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Calcifying Tendinitis

Calcifying or calcific tendinitis is a commonly used term to describe the painful disorder whereby there is a build up of calcium deposits in your rotator cuff tendons.

The rotator cuff tendons are a group of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) that encapsulate the shoulder joint providing it with dynamic stability.

Different types of calcification in the shoulder.  Which differ from calcifying tendinitis in shoulders from other joints.  An example is the build up of calcium deposits following a rotator cuff tear (dystrophic calcification) and the formation of calcium deposits in arthritis. These forms of calcification are quite different to true calcifying tendinitis.

The most commonly affected shoulder tendon in this condition is the supraspinatus tendon (approximately 50-90%) with the subscapularis tendon being the least commonly affected (approximately 3%).

Pathology occurs in four stages:

  1. The Pre-calcific phase:

    This is the earliest phase and is usually asymptomatic. In this  stage, there is a transformation within the tendon at  a cellular level.

  2. The Formative phase:

    This is the start of the deposition of chalk-like  calcium deposits within the tendon. Stage 2 may be asymptomatic.  More frequent occurrence of intermittent pain, usually related to movement.

  3. The Resorptive phase:

    At this stage, the most painful process of all occurs- the tendon begins to heal. Resorptive phase occurs with an increase of inflammatory markers in the area.  The markers assist with re-absorbing the calcium deposits which are now toothpaste like in texture. On some rare occasions, some of the calcium deposits infiltrate into a fluid filled, shock absorbing structure known as the subacromial bursa. Constant pain, fever and malaise will occur.

  4. The Post-calcifying phase:

    The tendon properties return to “normal”. The post calcifying stage is associated with some pain and stiffness in the joint.

Diagnosis of calcifying tendinitis

The diagnosis of calcifying tendinitis condition is usually based on a comprehensive history from the patient, a thorough physical examination and a plain x-ray.

With a diagnosis, treatment regime will begin according to the severity. In most cases, conservative treatment in the form of non- steroidal anti-inflammatory drugs and physiotherapy is the first port of call.

Physiotherapy includes a correction of shoulder biomechanics, manual therapy, self management advice and specific exercises for the rotator cuff tendons. There is conflicting evidence for the use of ultrasound therapy and some evidence for the use of extracorporeal shock wave therapy in this condition.

If conservative treatment fails, invasive techniques can treat this condition.  An example is lavage with needle aspiration. In more severe cases, a shoulder arthroscopy may be necessary to debride the shoulder joint.

How physiotherapy can assist calcifying tendinitis

As physiotherapists, we are trained to diagnose shoulder conditions and will refer for radiological imaging. It’s best to get to a physiotherapist as early as you can! Leaving the injury for longer may cause it to progress to the chronic form of the condition which requires more invasive forms of treatment. With early intervention and the right treatment plan, you will be back at the gym doing your usual exercise program in no time!

References

  • Robertson VJ, Baker KG. (2010) A review of therapeutic ultrasound: effectiveness studies. Journal of Women’s Health Physical Therapy. Sep-Dec;34(3):99-110
  • Gosens, T., Hofstee, D-J. (2009)Calcifying tendinitis of the shoulder: advances in imaging and management. Current rheumatology reports. 11:129-134
  • Hughes, P., Bolton-Maggs, B. (2002) Calcifying tenditis. Current Orthopaedics. 16(5): 389-394.
  • Lam, F., Bhatia, D., Rooyen, K., Beer, J. (2006) Modern management of calcifying tendinitis of the shoulder. Current Orthopedics. 20: 446-454.