely part of a systemic disease.

Pathophysiology

The pathophysiology of calcifying tendinitis is controversial. The early hypothesis of Codman and others was that the calcification is a consequence of age-related tendon degeneration; however, this is not supported by the following observations:

• The peak incidence of calcifying tendinitis occurs at an earlier age than that of degeneration.
• Calcifying tendinitis, in contrast to degenerative tendinopathy, may resolve, and the tendon heals spontaneously.
• Calcifying tendinitis is rarely associated with tears of the rotator cuff.
• The chemical composition of the calcium salts in degenerate tendons is different.
• The calcific deposit of calcifying tendinitis consists of poorly crystallized hydroxyapatite.
• Calcifying tendinitis appears to occur in viable, not necrotic, tissue, whereas dystrophic calcification appears to occur in necrotic tissue.

Uhthoff and Loehr proposed that calcifying tendinitis is a disease that progresses through correlating pathologic and clinical stages, as follows⁵:

• Formative phase: As a consequence of an unknown trigger, a portion of the tendon undergoes fibrocartilaginous transformation, and calcification occurs in the transformed tissue. The deposit enlarges; the calcific deposit resembles chalk.
• Resting phase: Once formed, the calcific deposit enters a resting period. The calcific deposit may or may not be painful. If large enough, the deposit may cause mechanical symptoms.
• Resorptive phase: After a variable period, an inflammatory reaction may ensue. Vascular tissue develops at the periphery of the deposit. Macrophages and multinuclear giant cells absorb the deposit during this phase. The calcific deposit resembles toothpaste and occasionally leaks into the subacromial bursa, which may result in very painful symptoms.
• Postcalcific phase: Once the calcific deposit has been resorbed, fibroblasts reconstitute the collagen pattern of the tendon.

Clinical

Calcifying tendinitis is a morphologic condition. It may be discovered serendipitously by an imaging study and cause no symptoms. If and when this condition is symptomatic, calcifying tendinitis may present in the following 3 ways:

1. Chronic, relatively mild pain with intermittent flares, similar to shoulder impingement syndrome, is believed to indicate that the condition is in the formative phase.
2. Mechanical symptoms may arise from a large calcific deposit, which may block elevation of the shoulder.
3. More severe acute pain is attributed to the inflammatory response of the resorptive phase.

The pain commonly radiates from the point of the shoulder to the deltoid insertion and, less frequently, to the neck. It is often aggravated by elevation of the arm above shoulder level or by lying on the shoulder. Pain may waken the patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder.

Physical examination

Patients with chronic or subacute symptoms may demonstrate loss of range of motion, a painful arc of motion from 70-110º of forward elevation, or impingement signs. Catching or crepitus may be noted. In the acute phase, the pain may be so severe that only little movement is allowed, and the tenderness is very marked. Laboratory studies are not required for the diagnosis of calcifying tendinitis.

INDICATIONS

Section 3 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The indications for surgical treatment of calcifying tendinitis are progressive symptoms, failure of conservative care, interference with the activities of daily living, and the patient's request.

CONTRAINDICATIONS

Section 4 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The presence of local infection is a contraindication to invasive treatment. Allergies to medications contraindicate the use of the offending agents.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Imaging Studies

• Plain x-rays
• • Plain x-rays demonstrate calcific deposits. Routine shoulder views, true anteroposterior (AP) and lateral views, AP views with the shoulder in internal and external rotation, axillary views, and supraspinatus outlet views should be sufficient to demonstrate calcification in any rotator cuff tendon. The sensitivity of plain x-rays for detecting calcific deposits is 0.90 (when using ultrasonography as the standard).
  • The calcific deposit can be characterized by its location (ie, which tendon is affected) and by its size. Symptoms usually occur if the deposit is larger than 1.5 cm, although one study found no correlation between the size of the deposit and the severity of the symptoms.
  • Many authors have noted the varying appearances of the calcific deposits. Two types of deposits have been recognized: a localized, homogeneous deposit with well-defined limits, which has been identified with the formative or resting phases, and a more diffuse, heterogeneous, amorphous, fluffy deposit that has a poorly defined periphery, which has been identified with acute symptoms and with the resorptive phase. However, poor correlation exists between the appearance of a calcific deposit on plain x-rays and its consistency on needling.⁶
• Arthrograms with radiopaque dye are not required to diagnose calcifying tendinitis, but if a rotator cuff tear is suspected, an arthrogram will demonstrate it.
• Computed tomography (CT) scanning may be used to accurately localize the calcific deposit, but this modality is probably unnecessary.⁶
• Magnetic resonance imaging (MRI)
• • The calcific deposit causes decreased signal intensity on T1-weighted images.^{7, 8}
  • If edema is present around the calcific deposit, as might occur in the resorptive phase, increased signal intensity around the calcific deposits may be present on T2-weighted images.⁷ Do not misinterpret this increased area of signal intensity that is due to edema as a rotator cuff tear.
  • MRI is not necessary to detect calcifying tendinitis, although its accuracy for finding calcification is more than 95%.
• Ultrasonography
• • Ultrasonography depends heavily on the skill of the technologists and the interpreting radiologist.
  • In experienced hands, ultrasonography is more sensitive than plain x-rays are.
  • Ultrasonography does not expose the patient to radiation.
  • Identification of soft, fluffy calcific deposits with ultrasonography is more accurate than with plain x-rays.⁶

