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 login to view 15 more bullets cellular biochemistry calcium hydroxyapatite crystals are deposited key molecular pathways involved login to view 3 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet techniques login to view 3 more bullets outcomes login to view 5 more bullets extracorporeal shock-wave therapy indications login to view 2 more bullets modalities login to view 1 more bullet outcomes login to view 3 more bullets ultrasound-guided needle lavage vs. needle barbotage indications login to view 1 more bullet outcomes login to view 1 more bullet Operative surgical decompression of calcium deposit indications login to view 3 more bullets outcome login to view 3 more bullets Techniques Ultrasound-guided needle lavage technique two needles to maintain an outflow system for lavage login to view 2 more bullets 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