27/11/2025
📌Calcific Tendinopathy of the Shoulder, a common and often painful condition . It is also known by several other names, including Calcific tendonitis, Rotator cuff disease of the shoulder, Rotator cuff calcific tendinopathy (RCCT), and Hydroxyapatite deposition disease.
Overview of Calcific Tendinopathy
🟦 Calcific tendinopathy of the shoulder involves the deposition of calcium crystals primarily in the insertions of the rotator cuff tendons and the subacromial-subdeltoid bursa.
🟦 The rotator cuff consists of four tendons: the supraspinatus, infraspinatus, subscapularis, and teres minor.
🟦 The supraspinatus tendon is the most commonly affected, involved in about 80% of cases.
🟦 The infraspinatus is involved 15% of the time, and the subscapularis is involved about 5% of the time.
Epidemiology and Risk Factors
🟦 Calcific tendinopathy generally affects adults, with the peak incidence reported to be between ages 30 and 60 years.
🟦 Women are reported to be affected twice as often as men.
🟦 The incidence is reported to be between 2.7% and 7.5% in asymptomatic adults.
Risk factors and associated conditions include:
🟦 Occupational activities that require using the arms in internal rotation and slight abduction for extended periods.
🟦 Excessive overhead movements may also increase risk.
🟦 Diabetes mellitus (30% of patients with insulin-dependent diabetes mellitus are reported to have the condition).
🟦 Metabolic disorders known to cause kidney stones, gallstones, or gout.
🟦 Hypothyroidism and menstrual disorders are also associated with an increased prevalence among patients with calcific tendinopathy.
🟦 Hypertension and ischemic heart disease.
Pathogenesis (Proposed Causes)
🟦 The cause of calcific tendinopathy has not been fully elucidated.
🟦 Multiple hypotheses have been proposed, including tissue degeneration ("wear-and-tear"), tissue ischemia, endochondral ossification, chondral metaplasia, and reactive calcification.
Reactive calcification pathway (three stages):
🟩 Precalcific stage
▪️ Fibrocartilaginous tissue forms within the tendon due to altered metabolic and mechanical conditions, providing the substrate for calcium deposition.
🟩 Calcific stage
▪️ Formative phase: Calcium crystals deposit within the tendon.
▪️ Resorptive phase: Macrophage phagocytosis of calcium deposits begins.
▪️ This phase typically causes swelling and acute pain and may involve extravasation of crystals into the subacromial-subdeltoid bursa.
🟩 Postcalcific stage
▪️ Fibroblasts reconstruct the tendon tissue.
▪️ This phase normally results in complete tendon healing.
Diagnosis
🟦 Patients typically present with atraumatic shoulder pain, pain with movement that limits range of motion, and localized tenderness.
🟦 Many patients may be asymptomatic.
🟦 Symptoms, including nocturnal pain, often occur bilaterally in about 10% to 25% of patients.
Imaging
🟩 X-ray
▪️ Usually the first imaging modality in patients with atraumatic shoulder pain.
▪️ Detects calcific tendinopathy and helps assess the location, density, and severity of the condition.
▪️ Calcific tendinopathy may be classified using systems such as Gartner and Heyer or Mole.
🟩 Ultrasound (US)
▪️ Useful for identifying radiolucent calcifications difficult to detect on x-ray.
▪️ Provides dynamic imaging and can evaluate associated injuries like rotator cuff tears.
▪️ Classification systems include Bianchi and Martinoli, and Sconfienza.
🟩 MRI
▪️ Usually not indicated for calcific tendinopathy itself.
▪️ Useful for assessing associated shoulder pathologies such as rotator cuff tears.
▪️ Susceptibility-weighted MRI has demonstrated high sensitivity and specificity.
Physical Exam
🟦 If pain is elicited during Hawkins test, Neer test, or Yocum test, subacromial impingement may be occurring.
Management
🟦 Nonoperative management is the typical initial approach.
Nonoperative Interventions
🟧 Conservative Measures
▪️ Avoidance of aggravating activities and physical therapy focusing on regaining range of motion and correcting scapular mechanics.
🟧 Medications
▪️ Acute pain management often starts with oral NSAIDs for short-term relief.
▪️ Corticosteroid injections may be considered in cases of poor response or associated bursitis/impingement.
🟧 Ultrasound-Guided Percutaneous Irrigation (US-PICT / Barbotage)
▪️ Appropriate for managing large calcifications (> 5 mm).
▪️ Involves injecting local anesthetic and saline to disrupt and aspirate deposits.
▪️ The microtrauma is thought to increase vascularity and promote resorption.
▪️ Appears to improve pain and function.
▪️ Double-needle technique creates a washing circuit that dissolves the calcification.
🟧 Extracorporeal Shock Wave Therapy (ESWT)
▪️ Uses repetitive pulses to break up calcium deposits and initiate resorption.
▪️ High-dose ESWT associated with reduced pain and improved function compared to low-dose.
▪️ Evidence remains limited, and some guidelines recommend use in research settings.
Operative Management
🟦 Reserved for patients with severe calcific tendinopathy or persistent symptoms refractory to more than 6 months of nonoperative management.
🟦 Primary approach is arthroscopy or open surgery to remove calcium deposits.
🟦 During arthroscopy, the surgeon identifies deposits and creates a longitudinal incision for removal.
🟦 Surgery is reported to reduce pain and improve function.
🟦 Postoperative rehabilitation involves immediate active and passive range of motion, with strengthening starting at 6–12 weeks.
Prognosis and Complications
🟩 Decreased risk of treatment failure:
▪️ Gartner type III deposits
▪️ Lack of sonographic sound extinction
🟩 Increased risk of persistent symptoms:
▪️ Bilateral occurrence
▪️ Localization to the anterior portion of the acromion
▪️ Medial extension
▪️ High volume of deposits
🟧 Common complications:
▪️ Adhesive capsulitis
▪️ Rotator cuff tear
🟧 Rare complications:
▪️ Greater tuberosity osteolysis
▪️ Ossifying tendinopathy
Conceptual Summary
🟦 Calcific tendinopathy is like finding a stubborn patch of concrete unexpectedly poured into a finely woven rope (the rotator cuff tendon).
🟦 Nonoperative treatment first uses anti-inflammatories and physical therapy.
🟦 If that fails, US-PICT (Barbotage) attempts to dissolve and wash away the "concrete," encouraging the body to repair the area.
🟦 Surgery is the last resort to chip out the deposits, giving the tendon a chance to rebuild.
