Calcific tendinitis of the shoulder

Calcific tendonitis of the shoulder: a comprehensive guide to understanding and treating this condition

Between 2.5% and 7.5% of adults have calcifications in their shoulder tendons, mainly affecting women in their 40s and 50s. 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 may be a sign that this healing process is underway.

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

What is calcific tendinitis of the shoulder?

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

Contrary to popular belief, these deposits are not pieces of hard bone. During certain phases, 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 cycle of three distinct phases: formation, rest, and resorption. Understanding these phases is essential for interpreting your symptoms and maintaining your motivation during treatment.

Phase 1: Training

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

Many people go through this phase without ever experiencing any 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 latent 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. It is often impossible to actively lift the arm. Intense nighttime pain can cause insomnia. These symptoms are usually accompanied by marked stiffness in the shoulder.

This phase usually lasts between one and six months. The good news is that around two-thirds of patients see their deposits disappear completely or partially after this phase. However, the cycle can stall at any stage.

What really causes calcific tendinitis?

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

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

The important thing to remember is that you have done nothing wrong. It is not your diet or the way you use your shoulder that has caused this condition. Your body can naturally reabsorb 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 an important role: calcific tendinitis occurs mainly between the ages of 30 and 50 and becomes rare after the age of 70. Women are affected twice as often as men, accounting for about 70% of cases.

The right shoulder is more commonly affected, and approximately 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, endocrine disorders, and thyroid disorders.

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

Even with these risk factors, it does not guarantee the development of the condition nor prevent recovery. Many people with multiple risk factors never develop calcific tendinitis.

What are the symptoms of calcific tendinitis?

Symptoms vary considerably depending on the stage of the disease. During the formation and resting phases, pain is often mild or absent. Vague discomfort may occur during certain movements. Mild 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, intense pain often appears without any obvious trauma. It is usually located on the top or side of the shoulder and may radiate down the arm. Severe nighttime pain with insomnia is characteristic. The inability to actively lift the arm significantly limits daily activities. Marked sensitivity to touch on the shoulder is common.

A distinctive feature of the resorption phase is that it often begins very suddenly. You may wake up with intense pain even though everything was fine the day before. This sudden onset is typical of the beginning of inflammatory resorption.

How is calcific tendinitis diagnosed?

The diagnosis combines your symptom history, physical examination, and medical imaging. The clinical evaluation includes questions about the onset of symptoms, their progression, 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 their stage to be assessed. A dense, well-defined deposit suggests a formation or resting stage. A translucent deposit with blurred edges indicates an active resorption stage, which is paradoxically a good sign as it indicates that the body is working to eliminate the calcium.

Ultrasound allows visualization of the deposit in real time. Doppler ultrasound can detect neovascularization, a sign of active resorption. MRI is rarely necessary, unless other associated problems such as 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

Physical therapy for shoulder pain is a mainstay of treatment. It includes gentle joint mobilization and manipulation, progressive exercises tailored to the stage of the condition, the application of ice or heat depending on the stage, and education on sleeping positions and ergonomics. A recent meta-analysis shows that comprehensive physical therapy approaches offer the best functional outcomes.

Extracorporeal shock wave therapy is an effective option. This treatment breaks up the deposit and stimulates healing. Between 3 and 6 sessions are usually necessary. This approach is particularly effective when combined with physical therapy.

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 barboteuse, is performed under ultrasound guidance. This procedure allows softened calcium to be aspirated and is particularly effective during the resorption phase. The addition of PRP after aspiration improves function in approximately 85% of cases.

Anti-inflammatory drugs control pain and inflammation in the short term but should not be used for long periods of time.

Surgery

Surgery is reserved for cases that fail after 6 to 12 months of conservative treatment. Indications include a deposit larger than 1 cm in diameter, which presents a 2.8 times higher risk of requiring surgery, chronic debilitating 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. The results are generally excellent with the 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 aggravate 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 fills the hollow of your neck and place a pillow under the affected arm to support it. 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 as you lean forward, help prevent stiffness. Light stretching within pain-free ranges of motion maintains joint mobility. Gradual resumption of activities should be done at a pace that matches the improvement in symptoms.

Consult a physiotherapist 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. In terms of natural progression, spontaneous resorption occurs in approximately two-thirds of cases within 1 to 2 years. The resorption phase, although very painful, usually lasts from 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 more than 90% of cases, with recurrence being very rare.

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

Certain factors suggest a more reserved prognosis: deposits greater 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 need to remember is reassuring. This pain is temporary. The resorption phase eventually ends. Severe pain, as unpleasant as it may be, 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: physical therapy, shock wave therapy, and guided aspiration speed up 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 pain and limitations. Shoulder bursitis frequently occurs during the resorption phase when calcium crystals irritate the bursa.

Shoulder sprains and other injuries can sometimes trigger or aggravate pre-existing calcific tendonitis. Adhesive capsulitis, or frozen shoulder, can develop if severe pain leads to prolonged immobilization of the shoulder.

Get help for your calcific tendonitis

If you are experiencing severe shoulder pain that matches the symptoms described in this article, our physical therapists can help you understand your condition and develop a treatment plan tailored to your stage. A comprehensive assessment will identify the factors contributing to your pain and develop a personalized approach.

Proper care can significantly reduce the duration and intensity of your symptoms. Make an appointment today to begin your journey toward relief.

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