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Medical therapy

General considerations

Treatment of calcifying tendinitis varies with the clinical and radiologic phase of the calcification. Although the resorptive phase is usually self-limited, patient pain may be severe, and the need for relief may be urgent. Needling, aspiration, and lavage are more likely to be successful in this phase. In the formative or resting phases, symptoms are milder and chronic. Lavage is less likely to be successful; however, extracorporeal shock wave therapy (ECSW) may be indicated in this phase.

In a matched-pair analysis of 100 patients who were monitored for 3-5 years, Wittenberg et al demonstrated that operative treatment gave significantly better and faster pain relief, more resolution of the calcium deposits, and fewer rotator tears than conservative treatment.⁹

Nonoperative treatment is widely recommended and reported to be successful in most cases. For example, Wolk and Wittenberg reported that 70% of their 159 patients had a good result within 49 months after nonoperative treatment and that, by 104 months, the calcific deposits were no longer detectable by ultrasonography in 82% of cases.¹⁰

Medications

Analgesics of the appropriate strength are indicated. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed. The analgesic properties of these agents are presumably useful, but the effectiveness of their anti-inflammatory properties for treatment of calcifying tendinitis has not been established.

Physical therapy

Exercises are prescribed to maintain or regain the patient's shoulder range of motion and all muscle strength. Physical therapy modalities are frequently employed with unknown effectiveness. Such modalities include electroanalgesia, ice therapy, and heat. Ultrasound is ineffective according to a controlled study quoted by Perron and Malouin.¹¹

Iontophoresis

Although uncontrolled studies of acetic acid iontophoresis have reported successful results, in a controlled study, acetic acid iontophoresis combined with ultrasound provided no better clinical results or shrinkage of the calcific deposits than did no treatment.¹¹

Extracorporeal shock wave therapy

ECSW uses sound waves that are focused to a point within the target tissue. The mechanism of action of ECSW on calcifying tendinitis is unknown. It is probably not simply a mechanical disintegration of the calcific deposit; a tissue response is required to absorb the calcium deposit.

The results of ECSW depend on the energy of the waves and on the number of pulses. The optimal dose has not yet been established. The advantages of ECSW are its noninvasiveness and low complication rates, although hematomas develop in most patients (80% for all musculoskeletal areas). However, the procedure is painful, and the use of high-energy shock may require anesthesia.

Loew et al reported a large series of patients treated with ECSW, using either electrohydraulic or electromagnetic generators and different dosages.¹² With different protocols, 30-70% of patients obtained pain relief, and in 20-77% of cases, the calcific deposit disappeared or disintegrated. The best results were observed following 2 applications of high-energy shock waves.¹²

Rompe et al reported that good or excellent results were achieved in 52% of patients who received low-energy ECSW and in 68% of those who received high-energy ECSW.¹³ Partial or complete disintegration of the calcific deposit was observed in 50% and 64% of patients receiving low- and high-energy ECSW, respectively. The higher energy could be applied only after regional anesthesia had been induced. Clinical results are significantly better if the calcific deposit disappears. Similarly, Seil et al obtained at least some resorption of the calcium deposits in patients given 2 low-energy applications (32%) and high-energy applications (48%) of ECSW.¹⁴

A meta-analysis of 24 papers by Heller and Niethard that reported the results of ECSW for a variety of musculoskeletal conditions, not just for calcifying tendinitis, suggested that ECSW was as effective as established methods of treatment.¹⁵

Injections, needling, and lavage

Breaking up the calcific deposits by repeatedly puncturing them with a needle, aspirating the calcific material, usually with the help of repeatedly injecting and aspirating saline, is a commonly advised treatment. Some operators use 2 needles to facilitate the lavage of the subacromial space. Arthroscopic treatment is similar. The deposit can be localized by fluoroscopy or by ultrasonography.

According to some reports, injection of a local anesthetic alone gives good results, as does needling. In one study, 13 of 23 patients obtained a good result from needling and aspiration; in another study, good results were achieved with needling and an injection of a corticosteroid. 

