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ALL ABOUT CALCIFIC SHOULDER TENDINOPATHY: SYMPTOMS AND REMEDIES

Discover the causes, symptoms, and effective treatments for calcific tendinopathy of the shoulder. Learn about non-invasive options, conservative therapies, and minimally invasive surgery.

Gabriele February

15 min. Dec 18, 2024

All about calcific tendinopathy of the shoulder: symptoms and treatments

Introduction

Calcific tendinitis of the shoulder, also known as calcific tendinopathy, is characterized by the deposition of calcium phosphate crystals in the rotator cuff tendons. Calcific tendinitis can cause severe acute or chronic pain, and it is important to differentiate it from other shoulder conditions with similar presentations.

It is a self-limiting disease that commonly affects people between the ages of 30 and 50, with a higher incidence in women than men. The condition is more common in the right shoulder than the left and can involve both shoulders in 10% of patients.

Understanding Calcific Tendinopathy of the Shoulder

What is Calcific Tendinopathy?

Calcific tendinitis of the shoulder, also known as calcific tendinosis, is a painful condition characterized by the deposition of calcium phosphate crystals in the rotator cuff tendons, particularly the supraspinatus and infraspinatus tendons. The most common site of onset is near the insertion of the supraspinatus tendon on the greater tuberosity (humeral trochlea - lateral portion of the humeral head).

The disease can be asymptomatic in 27-20% of cases and is diagnosed through history, physical examination and diagnostic imaging.

The formative phase It generally does not present clinical symptoms, while the reabsorption phase is characterized by a severe sharp pain, above all at night, and limited movement of the shoulder joint.

Plain shoulder radiographs are essential for determining the location of calcific deposits and predicting the possibility of impingement symptoms. The size of the calcific deposits (the size of the calcification) do not change significantly over time and radiological findings can help differentiate the disease from osteoarthritis.

Mechanisms of Calcification Formation

Calcific tendinitis of the shoulder is characterized by the deposition of calcium hydroxyapatite crystals within the tendons of the rotator cuff, particularly in the supraspinatus and infraspinatus tendons, but can sometimes, more rarely, also involve the subscapularis tendon.

The exact mechanisms underlying the formation of these calcifications remain unclear. Several hypotheses have been proposed, including an active cell-mediated process, tendon degeneration, genetic predisposition, local metabolic or hemodynamic abnormalities, and subacromial impingement.

The condition often progresses through distinct phases, including the formative phase, the quiescent calcific phase, and the painful resorptive phase.

The pathophysiology of calcific tendinitis is complex and multifactorial, involving a combination of local and systemic factors that contribute to the development and progression of the condition.

The pathogenesis of calcific tendinitis involves a complex interaction of cellular and molecular processes. Recent scientific evidence suggests that the disease is a cell-mediated process, with metaplastic transformation of tenocytes into chondrocytes which leads to subsequent calcification within the tendon.

The metaplastic transformation is A biological process by which one type of adult tissue transforms into another type of tissue. This phenomenon can occur as an adaptive response to chronic environmental conditions or irritation. For example, calluses on the skin are an example of metaplastic transformation. When the skin is subjected to continuous pressure or friction, the cells of the epidermis can harden and thicken, forming a callus. This is a change in the epithelial tissue from a normal state to a thicker and more resistant stratum corneum, a protective response to prevent further damage to the underlying skin.

This process is followed by phagocytosis of the metaplastic areas of the tendon by multinucleated giant cells, resulting in tendon remodeling and reformation. The formation and resorption of calcifications in calcific tendinitis are often multifocal processes, and the condition often resolves spontaneously. However, in some cases, the self-healing process is disrupted, leading to symptomatic presentations.

The etiology of the disease remains partially unknown.

Calcific tendinitis of the shoulder has been associated with endocrine disorders, particularly thyroid dysfunction. A retrospective study found a significant prevalence of endocrine disorders in patients with calcific tendinitis, with a higher incidence in women than men. A relationship between thyroid disorders and shoulder pain has been hypothesized, suggesting a potential link between thyroid disease and idiopathic tendinopathies, including calcific tendinitis.

The condition progresses through distinct stages, including the pre-calcified phase, the calcific phase, and the post-calcified phase, each characterized by specific cellular and tissue changes. Understanding the pathogenesis of calcific tendinitis is evolving, with emerging evidence highlighting the role of biological factors and genetic in the development and progression of the disease.

The concomitant presence of rotator cuff tears with calcific tendinitis is a significant consideration in the management of shoulder disorders. Some studies have reported that Approximately 15% of patients with calcific tendinitis also have a coexisting rotator cuff tear, with partial-thickness tears more common than full-thickness tears. The presence of rotator cuff tears is associated with advanced age, recurrent symptoms, and menstrual irregularities. Furthermore, patients with rotator cuff tears may require more active surgical treatment. The coexistence of these conditions can influence prognosis and therapeutic approach, requiring careful evaluation and consideration before initiating therapy.

