Calcific Tendonitis

Abstract

Calcific tendonitis is a disorder of the shoulder marked by severe pain and loss of active motion. The etiology is unknown, although metabolic and endocrine disorders have been implicated. A calcific lesion forms in the tendon (usually the supraspinatus), which can be seen on radiographs. MRI is performed if rotator cuff tear is suspected and for surgical planning. There are two subtypes, including degenerative and reactive. The reactive subtype has three stages which describe the pathology and symptoms. They are precalcific, calcific, and postcalcific. Treatment is generally nonoperative, including PT, NSAIDs, subacromial injections, and barbotage. If nonoperative therapies fail to relieve symptoms, operative treatment may be employed, including debridement with or without extraction of the deposit.

The original version of this chapter was revised. An erratum to this chapter can be found at https://doi.org/10.1007/978-3-319-52567-9_159

Definition

Shoulder disorder noted for:

• Severe pain, usually worse in the a.m.

• Sometimes with loss of motion (ROM)

  • Secondary to pain

• Calcific lesion located within the tendon

Epidemiology

• Women > men (slightly)

• Ages 40–60 more common

Etiology

• Unknown etiology

• Metabolic and endocrine disorders have been implicated:

  • Thyroid

  • Diabetes

  • Genetic predisposition

Pathology

• Degenerative calcification

  • Long-term impingement, aging, and decreased vascularity changes to microstructure of tendon fibers.

  • Degeneration of fibers results in necrosis and calcification.

  • Supraspinatus most commonly affected.

• Reactive calcification

• Calcification occurs within the tendon itself typically 1.5–2.0 cm from tendon insertion

Diagnosis

• History and physical exam

  • Severe pain

• Spontaneous onset

• Usually worse in the morning and/or at night

• May also have stiffness and decreased ROM

  • Usually secondary to pain

• Radiographs (Fig. 10.1)

  • Calcification seen in area of the tendon, most often in supraspinatus

  • Two radiographic types:

    • Type 1 – fluffy appearance with poorly defined periphery

    • Type 2 – discrete homogeneous deposits

  • Osteolysis of greater tuberosity seen in a variant form of the condition

• MRI

  • If rotator cuff tear suspected

  • T1 – calcifications manifest as decreased signal

  • T2 – increased intratendinous signal with edema

  • May help localize for barbotage procedure if performed intraoperatively during rotator cuff repair

Fig. 10.1

Shoulder radiographs. (a) AP; (b) scapular Y, axillary lateral

Stages: Reactive Calcification

• Precalcific

  • No symptoms yet

  • Fibrocartilaginous metaplasia of tendon tissue

• Calcific

  • Formative phase

    • Appearance of chondrocytes within tendon tissue

    • Well-delineated, dense homogeneous calcification

    • Calcium excreted from cells into chalky form

  • Resting phase

    • Fibrocartilaginous tissue borders calcium deposit indicating calcium deposition has stopped

    • Painless

  • Resorptive phase

    • Spontaneous resorption of calcium.

    • Vascular invasion at periphery with calcium granuloma.

    • Most painful. Calcification appears like toothpaste.

• Postcalcific

  • Calcification disappears with appearance of vascular channel remodeling calcium granulation tissue with maturing fibroblasts.

  • Rotator cuff tendon replaces the void.

  • Painless.

Treatment

• Nonoperative

  • Physical therapy

    • Prevent loss of motion

    • Strengthen cuff

    • Therapy modalities:

      • Heat

      • Cryotherapy

      • ROM

      • Pendulum

  • NSAIDs

  • Corticosteroid subacromial injections (SAI)

  • Needling (barbotage)

    • Performed with U/S guidance

    • Can be combined with subacromial injection

• Operative

  • Indicated for failure of conservative management especially during the formation phase

  • Arthroscopic or open debridement with extraction of the deposit:

    • Palpate rotator cuff for calcium deposits.

    • Rotator cuff should be assessed at the time of surgery for competency after removal of large deposits.

    • Postoperative pain may continue for weeks.

Outcomes

• In a 2013 study comparing barbotage + SAI vs. isolated SAI, the barbotage group had decreased calcification size (11.6 mm vs 5.1 mm decrease), more cases of total resorption (13 vs 6), improved constant score at 1 year (86 vs 74), lower rates of secondary barbotage, and similar DASH and WORC scores.

• Outcomes worse in the osteolysis variant.