summary Calcific tendonitis is the calcification and tendon degeneration near the rotator cuff insertion, most commonly leading to shoulder pain with decreased range of motion. Diagnosis can be made radiographically with orthogonal radiographs of the shoulder showing calcium deposits overlying the rotator cuff insertion. Treatment is a course of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Arthroscopic decompression of the calcium deposit is indicated for patients with progressive symptoms having failed conservative measures. Epidemiology Demographics typically affects patients aged 30 to 60 more common in women Anatomic location supraspinatus tendon is most often involved Risk factors association with endocrine disorders diabetes hypothyroidism Etiology Pathophysiology unknown etiology pathoanatomy three stages of calcification precalcific fibrocartilaginous metaplasia of the tendon clinically this stage is pain-free calcific subdivided into three phases formative phase characterized by cell-mediated calcific deposits +/- pain resting phase lacks inflammation or vascular infiltration +/- pain resorptive phase characterized by a phagocytic resorption and vascular infiltration clinically this phase is most painful postcalcific cellular biochemistry calcium hydroxyapatite crystals are deposited key molecular pathways involved osteopontin cathepsin K transglutaminase 2 Classification Gartner and Heyer Classification of Calcific Tendinitis Type I Well circumscribed, dense calcification, formative Type II Soft contour/dense or sharp/transparent Type III Translucent and cloudy appearance without clear circumscription, resorptive Mole et al. Classification of Calcific Tendinitis Type A Dense, homogeneous, sharp contours Type B Dense, segmented, sharp contours Type C Heterogeneous, soft contours Type D Dystrophic calcifications at the insertion of the rotator cuff tendon Presentation History similar to the clinical presentation of subacromial impingement Symptoms atraumatic pain (most severe in resorptive phase) catching, crepitus mechanical block Physical exam inspection supraspinatus fossa muscle atrophy motion decreased active range of motion scapular dyskinesia may be associated with a decrease in rotator cuff strength provocative tests subacromial impingement signs Imaging Radiographs gold standard for diagnosis views AP, supraspinatus outlet, and axillary views show supraspinatus calcification internal rotation view shows infraspinatus and teres minor calcification external rotation view shows subscapularis calcification findings deposits usually 1 to 1.5cm from supraspinatus tendon insertion useful to monitor progression over time allow assessment of location, density, extent, and delineation of deposit CT indications rarely required may characterize the three-dimensional shoulder anatomy MRI indications limited utility in the diagnosis of calcific tendonitis consider in patients with refractory pain as it can assess for concomitant pathology (e.g., rotator cuff tears) findings cacific deposits have low signal intensity on all sequences Ultrasound indications may be useful to quantify the extent of the calcification also utilized for guidance during needle decompression and injection findings deposits are hyperechoic Treatment Nonoperative NSAIDs, physical therapy, stretching & strengthening, steroid injections indications first line of treatment for all phases techniques steroid injections commonly used but controversial duration of relief is variable outcomes resolution of symptoms in 60-70% of patients after 6 months increased probability of failure when: bilateral or large calcifications deposits underlying the anterior third of acromion deposits extending medial to the acromion extracorporeal shock-wave therapy indications adjunct treatment most useful in refractory calcific tendonitis in the formative and resting phases modalities high- vs. low-energy therapy outcomes dose dependent outcomes high-energy > low-energy in clinical outcome scores, and rate of calcific deposit resorption high-energy > low-energy in procedural pain and local reaction (e.g. ecchymosis) ultrasound-guided needle lavage vs. needle barbotage indications persistent symptomatic calcific tendonitis in the resorptive phase outcomes improved outcomes in patients with Type II/III calcific tendinitis vs Type I Operative surgical decompression of calcium deposit indications progression of symptoms refractory to nonoperative treatments interference with activities of daily living outcome good results in short term outcome studies longer return to work with subacromial decompression and/or rotator cuff repair risk of shoulder stiffness with operative treatment Techniques Ultrasound-guided needle lavage technique two needles to maintain an outflow system for lavage small amount of saline+/-anesthetic injected around the calcification aspiration of calcific material with other needle Needle barbotage technique use needle to break up calcium deposit then follow with by corticosteroid injection Surgical decompression of calcium deposit approach may be done arthroscopically or with mini-open approach technique +/- subacromial decompression +/- rotator cuff repair Complications Recurrence Persistent shoulder pain Shoulder stiffness Iatrogenic injury to rotator cuff with operative treatment