Calcific tendinitis of the shoulder

Calcific Tendinitis in the Shoulder: A Complete Guide to Understanding and Treating This Condition

Between 2.5% and 7.5% of adults experience calcifications in their shoulder tendons, primarily affecting women in their forties and fifties. Here's the good news: in most cases, these deposits resolve naturally. Your body has the ability to eliminate them on its own, and the intense pain you feel can be a sign that this healing process is underway.

You will discover why these calcifications form, how to recognize the different phases, and most importantly, how to regain full use of your shoulder. For an overview of conditions affecting the shoulder, consult our complete guide to shoulder pain.

What is calcific tendinitis of the shoulder?

Calcific tendinitis is characterized by the presence of calcium crystal deposits, called hydroxyapatite, within the rotator cuff tendons. The supraspinatus tendon is affected in 51.5% to 90% of cases, which explains why pain is often located on the top or side of the shoulder.

Contrary to popular belief, these deposits are not hard bone fragments. During certain phases, the calcium forms a viscous liquid that can soften and be reabsorbed by your body. This condition is unique because it follows a predictable cycle with distinct phases, and the healing process often involves a period of intense pain before improvement.

What are the three phases of calcific tendinitis?

Calcific tendinitis follows a three-phase cycle: formation, resting, and resorption. Understanding these phases is essential for interpreting your symptoms and maintaining your motivation during treatment.

Phase 1: Formation

Cells in your tendon transform and actively deposit calcium into the tendon matrix. This phase can last for months or years. Pain is often absent or mild during this period. On an X-ray, the deposit appears dense with clear, well-defined outlines.

Many people go through this phase without ever experiencing symptoms. Calcifications are sometimes discovered by chance during imaging tests performed for other reasons.

Phase 2: Rest

During this phase, the deposits are stable, with no progression or resorption. Symptoms are generally absent or very mild. This dormant phase can also last for months or years before the body decides to resorb the deposits.

Phase 3: Resorption

Paradoxically, this is the most painful phase, but also the one that leads to healing. Your body reabsorbs the deposit through a strong inflammatory reaction. The calcium softens, its volume increases, and microcrystals are released into the subacromial bursa, triggering intense inflammation.

Typical symptoms of the resorption phase include severe and sudden pain, often without apparent trauma. The inability to actively lift the arm is common. Intense nocturnal pain can cause insomnia. Marked shoulder stiffness usually accompanies these symptoms.

This phase usually lasts from 1 to 6 months. The good news is that about two-thirds of patients see their deposits disappear completely or partially after this phase. However, the cycle can get stuck at any stage.

What truly causes calcific tendinitis?

A popular belief is that calcifications are caused by too much calcium in the diet. The scientific reality is different: calcifications are not linked to your dietary calcium intake. They result from an active biological process where tendon cells transform and deposit calcium locally.

The most accepted hypothesis suggests that tenocytes, the tendon cells, undergo metaplasia. They transform into cartilage-like cells that trigger calcium deposition. Several contributing factors have been identified, including decreased local oxygen in the tendon, repeated micro-traumas, a genetic or metabolic predisposition, and mechanical factors related to shoulder use.

It's important to remember this: you haven't done anything wrong. It's not your diet or how you've used your shoulder that caused this condition. Your body can naturally resorb these deposits, and intense pain is often a sign that this process is underway.

Who is most at risk of developing calcific tendinitis?

Several factors increase the risk of developing this condition. Age plays a significant role: calcific tendinitis primarily occurs between 30 and 50 years old and becomes rare after 70. Women are affected twice as often as men, accounting for about 70% of cases.

The right shoulder is more frequently affected, and about 10% of people have bilateral calcifications. Certain medical conditions increase the risk, including diabetes, which is associated with an increased risk and sometimes less effective treatments, as well as endocrine and thyroid disorders.

Occupational factors also play a role. Jobs involving repetitive lifting, prolonged arm elevation, and overhead sports like volleyball, tennis, or swimming are associated with a higher risk.

Even with these risk factors, it doesn't guarantee the development of the condition or prevent healing. Many people with several risk factors never develop calcific tendinitis.

What are the symptoms of calcific tendinitis?

Symptoms vary considerably depending on the phase of the condition. During the formation and rest phases, pain is often mild or absent. A vague discomfort may occur with certain movements. Slight morning stiffness is sometimes present. Approximately 35% of calcifications are completely asymptomatic and discovered incidentally.

During the resorption phase, symptoms are much more pronounced. Sudden and intense pain often appears without obvious trauma. It is generally located on the top or side of the shoulder and can radiate into the arm. Severe nocturnal pain with insomnia is characteristic. The inability to actively lift the arm significantly limits daily activities. Marked tenderness to the touch of the shoulder is frequent.

A peculiarity of the resorption phase is its often very sudden onset. You might wake up with intense pain even though everything was fine the day before. This abrupt onset is typical of the beginning of inflammatory resorption.

How is calcific tendinitis diagnosed?

Diagnosis combines your symptom history, physical examination, and medical imaging. Clinical evaluation includes questions about the onset of symptoms, their evolution, intensity, aggravating movements, and impact on sleep. The physical examination assesses range of motion, muscle strength, palpation of structures, and specific orthopedic tests.

X-rays are the first-line examination. They clearly show calcium deposits and allow for assessment of their phase. A dense, well-defined deposit suggests a formation or rest phase. A translucent deposit with blurred edges indicates an active resorption phase, which is paradoxically a good sign as it indicates the body is working to eliminate the calcium.

Ultrasound allows real-time visualization of the deposit. Doppler ultrasound can detect neovascularization, a sign of active resorption. MRI is rarely necessary, unless other associated problems like a rotator cuff tear are suspected.

