Shoulder and Elbow 2024, Jan, 26 | 12:00 am

Calcific Tendonitis - A Comprehensive Guide<

Introduction

Calcific tendonitis is the calcification and tendon degeneration near the rotator cuff insertion, resulting in shoulder pain and decreased range of motion.

Diagnosis

Radiographic examination, specifically orthogonal radiographs of the shoulder, can confirm the presence of calcium deposits overlying the rotator cuff insertion.

Treatment

Treatment options for calcific tendonitis include NSAIDs, physical therapy, corticosteroid injections, and ultrasound-guided needle lavage. In cases where conservative measures fail, arthroscopic decompression may be necessary.

Epidemiology

Calcific tendonitis typically affects patients aged 30 to 60 and is more common in women. The supraspinatus tendon is most often involved. It has been associated with endocrine disorders such as diabetes and hypothyroidism.

Etiology

The exact cause of calcific tendonitis is unknown. The condition involves three stages of calcification: precalcific, calcific, and postcalcific. Key molecular pathways involved include osteopontin, cathepsin K, and transglutaminase 2.

Classification

Gartner and Heyer Classification of Calcific Tendonitis

  • Type I - Well circumscribed, dense calcification, formative
  • Type II - Soft contour/dense or sharp/transparent
  • Type III - Translucent and cloudy appearance without clear circumscription, resorptive

Mole et al. Classification of Calcific Tendonitis

  • Type A - Dense, homogeneous, sharp contours
  • Type B - Dense, segmented, sharp contours
  • Type C - Heterogeneous, soft contours
  • Type D - Dystrophic calcifications at the insertion of the rotator cuff tendon

Presentation

History

The clinical presentation of calcific tendonitis is similar to that of subacromial impingement.

Symptoms

  • Atraumatic pain (most severe in resorptive phase)
  • Catching, crepitus
  • Mechanical block

Physical Exam

Inspection may reveal supraspinatus fossa muscle atrophy. There is often decreased active range of motion, scapular dyskinesia, and a decrease in rotator cuff strength. Provocative tests for subacromial impingement signs can be performed.

Imaging

Radiographs

Radiographs, including AP, supraspinatus outlet, and axillary views, are the gold standard for diagnosing calcific tendonitis. They can show supraspinatus, infraspinatus, and subscapularis calcification.

CT

CT scans are rarely required but may be used to characterize the three-dimensional shoulder anatomy.

MRI

MRI has limited utility in the diagnosis of calcific tendonitis but may be considered in patients with refractory pain to assess for concomitant pathology, such as rotator cuff tears.

Ultrasound

Ultrasound can be used to quantify the extent of calcification. It is also utilized for guidance during needle decompression and injection. Deposits appear hyperechoic.

Treatment

Nonoperative

Nonoperative treatment options for calcific tendonitis include NSAIDs, physical therapy, stretching, strengthening, and steroid injections. These are the first line of treatment for all phases of the condition.

Operative

If nonoperative treatments fail, surgical decompression of the calcium deposit may be considered. This can be done arthroscopically or with a mini-open approach.

Complications

  • Recurrence
  • Persistent shoulder pain
  • Shoulder stiffness
  • Iatrogenic injury to the rotator cuff with operative treatment