The use of corticosteroid injections is controversial. In separate reports, Harmon and Murnaghan found no difference in results, whether a corticosteroid was injected with the local anesthetic or not.^{16, 17} There is some suggestion that a corticosteroid injection provides more prolonged analgesia following the injection.

Needling can be combined with lavage, in which the subacromial space is flushed with saline after the calcific deposits are broken up by repeated needling. Farin et al demonstrated excellent results with needling and lavage in 45 of 61 patients (74%) at 1-year follow-up.¹⁸ The calcification had disappeared or diminished in 74% of cases. Pfister and Gerber reported that this procedure was completed successfully in 76% of 62 shoulders in their case series, and it produced significant improvement.¹⁹

Radiotherapy

Historically, radiation therapy was used for calcifying tendinitis. In a controlled trial, no difference in results was demonstrated, whether or not a lead shutter was placed in front of the x-ray source. Due to its possible adverse consequences, radiation is no longer used to treat calcifying tendinitis.

Surgical therapy

An open or an arthroscopic approach may be used for surgical treatment.^{20, 21, 22} An arthroscopic procedure provides a better cosmetic result and possibly a shorter rehabilitation,⁹ but arthroscopic localization of the calcific deposits is technically demanding. Preoperative ultrasonic localization and probing with a needle are helpful.^{23, 24} Once the calcific deposit is localized, it can be needled and aspirated under arthroscopic control or teased out of the tendon with a hook through a longitudinal (coronal) incision in the tendon. The subacromial space is then thoroughly irrigated.

In an open procedure, the tendon is similarly incised, the deposit is curetted out, and adjacent tendon edges are debrided and, if necessary, reapproximated. Postoperatively, a sling is used for 3 days. Range-of-motion exercises are then started.

Gschwend reported eventual good arthroscopic results in 90% of cases.²⁵ At an average of 4 years following open subacromial decompression and removal of the calcific deposit, 88% of 122 patients had good results.²⁵ McKendry et al reported that 60% of patients were pain free 6 weeks following the operation, and 70% were pain free at 12 weeks.²⁵

American and European multicenter experiences have revealed excellent results from arthroscopic treatment. The necessity for routinely adding acromioplasty is debated, but it has been reported that 10% of patients in whom acromioplasty was omitted later required a second operation.²⁶

COMPLICATIONS

Section 7 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Calcification can recur following surgical treatment. Rupp et al reported a 16% incidence of recurrence,⁴ and Wittenberg et al reported an 18% incidence.⁹

OUTCOME AND PROGNOSIS

Section 8 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

In general, it appears that the acute severe symptoms of calcifying tendinitis are likely to resolve spontaneously within 3 weeks. Chronic symptoms also tend to resolve over a period of months to a few years, although some have been reported to persist up to 15 years. Initially, asymptomatic shoulders with calcific deposits have been reported to become painful. This tendency for spontaneous recovery means that the effectiveness of any treatment can be established only with controlled trials.

A 2-year follow-up of 24 patients treated by arthroscopic subacromial decompression who had calcific deposits demonstrated that in 19 patients (79%), the calcific deposits became smaller, although they had not been touched.²⁷ The postoperative clinical results of these patients were indistinguishable from those of matched patients without calcific deposits who underwent similar decompressions.

FUTURE AND CONTROVERSIES

Section 9 of 10  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The role of ECSW for treating calcifying tendinitis is still being evaluated. To date, studies appear to indicate this technique is of value in alleviating the shoulder pain and loss of function caused by calcifying tendinitis.^{28, 29}