Identifying the Symptoms of Calcific Tendinopathy

Warning Signs and Discomfort

Calcific tendinitis of the shoulder presents with a series of warning signs and symptoms. Patients may experience nighttime pain that disrupts sleep, a constant dull ache, and increased pain with active movement.

Additionally, subjects may report a reduction in range of motion and complain of stiffness in the affected shoulder.

The clinical presentation may vary depending on the stage of the condition, with asymptomatic chronic formative phases and acute resorption phases characterized from severe pain, limited movement of the shoulder joint and tenderness over the insertion of the supraspinatus.

The pain may radiate also to the suboccipital region or to the fingers, indicating the varied and impactful nature of the symptoms associated with calcific tendinitis of the shoulder.

When to See a Shoulder Surgeon?

A shoulder surgeon should be consulted if calcific tendinitis is suspected when one or more of the following symptoms and conditions occur:

  1. Persistent pain: If shoulder pain persists for several weeks despite rest, the use of anti-inflammatory drugs, and conservative therapies (such as physiotherapy), a specialist consultation may be necessary.
  2. Limitation of movement: Significant difficulty or reduction in the range of motion of the shoulder, which interferes with daily activities.
  3. Night pain: Pain that disturbs sleep or worsens during the night, often indicating a condition that may require more invasive intervention.
  4. Presence of calcifications: If tendon calcifications are identified through diagnostic tests, such as x-rays or ultrasound, that contribute to the symptoms.
  5. Failure of conservative therapies: When non-invasive therapies, including infiltrates, do not lead to significant improvement in symptoms.
  6. Severe symptoms: Severe pain or swelling that significantly limits shoulder function.

It's important to note that a large percentage of patients experience shoulder pain that isn't caused by calcifications. During pain tests, calcification is found, leading to the assumption that the pain is caused by this, while other conditions or injuries (such as capsulitis or a tendon tear) may be causing the symptoms.

But having calcification doesn't necessarily mean suffering from it. Many people have tendon calcifications in the rotator cuff but don't feel pain, or they suffer from other shoulder problems and not from the calcification, which remains dormant without causing discomfort or inflammation.

Among patients with calcific tendinitis, 2.7%–20% are asymptomatic, and only 35%–45% of patients whose calcific deposits are inadvertently discovered later develop shoulder pain due to these calcifications.

First Steps to Diagnosis

Recommended Instrumental Tests

Recommended imaging tests for calcific tendinitis of the shoulder include x-rays, ultrasound, and, in some cases, magnetic resonance imaging (MRI).

An ultrasound scan, performed by an experienced radiologist or shoulder surgeon, is a cost-effective and quick test that can be performed in the office during a physical examination and allows calcifications to be identified early.

X-rays are commonly used to visualize larger calcium deposits, while ultrasound provides a better view of smaller deposits and helps determine their size.

MRI, although not essential, can be useful, especially in cases of chronic calcific tendinitis, as it can show the location of the calcific deposits and the condition of the rotator cuff.

These instrumental tests play a fundamental role in confirming the diagnosis, assessing the extent of calcific tendinopathy, and guiding the choice of the most appropriate therapeutic option for the patient.

Treatment Options for Calcific Tendinopathy

Conservative Approaches to Pain Management

Conservative approaches to pain management in calcific tendinitis of the shoulder include a variety of noninvasive treatments aimed at alleviating symptoms and promoting healing.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve acute pain, while rest and the use of an arm brace can help minimize discomfort in the affected shoulder joint.

Furthermore, the Subacromial steroid injections (infiltrations) have been shown to be effective In relieving pain, particularly in cases where there are signs of impingement or during the resorption phase. Sometimes even a single injection is sufficient for significant pain relief.

Furthermore, ultrasound therapy and therapy with extracorporeal shock wave therapy (ESWT) have shown effects similar to those of surgical treatment and are recommended as non-invasive treatment options before considering surgery.

The therapy to shock waves Extracorporeal thermal energy (ESWT) has emerged as a widely used and effective treatment for calcific tendinitis of the shoulder. Research has shown that high-energy ESWT in patients with chronic calcific tendinitis has a high treatment success rate and few side effects, making it one of the most effective treatments for pain relief.

The therapy involves applying shockwaves to the affected area, which can relieve pain and promote the resolution of calcific deposits. Furthermore, ESWT has demonstrated encouraging results in the treatment of calcified deposits, further supporting its effectiveness in managing calcific tendinitis.

A shock wave treatment high energy (Approximately 1,500 shock waves of 0.32 mJ/mm2 per treatment—there are lower-energy treatments that are LESS effective according to the studies in the literature, so be careful!) has led to complete disappearance of the calcific deposit in 60% of affected patients, according to some articles. This rate is almost triple that of those who received a placebo treatment. The authors discuss the potential of extracorporeal shock waves in breaking down calcific deposits, although the mechanisms are unclear. Some studies have shown a correlation between shock wave energy and the rate of disintegration, assuming careful focusing.