It is important to differentiate calcific tendinitis from other conditions that can cause similar symptoms, such as subacromial impingement, shoulder bursitis, adhesive capsulitis, or, more rarely, septic arthritis.

What treatments are available for calcific tendinitis?

Treatment always begins with conservative approaches, with surgery reserved for chronic cases that do not respond to other treatments.

Conservative Treatments

Physiotherapy for shoulder pain is a cornerstone of treatment. It includes gentle joint mobilizations and manipulations, progressive exercises tailored to the condition's phase, applying ice or heat depending on the phase, and education on sleeping positions and ergonomics. A recent meta-analysis shows that comprehensive physiotherapy approaches offer the best functional outcomes.

Extracorporeal shockwave therapy is an effective option. This treatment breaks down the deposit and stimulates healing. Between 3 and 6 sessions are usually needed. This approach is particularly effective when combined with physiotherapy.

Cortisone injections can quickly reduce inflammation during the resorption phase. However, their effect is often temporary, and they do not directly treat the calcium deposit.

Guided aspiration, also known as barbotage, is performed under ultrasound guidance. This procedure allows for the aspiration of softened calcium and is particularly effective during the resorption phase. Adding PRP after aspiration improves function in approximately 85% of cases.

Anti-inflammatory medications control pain and inflammation in the short term but should not be used for extended periods.

Surgery

Surgery is reserved for cases where conservative treatment has failed after 6 to 12 months. Indications include a deposit larger than 1 cm in diameter, which carries a 2.8 times higher risk of requiring surgery, debilitating chronic pain that does not respond to other treatments, and the presence of endocrine conditions that make conservative treatment less effective.

The procedure is performed arthroscopically. The surgeon locates the deposit, excises it, cleans the area, and repairs the tendon if necessary. Results are generally excellent with various surgical techniques.

What can I do at home to relieve my calcific tendinitis?

Several strategies can be implemented at home to manage your symptoms. For acute pain management, relative rest is recommended, but complete immobilization should be avoided. Applying ice for 15 to 20 minutes, 3 to 4 times a day, helps control inflammation. Temporarily modifying activities that worsen the pain is advised.

Sleeping positions play a crucial role in managing nighttime pain. Avoid sleeping on the painful shoulder. Do not place your arm behind your head while sleeping. Use a pillow that properly supports the curve of your neck and place a pillow under the affected arm for support. A semi-sitting position may be necessary during the most painful periods.

Maintaining some mobility is important even during painful phases. Gentle pendulum exercises, where you let your arm swing gently while leaning forward, help prevent stiffness. Light stretches within pain-free ranges maintain joint mobility. Activities should be gradually resumed as symptoms improve.

Consult a professional if the pain persists after 10 days despite your efforts, if you have difficulty performing daily activities, or if nighttime pain significantly affects your quality of life. You do not need to see a doctor before consulting a physiotherapist.

What is the prognosis for calcific tendinitis?

The prognosis for calcific tendinitis is generally favorable. Regarding its natural progression, spontaneous resorption occurs in about two-thirds of cases within 1 to 2 years. The resorption phase, although very painful, usually lasts 1 to 6 months. Most people regain normal shoulder function.

With conservative treatments, significant improvement is observed within 3 to 6 months. Surgery, when necessary, brings improvement in over 90% of cases with very rare recurrence.

Several factors are associated with a better prognosis: age between 30 and 50 years, an active resorption phase identified on imaging, a deposit less than 1 cm, the absence of diabetes, and early intervention with appropriate treatment.

Some factors suggest a more guarded prognosis: deposits larger than 1.5 cm, the presence of metabolic comorbidities, very dense calcifications on imaging, and chronic symptoms present for more than 2 years.

What you should remember is reassuring. This pain is temporary. The resorption phase will eventually end. Severe pain, however unpleasant, is a sign that your body is working to eliminate the deposit. You are not alone: thousands of people experience this every year and regain normal function. Treatments help: physiotherapy, shockwave therapy, and guided aspiration accelerate the process and reduce pain. Your shoulder is not broken, and with the right support, you will regain full use of your shoulder.

Conditions associated with calcific tendinitis

Calcific tendinitis can coexist with other shoulder conditions. Rotator cuff tendinopathy can accompany calcium deposits, adding to the pain and limitations. Shoulder bursitis frequently occurs during the resorption phase when calcium crystals irritate the bursa.

Shoulder sprains and other traumas can sometimes trigger or worsen pre-existing calcific tendinitis. Adhesive capsulitis, or frozen shoulder, can develop if intense pain leads to prolonged shoulder immobilization.

Getting help for your calcific tendinitis

If you are experiencing intense shoulder pain that matches the symptoms described in this article, our physiotherapists can help you understand your condition and develop a treatment plan tailored to your phase. A comprehensive evaluation will identify the factors contributing to your pain and help create a personalized approach.

Appropriate management can significantly reduce the duration and intensity of your symptoms. Book an appointment today to start your journey toward relief.

Sources

De Carli A, Pulcinelli F, Delle Rose G, Pitino D, Ferretti A. Calcific tendinitis of the shoulder. Joints. 2014;2(3):130-136.

Speed CA, Hazleman BL. Calcific tendinitis of the shoulder. N Engl J Med. 1999;340(20):1582-1584.

Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg. 1997;5(4):183-191.

Chianca V, Albano D, Messina C, et al. Rotator cuff calcific tendinopathy: from diagnosis to treatment. Acta Biomed. 2018;89(1-S):186-196.

Louwerens JKG, Sierevelt IN, van Noort A, van den Bekerom MPJ. Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2014;23(8):1240-1249.