Calcific tendinitis
Calcific tendonitis is a painful shoulder condition due to the deposition of calcium hydroxyapatite crystals within the rotator cuff tendons. There is associated inflammation of the subacromial bursa that also contributes to the pain. The most common location is the supraspinatus tendon in the rotator cuff of the shoulder, though they can appear in any tendon location. Typically, the age of onset is around the 30–60-year-olds and with a slight predilection for women.
Symptoms of acute Calcific tendonitis can be very severe; they usually manifest abruptly without any rhyme or reason. Patients are reluctant to move their shoulder and typically present to AE due to the severity of symptoms.
Why does it happen?
We are unsure; the exact pathophysiology is complex and still debated, with no clear consensus as to its exact cause. The following article identifies 4 different potential pathogenic mechanisms and, if of interest, can be accessed for more information here (Hydroxyapatite Deposition Disease: A Comprehensive Review of Pathogenesis, Radiological Findings, and Treatment Strategies – PubMed)
Research has shown an increased risk of developing the disease in patients with metabolic health issues such as diabetes, hyperlipidaemia, hypertension and hypothyroidism. There is a hypothesised genetic factor as well with a link to the HLA-A1 genotype (Hydroxyapatite Deposition Disease: A Comprehensive Review of Pathogenesis, Radiological Findings, and Treatment Strategies – PubMed)
How is it diagnosed?
Clinically the nature and history of your symptoms can give a clue to the likely presence of this disease. It will be confirmed with imaging. Calcifications of the rotator cuff can be seen on plain film X-ray. They are, however, often better evaluated on ultrasound, which is more sensitive at seeing smaller and less mature-appearing calcifications. They can also evaluate for any concurrent rotator cuff pathology, such as rotator cuff tears and bursitis. MRI can do the same but can be less sensitive than ultrasound in detecting calcifications.
How is it treated?
In some patients there can be spontaneous resolution; again, why this happens in some patients but not in others we are unsure. It is also widely accepted that calcifications can be asymptomatic, meaning they can be present in shoulders of patients without pain.
If symptoms are progressive and you have been diagnosed with symptomatic calcific tenonitis then you have treatment options. These include:
- NSAIDs
Simple anti-inflammatory medication such as naproxen can sometimes be helpful in these patients with ongoing pain and inflammation. This is typically not a long-term solution but can be used on a short-term basis to see if your shoulder will settle before considering more invasive treatment options.
- Injections of local anaesthetic and steroid.
This can be injected under ultrasound guidance accurately into the subacromial bursa, which is very effective at reducing inflammation and associated pain. Sometimes this can break the pain cycle and allow the symptoms to settle. If symptoms do return, you have other options.
- Barbotage
Ultrasound-guided barbotage is a procedure that aims to break up the calcification within the tendon under local anaesthetic using a needle. Please visit our barbotage page for more information.
- Arthroscopic Surgery
For completeness, typically after other options have failed, arthroscopic (keyhole) excision +/- decompression is usually definitive. The calcification is removed, and the shoulder is thoroughly washed out. If required, the inflamed bursa around the tendon can also be removed, and the undersurface of the acromion (roof of the shoulder) can be ‘shaved’ to make more room around the tendon.
Despite this, a very small proportion of patients will still have residual symptoms even following surgery.
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