The calcific tendonitis is a pathological condition of the shoulder that usually affects people over the age of 40 and is characterized by the deposition and accumulation of calcium (hydroxyapatite crystals) on the tendon of the rotator cuff of the shoulder.
This deposition is usually located slightly more centrally than the supraspinatus insertion and similar lesions can be observed in tendons and ligaments and in other parts of the body (ankle, knee, hip, and elbow).
Who is affected by calcific tendonitis?
This type of tendonitis affects patients aged 30-50 years and women appear to be more frequently affected than men.
People with endocrinological disorders (diabetes, hypertension and hypothyroidism) are thought to present an increased risk of developing calcific tendonitis.
Why does calcific tendonitis occur?
The exact cause is unknown, but it is believed that local ischemia (reduced oxygen supply) in the rotator cuff tendons, as part of the normal aging process or possibly due to mechanical factors (impingement syndrome) leads to fibroblast metaplasia and crystalline deposition by chondrocytes.
Calcific tendonitis is presented in two different stages.
- The pre-calcification stage (formative)
- The calcification stage (absorption)
The first stage is characterized by the deposition of the crystals by the cells, while the second stage is characterized by the phagocytic absorption of the crystals and the vascular invasion which is the most painful phase.
Patients suffering from calcific tendonitis may experience pain during any stage, but more often during the absorption phase.
It is believed that the reason pain occurs during the absorption phase is because the calcium crystals are under pressure inside the tendon.
In addition, it is believed that a large proportion of people (possibly up to 75% of the population) exhibit deposition of crystals on the rotary cuff’s tendons without pain symptoms.
The most common symptom reported by patients is pain.
Sometimes the pain results in a reduction in the range of motion of the shoulder joint, as well as stiffness.
In addition, patients are sensitive to palpation in areas where calcium deposits are found.
Radiologic imaging with a simple anterior-posterior X-ray can reflect the deposition of calcium crystals, while other imaging tests such as:
- Computed tomography
- Magnetic resonance imaging
are more accurate in depicting calcium depositions, but are not necessary for diagnosis.
The vast majority of patients are treated conservatively (non-surgically), due to the fact that tendon calcifications will be absorbed over time.
In general, patients regain joint functionality with pain relief within 2 to 3 weeks without any treatment.
About 1/3 of patients will achieve complete absorption of calcium crystal deposition within 3 to 10 years.
If no clinical improvement is observed, then pain treatment may be needed. However, very few patients will have persistent symptoms (mainly pain).
In most cases, the treatment is non-surgical and involves treatment with oral anti-inflammatory drugs and physiotherapy, depending on the degree of stiffness and pain reported by the patient.
Patients with severe pain may be administered a corticosteroid (cortisone) injection in combination with local anesthesia.
The use of oral medication and local injections relieves the patient but does not affect the physical progression of the condition.
In cases where conservative treatment does not help the patient and the pain does not recede or recurs, arthroscopic surgery to remove the calcium deposits is recommended.
The surgeon inserts the arthroscope into the joint through 2 – 3 very small incisions and detects the depositions of calcium crystals among the rotator cuff fibers.
Then the calcifications are removed with special tools followed by the rinsing of the area and the joint and then by stitching of the skin. Usually the patient is discharged on the same day.