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CALCIFIC TENDONITIS

Calcific tendonitis is a painful shoulder condition where there is a build-up of calcium in the rotator cuff (calcific deposit). When calcium builds up in the tendon, it can cause a chemical irritation and increase in pressure which leads to pain. The pain can be extremely intense and is one of the worst pains in the shoulder (the other being Frozen Shoulder).

The calcific (calcium) deposit reduces the space between the rotator cuff and the acromion, as well as affecting the normal function of the rotator cuff. This may lead to subacromial impingement (rubbing) between the acromion and the calcium deposit in the rotator cuff when lifting the arm overhead.

The cause of the calcium build-up is unknown. Commonly found in people between the ages of 30-60 years. It does eventually disappear spontaneously, but this can take between 5 to 10 years to resolve.

Rotator Cuff Calcific Tendinitis Reactive Calcification of the Shoulder
Calcific Deposit Diagnosis

Diagnosis

Calcific deposit on x-ray

The calcific deposit can be seen on plain x-rays; however ultrasound scan is better to find small calcific deposits which can be missed on x-rays. Ultrasound also makes it possible to assess the size of the deposit in all directions. The clinician can also see the blood vessels around the calcific deposit.

Calcific Deposit On Ultrasound Scan

Calcific deposit on ultrasound scan

Treatment

  1. Painkillers and anti-inflammatory medications
  2. Physiotherapy - keeps your shoulder strong and flexible and reduce the irritation
  3. Cortisone steroid injections - reduces inflammation and control the pain
  4. Ultrasound guided Barbotage: Under ultrasound guidance the calcific deposit is injected with a salt water solution and the calcium is also sucked out into a syringe. The area is then repeatedly washed.
  5. Surgical excision (arthroscopy)
Arthroscopic Calcium Excision Surgery

Surgery for Calcific tendonitis:

Arthroscopic Calcium Excision —
http://www.youtube.com/watch?v=1vNg9qJPgto

Surgery is required if the pain is not controlled with the methods above and/or the pain is extremely severe, with night pain. The goal of any surgery to reduce the effects of impingement. This is done arthroscopically (“key-hole surgery”) and increases the amount of space between the acromion and the rotator cuff tendons, which will then allow for easier movement and less pain and inflammation. The calcium deposit is also debrided and released at the same time.

Removing the Calcium

Commonly asked questions about Calcifying Tendinitis

Q: What causes calcifying tendinitis?

A: We still do not know. There is evidence that the oxygen concentration and blood supply to the tendon may be decreased. It is certainly not related to diet, osteoporosis, exercise nor injury

Q: How common is this condition?

A: It is a very common disorder of the rotator cuff and accounts for approximately 10% of all consultations presenting with a painful shoulder. It affects women more often than men with its peak incidence in the fifth decade

Q: What symptoms do I get with this condition?

A: The pain can be constant and nagging and is felt in the shoulder and sometimes down the arm/hand. It is made worse by elevating the arm. Some patients also have excruciating attacks of pain, which then abate to a lower level after a few days. The calcium can spontaneously absorb and this process is associated with severe pain.

Q: What does a cortisone injection do?

A: It helps with the pain for a short term basis but it does not take away the underlying problem – the calcium deposit.

Q: How many injections can I have?

A: Most doctors would say a maximum of three. There is in fact no absolute maximum. However, if you are having a lot of injections, then this is a sign that something definite ought to be done about it

Q: What treatment options are available for calcifying tendinitis?

A: Treatments include:

  1. Non steroidal anti-inflammatory drugs
  2. Subacromial injection of steroid
  3. Physiotherapy
  4. Needle aspiration and irrigation
  5. Extracorporeal shockwave therapy
  6. Surgery

Q: Can physiotherapy help?

A: The physiotherapist can help you to maintain the range of movements in your shoulder. Some patients also find therapeutic ultrasound to be of benefit. However, the evidence that it works is conflicting. The Cochrane Musculoskeletal Database Review of 26 trials found that both ultrasound and pulsed electromagnetic field therapy resulted in significant improvement in pain compared to placebo. However, a further meta-analysis of 35 randomised controlled trials found that only 2 studies supported the use of therapeutic ultrasound over placebo. The remaining 8 showed that therapeutic ultrasound is no more effective than placebo.

Q: What is extracorporeal shockwave therapy?

A: Extracorporeal shock wave therapy utilises acoustic waves to induce fragmentation of the mechanically hard crystals

Q: Would you recommend extracorporeal shockwave therapy?

A: Although this is used in some places, we do not recommend it. The recurrence rate following extracorporeal shockwave therapy is relatively high and many patients also find the procedure to be quite painful and can develop troublesome haematomas (blood clots) afterwards

Q: What does the operation entail?

A: This is a very successful and satisfying operation carried out using arthroscopic (key hole surgery) techniques. Two to three mini skin incisions (about 0.5 to 1cm each in size) are made around the shoulder. Through these arthroscopic portals, the camera as well as a variety of surgical instruments is inserted into the shoulder and the calcium is removed from the tendon under magnified vision. When the calcifying tendinitis condition is acute, the calcium is easily expressed from the tendon using a fine needle and appears like a toothpaste material. When the calcifying tendinitis condition is chronic, the calcium is more ‘stuck’ to the underlying tendon

Q: How long does it take to recover from surgery?

A: There is dramatic instant relief of pain after surgery. Total recovery in terms of regaining full muscle power may take 3 to 4 months. There is no restriction on what you can and cannot do after surgery and most people return to work within a few days and return to sports as they feel comfortable

Q: Are there any serious complications with surgery?

A: The most common complication is stiffness (approx 10%), sometimes referred to as Frozen shoulder. This is more common in patients with diabetes. If it does occur, it does not mean that further surgery is necessary. It just means the recovery may take a little longer.