Studies suggest that certain types of calcification may respond more favorably to extracorporeal shock wave therapy (ESWT) in the treatment of calcific tendinitis of the shoulder. One article classified patients into three groups: noncalcified tendinosis (NCTS), type I calcification (DCTS), and type II/III calcification (TCTS) based on the Gartner and Heyer classification system.

The study found that ESWT had superior results for type II and III calcifications compared to type I calcifications and non-calcified tendinosis. Type I calcification refers to well-circumscribed, dense calcification, while type II refers to clearly circumscribed, translucent, cloudy, and dense calcification. Type III calcification is characterized by cloudy, translucent, and resorbable calcification.

Ultrasound-guided lithoclasia (barbotage) without surgery

Ultrasound-guided barbotage (or lithoclasis) is a minimally invasive procedure used to treat calcific tendinitis of the shoulder. The technique involves the use of ultrasound guidance to locate the calcific deposits within the tendon and the subsequent insertion of a needle to break up the crystals.

After barbotage, a wash is performed to remove the fragmented calcium deposits.

The procedure aims to reduce pain and promote crystal resorption, resulting in improved clinical outcomes. Some studies have shown that barbotage can lead to reduced pain and faster crystal resorption, although some articles suggest similar results with conservative treatment and barbotage. Adverse effects of the procedure may include skin or joint infections, steroid flare-ups, and tendon rupture. However, the procedure generally results in reduced pain and faster crystal resorption, making it an effective treatment option for patients with calcific tendinitis of the shoulder.

Ultrasound-guided barbotage, which involves the aspiration and washing of calcific deposits, has achieved satisfactory results in a significant percentage of patients, with success rates reported as high as 70%.

Minimally Invasive Surgical Options

Arthroscopic surgical treatment of calcific tendinitis of the shoulder involves the use of minimally invasive techniques for address the condition. The arthroscopy procedure typically begins with the insertion of an arthroscope, a small camera and surgical instruments, through small incisions In the shoulder. Once the calcium deposits have been identified, after removing the often inflamed bursa (bursitis), they can be removed with specialized instruments and the associated damaged tissues treated.

The duration of the procedure can vary from 30 minutes to two hours, depending on the extent of the calcifications and the tendon involved. Hospitalization usually lasts one night, mostly for anesthesia reasons, not so much for the procedure itself.

The goal of surgery is to relieve pain, restore function, and promote healing of the affected tendon. Studies have shown that arthroscopic treatment leads to significant improvements in pain relief and shoulder function, making it an effective option for patients with calcific tendinitis of the shoulder.

Post-Treatment Rehabilitation

Specific Exercise Protocols

Physical therapy plays a key role in managing calcific tendinitis, employing various protocols to relieve pain, reduce inflammation, and restore shoulder function. These protocols often include a combination of exercises aimed at strengthening the muscles around the shoulder joint, promoting flexibility, and improving range of motion.

Additionally, physical therapists may incorporate modalities such as ultrasound, electrical stimulation, and shockwave therapy to reduce swelling, inflammation, and the size of calcium deposits.

Treatment may also include passive range-of-motion exercises to address initial pain and stiffness, gradually transitioning to active exercises as the condition improves. Additionally, physical therapy protocols focus on restoring shoulder coordination and mobility, essential for long-term recovery from calcific tendinitis.

FAQ

What is the average length of a course of conservative therapy?

The average duration of a conservative therapy cycle is approximately 40 days, calculating one to two treatments per week, including infiltrative treatments in the acute phase. It obviously depends on the individual situation.

Does minimally invasive surgery guarantee a permanent resolution?

Arthroscopic treatment of calcifications is an extremely effective procedure, but there's no guarantee like buying a blender. It's never the procedure that "cures," but the body that heals, and there can be many variables, both positive and negative. Surgery serves to put the body in the best possible condition for this healing process. That said, arthroscopic removal of calcifications is one of the most effective procedures in shoulder surgery.

What daily activities should I avoid to avoid worsening calcific tendinopathy?

To avoid aggravating this condition, it's important to avoid activities and jobs that involve repetitive strain or movements that require maintaining a position with the elbows above the heart, such as painting a ceiling or placing objects on high shelves. During the acute phase, even minimal movements can trigger severe pain; therefore, it's recommended to limit movement of the affected limb using devices such as slings or braces to promote healing and reduce discomfort.

Can imaging techniques such as ultrasound guide focused shock wave treatment?

Ultrasound support in shockwave therapy represents a significant advancement in modern physiotherapy, making it a nearly standard practice. This technology allows for unprecedented precision in the localization of tissues to be treated, significantly improving the effectiveness of shockwave therapy. For example, in the treatment of tendinopathies or calcifications, ultrasound guides the practitioner in precisely targeting the shockwave energy to the affected area, reducing discomfort and accelerating healing. This integrated approach not only optimizes patient recovery but also reduces recovery time, highlighting the importance of technological innovation in rehabilitation.

For further information please see the section dedicated to the rotator cuff in the section News and Research,

Further Frequently Asked Questions (FAQ) can be found in the FAQ section of the website.

Bibliography / References

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