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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2. Riley GP, Harrall RL, Constant CR, Cawston TE, Hazleman BL. Prevalence and possible pathological significance of calcium phosphate salt accumulation in tendon matrix degeneration. Ann Rheum Dis. Feb 1996;55(2):109-15. [Medline]. [Full Text].
3. Re LP Jr, Karzel RP. Management of rotator cuff calcifications. Orthop Clin North Am. Jan 1993;24(1):125-32. [Medline].
4. Rupp S, Seil R, Kohn D. [Tendinosis calcarea of the rotator cuff] [German]. Orthopade. Oct 2000;29(10):852-67. [Medline].
5. Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg. Jul 1997;5(4):183-191. [Medline].
6. Farin PU. Consistency of rotator-cuff calcifications. Observations on plain radiography, sonography, computed tomography, and at needle treatment. Invest Radiol. May 1996;31(5):300-4. [Medline].
7. Loew M, Sabo D, Mau H, Perlick L, Wehrle M. [Proton spin tomography imaging of the rotator cuff in calcific tendinitis of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1996;134(4):354-9. [Medline].
8. Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. J Shoulder Elbow Surg. Jul-Aug 1996;5(4):314-9. [Medline].
9. Wittenberg RH, Rubenthaler F, Wölk T, et al. Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients. Arch Orthop Trauma Surg. 2001;121(1-2):56-9. [Medline].
10. Wölk T, Wittenberg RH. [Calcifying subacromial syndrome--clinical and ultrasound outcome of non-surgical therapy] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1997;135(5):451-7. [Medline].
11. Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. Apr 1997;78(4):379-84. [Medline].
12. Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. J Bone Joint Surg Br. Sep 1999;81(5):863-7. [Medline]. [Full Text].
13. Rompe JD, Bürger R, Hopf C, Eysel P. Shoulder function after extracorporal shock wave therapy for calcific tendinitis. J Shoulder Elbow Surg. Sep-Oct 1998;7(5):505-9. [Medline].
14. Seil R, Rupp S, Hammer DS, et al. [Extracorporeal shockwave therapy in tendionosis calcarea of the rotator cuff: comparison of different treatment protocols] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1999;137(4):310-5. [Medline].
15. Heller KD, Niethard FU. [Using extracorporeal shockwave therapy in orthopedics--a meta-analysis] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1998;136(5):390-401. [Medline].
16. Henningan SP, Rome AA. Calcifying tendinitis. In: Ianotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Managament. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.
17. Uhthoff HK, Sarkar K. Calcifying tendonitis. In: Rockwood CA, Matsen FA III, eds. The Shoulder. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1990.
18. Farin PU, Räsänen H, Jaroma H, Harju A. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage. Skeletal Radiol. Aug 1996;25(6):551-4. [Medline].
19. Pfister J, Gerber H. Chronic calcifying tendinitis of the shoulder-therapy by percutaneous needle aspiration and lavage: a prospective open study of 62 shoulders. Clin Rheumatol. May 1997;16(3):269-74. [Medline].
20. Boyer T. [Arthroscopic treatment of calcifying tendinitis of the rotator cuff] [French]. Chir Main. Nov 2006;25 Suppl 1:S29-35. [Medline].
21. Jacobs R, Debeer P. Calcifying tendinitis of the rotator cuff: functional outcome after arthroscopic treatment. Acta Orthop Belg. Jun 2006;72(3):276-81. [Medline].
22. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy. May 2006;22(5):521-7. [Medline].
23. Kayser R, Hampf S, Seeber E, Heyde CE. Value of preoperative ultrasound marking of calcium deposits in patients who require surgical treatment of calcific tendinitis of the shoulder. Arthroscopy. Jan 2007;23(1):43-50. [Medline].
24. Rupp S, Seil R, Kohn D. Preoperative ultrasonographic mapping of calcium deposits facilitates localization during arthroscopic surgery for calcifying tendinitis of the rotator cuff. Arthroscopy. Jul-Aug 1998;14(5):540-2. [Medline].
25. Rubenthaler F, Wittenberg RH. [Intermediate-term follow-up of surgically managed tendinosis calcarea (calcifying subacromion syndrome--SAS) of the shoulder joint] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1997;135(4):354-9. [Medline].
26. Weber SC. Arthroscopic treatment of calcific tendonitis. Presented at: The 16th Annual Meeting of the San Diego Shoulder Arthroscopy Course; June 1999; San Diego, Calif.
27. Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg. May-Jun 1998;7(3):213-7. [Medline].
28. Albert JD, Meadeb J, Guggenbuhl P, et al. High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. J Bone Joint Surg Br. Mar 2007;89(3):335-41. [Medline].
29. Sabeti M, Dorotka R, Goll A, Gruber M, Schatz KD. A comparison of two different treatments with navigated extracorporeal shock-wave therapy for calcifying tendinitis - a randomized controlled trial. Wien Klin Wochenschr. 2007;119(3-4):124-8. [Medline].
30. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy. 1992;8(2):183-8. [Medline].
31. Jim YF, Hsu HC, Chang CY, Wu JJ, Chang T. Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study. Skeletal Radiol. 1993;22(3):183-5. [Medline].
32. Perlick L, Korth O, Wallny T, et al. [The mechanical effects of shock waves in extracorporeal shock wave treatment of calcific tendinitis--an in vitro model] [German]. Z Orthop Ihre Grenzgeb. Jan-Feb 1999;137(1):10-6. [Medline].
33. Rompe JD, Zöllner J, Nafe B, Freitag C. [Significance of calcium deposit elimination in tendinosis calcarea of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 2000;138(4):335-9. [Medline].
34. Sistermann R, Katthagen BD. [Complications, side-effects and contraindications in the use of medium and high-energy extracorporeal shock waves in orthopedics] [German]. Z Orthop Ihre Grenzgeb. Mar-Apr 1998;136(2):175-81. [Medline].

Article Last Updated: Oct 23, 2007