Calcific Tendinitis

Classification of calcific tendinitis

There are two different types of calcification in the shoulder: degenerative calcification and reactive calcification.

Wear and tear and the injuries that come with age are the main cause of degenerative calcification. As we grow older, the blood flow reaching the rotator cuff tendons decreases and the tendon becomes weaker. Calcium deposits form in the damaged tendons during the healing process.

Reactive calcification is different. There are three stages of reactive calcification:

• In the pre-calcific stage, changes occur in the tendon that favour the formation of calcium deposits.
• In the calcific stage, calcium crystals are deposited in the tendon. They then begin to disappear. Ironically, pain most often appears at this stage.
• In the post-calcific stage the tendon heals, remodelling with new tissue.

Which part of the shoulder is affected

Calcific tendinitis occurs in the rotator cuff tendons. The rotator cuff is a group of tendons connecting the shoulder muscles to the humerus (the upper arm bone). These muscles are called rotators because they rotate the arm at the shoulder joint. Calcium deposits usually appear in the tendon of the supraspinatus muscle.

Causes of calcific tendinitis

No one knows exactly what causes calcific tendinitis. Wear and tear, severe injury, ageing, or a combination of these are implicated in degenerative calcification. Some researchers believe calcium deposits form because of insufficient oxygen supply to the tendon. Others believe that pressure on the tendons can cause damage, leading to the formation of calcium deposits. Reactive calcification is an even greater mystery. This type of condition appears in younger patients and seems to resolve spontaneously in many cases.

Symptoms of calcific tendinitis

While the calcium is being deposited, the patient may feel only mild to moderate pain, or may have no symptoms at all. For reasons that are not understood, calcific tendinitis becomes very painful when the deposits are being reabsorbed. The pain and inflammation of calcific tendinitis can limit movement in the shoulder joint. Raising the arm can become painful. At its most severe, the pain can wake the patient from sleep.

Conservative treatment

The role of a good orthopaedic surgeon is to bring the pain and inflammation under control.

• Rest and anti-inflammatory medication — this is the initial treatment
• Cortisone injections — these may be recommended when the pain persists even after other anti-inflammatory medication has been used. Cortisone is a powerful steroid that can be very effective in temporarily reducing inflammation and pain.
• Lavage with sterile saline — this involves removing the calcium deposits by introducing two thick needles into the calcification.
• Physiotherapy — carried out with a physiotherapist. Treatments may include the use of heat or ice, as well as ultrasound; ultrasound has proven effective in reducing the size of the deposits.
• Shockwave therapy — a newer form of non-surgical treatment. It uses a device that generates shockwaves at the inflamed area; the aim of the pulses is to break up the deposits so that the body can reabsorb them more easily.

Surgical treatment

If the pain and restricted movement worsen or affect daily life, the patient requires surgery.

Arthroscopic resection

Most operations to treat calcific tendinitis of the shoulder are arthroscopic. The arthroscope is a special camera that can be inserted into the shoulder joint through a small incision in the skin. The orthopaedic surgeon uses the arthroscope to locate the calcium deposits in the rotator cuff. Once found, the deposit is resected (removed) using small instruments and the area is washed out.

Open resection

In rare cases, open resection is necessary. In open surgery the orthopaedic surgeon removes the calcium deposits by cutting through the surrounding muscles and tissues.

It is very important to see a good orthopaedic surgeon in the early stages of the pain. Delaying brings complications.