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Updated: Feb 14 2024

Calcific Tendonitis

Images tendinitis.jpg i.jpg
  • 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
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