Calcific Tendonitis - Diagnosis and Treatment Options
There are many different conditions that can lead to shoulder joint stiffness and
pain. Many of these conditions remain unknown to the afflicted individual because
they do not present any noticeable symptoms and will ultimately resolve on their
own. It is estimated that thirty percent of the population older than the age of
thirty but younger than seventy and seventy percent of the population over seventy
have some sort of shoulder impingement. Calcific tendonitis is one of the more common
types of shoulder impingements and most of the time it too will resolve on its own.
What is a shoulder impingement?
A shoulder impingement is a generalized term for an inflammation that prevents the
tendons and bursa in the shoulder joint from moving freely.
Tendons are the tough connecting tissues that anchor the muscles to the bones.
When the muscles contract, they tug on the tendon which in turn pulls on the bone.
The tendons need to slide effortlessly between the bones of the joint to achieve
optimal performance. The body facilitates this by placing a bursa under the tendons
that must pass over joints that have bony extensions (e.g. the shoulder bones).
Not all joints need to have a bursa under the tendons but bursas are distributed
in muscle tissue around the body.
Inflammation of the tendons and the bursa causes them to swell. Since there
is limited space between the bones of the shoulder joint, the swelling prevents
the tendons from sliding through the joint. The result is pain, stiffness
and restricted movement.
In the case of calcific tendonitis calcium deposits thicken the tendons (called
the rotor cuff) and thus cause the impingement between the rotor cuff and the acromion
(the bony protrusion of the scapula that forms part of the shoulder).
Calcific tendonitis (a.k.a. calcium deposits) may not cause any symptoms at all;
especially if they are located deep within the tendons. If the calcium deposit
is large enough or located in more exposed position, pain and restricted movement
may be the result. As the calcium deposits increase in size more pressure
is placed on the tendons and joint. Chemical irritation from the calcium may also
contribute to the inflammation. In this case, the pain can be very intense
and lead to frozen shoulder syndrome (an extremely painful condition where the shoulder
is largely or completely immobilized).
What causes calcific tendonitis?
Scientists are not certain as to what precipitates the calcium deposits, but they
are certain that it is not an excess of calcium in the diet or blood. Individuals
who have calcific tendonitis will very often have normal blood calcium levels.
Thus there is no point in restricting dietary calcium since this may rob the body
of the calcium it needs to function properly. When this happens the body
will attempt to compensate for this calcium deficiency by releasing calcium from
the bones (leading to osteoporosis).
In rare incidences, there may be a metabolic condition that leads to the depositing
of calcium in the tissues. In other cases, there may be an irregularity with the
kidneys that leads to high calcium levels.
Calcium deposits are also not believed to be caused by an injury to the shoulder
joint. While injury may indeed lead to tendon inflammation and shoulder impingement,
it is not responsible for the buildup of calcium in the tendons.
Studies show that calcific tendonitis forms in people who are minimally thirty to
forty years old and is most common in people with diabetes. Thus the condition
has age related and metabolic components.
What is the progression of symptoms?
Doctors have recognized that there is a fairly predictable pattern for calcific
· Pre-calcification is the stage when the joint cells
are experiencing changes permitting the tissues to develop excess calcium.
During this stage there is no pain.
· The calcific stage is when the cells start to discharge
the calcium which in turn starts to coalesce into deposits. This calcification stage
is followed by a resting stage which may last for any length of time. Since
the calcium is soft (resembling toothpaste) it is not painful. The individual
may still be unaware of the situation. The next step is when the body starts
to reabsorb the calcium. This is the painful portion of the process.
· The post-calcific stage is when the body has reabsorbed
the calcium and the rotor cuff returns to having a more normal appearance. This
usually happens in one to four weeks.
Patients typically seek treatment during the painful re-absorption stage.
Other people may have calcium deposits discovered in the course of an examination
for another issue (e.g. shoulder impingement).
Diagnosis of calcific tendonitis
Loss of arm and shoulder mobility as well as pain will alert your physician to the
possibility of calcific tendonitis.
The diagnosis of calcific tendonitis may be confirmed with x-rays since the calcium
deposits will be visible. Large calcium deposits may be up to a half inch
in diameter but even small deposits will show up on the x-ray.
Calcific tendonitis treatment options
Since most acute cases will eventually go away on their own, initial treatments
are usually given to alleviate symptoms. These include:
· Application of ice to reduce pain and inflammation
· Anti-inflammatory medications such as a steroid injection
(e.g. cortisone). The injection applies the steroid locally and thus prevents most
of it from circulating around the body. Since overusing steroids can weaken
tissues, many doctors will not inject cortisone in the same location more than three
· Range of motion exercises in physical therapy and
practiced at home will help prevent frozen shoulder from occurring.
· A warm moist cloth will increase circulation to the
area to relieve pain
· Ultrasound can be used to guide a procedure that injects
salt water solution to the targeted area. This loosens the calcium which
is then sucked out with a syringe. This procedure is minimally invasive.
Patients are able to resume normal functioning within a couple of days.
· The most radical procedure is surgical removal of
the calcium deposits. This becomes necessary if the pain is extreme and cannot
be controlled. It may also be required if a very large deposit which greatly
impedes movement cannot be removed with the needling procedure. Surgery may
be of the arthroscopic type (e.g. an endoscope is inserted through a small incision)
or less frequently during open surgery.
For most patients, the first choice is usually to control the symptoms in order
to allow sufficient time for natural resolution of the problem.