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    Calcific Tendinopathy

    What is calcific tendinopathy?

    • Rotator cuff calcific tendinopathy is caused by the presence of calcific deposits in the tendons of the rotator cuff (deep shoulder muscles).

    How common is calcific tendinopathy?

    • Fairly common but can be painless.
    • People will have calcium deposits in their rotator cuff tendons without being aware as they will have no symptoms (1).
    • In people with shoulder pain, around 20% of people will have some element of calcific change in rotator cuff muscles (3).

    Should I worry?

    • No.
    • Calcium deposits have been observed in those not experiencing pain or disability; there may be no cause for concern.
    • Rotator cuff calcific tendinopathy is not linked to other serious pathology.

    Who is most likely to suffer from calcific tendinopathy?

    • Females aged 50-70 represent 70% of cases.
    • It commonly affects those who spend prolonged periods with the arms turned inwards and slightly away from the body such as office-based workers, cashiers and production line operatives (3, 7).

    What are the common symptoms?

    • Localised swelling and tenderness where the affected tendon(s) attach to the arm – usually around the ‘tip’ of the shoulder.
    • Gradual onset of pain can worsen relatively fast.
    • Pain when lying on the affected side can disrupt sleep.
    • Pain with repetitive movements.
    • Restricted movement resulting in reduced function (1).

    What can I do?

    • Relative rest is recommended when initially painful, alongside using non-steroidal anti-inflammatories where appropriate.
    • If your sleep is poor, try supporting your arm on a pillow and roll a pillow up behind your back to stop you from rolling onto your painful shoulder.
    • Graded exercise rehabilitation to improve range of motion and develop strength and resilience of the affected tendon(s) (1,2,3).

    How long will it take to recover?

    • This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
    • Symptoms tend to resolve spontaneously as the calcium is reabsorbed by the body.
    • If managed well, positive changes usually occur within 3-6 months.
    • If symptoms persist for more than 6 months additional, more invasive treatment options may be explored.
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    1. Introduction

    Rotator cuff calcific tendinopathy (RCCT) of the shoulder is a condition in which calcium builds up within the rotator cuff tendons – usually near to where they attach to the humerus (upper arm bone) (1, 2). Calcium deposits can be present in those without shoulder pain however, some will experience significant pain and disability.

    Alongside the presence of calcium deposits, the size has been another key factor with calcifications of >1.5cm in diameter being correlated with symptomatic cases (3). Alternative evidence, however, suggests that deposits <1cm in diameter do not relate to symptoms but calcification within a specific tendon, the supraspinatus, is highly correlated with symptom development (4).

    The supraspinatus tendon was thought to be the most affected in up to 80% of cases. However, conflicting evidence demonstrated the presence of calcium deposits within the infraspinatus (approximately 50%) and subscapularis (33%) tendons in 62 patients with painful and non-painful shoulders (3). Nonetheless, the presence of calcium deposits within the supraspinatus has been firmly linked to pain (4) and may suggest why it is more frequently observed in symptomatic cases.

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    2. Signs & Symptoms

    3. Causes

    The exact cause of calcific tendinopathy is unclear despite significant research. Several reasons have been suggested, including reduced blood flow, excessive compression and those with metabolic conditions (such as diabetes). When there is already poor blood supply to portions of these tendons, prolonged contraction of the rotator cuff muscles may cause a further reduction in blood supply, meaning healing capacity may be limited (1).

    The processes involved in developing rotator cuff calcific tendinopathy have been associated with cellular activity and the creation and elimination of calcium crystals, which is generally broken down into 3 phases:

    • Pre-calcific – patients are typical without symptoms, metabolic and mechanical alterations within the affected tendon pre-dispose it to developing calcium deposits.
    • Calcific – calcium is released from cells and, once calcified, goes into resting. After this, reabsorption begins which is typically the most painful phase.
    • Post-calcific – as the calcium deposit is removed, symptoms tend to alleviate and tendon structure normalises (5, 6).
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    4. Risk Factors

    This is not an exhaustive list. These factors could increase the likelihood of someone developing rotator cuff calcific tendinopathy. It does not mean everyone with these risk factors will develop symptoms.

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    5. Prevalence

    The prevalence of rotator cuff calcific tendinopathy in adults ranges between 2.7% and 10.3% in healthy shoulders (3); approximately 42% of these patients eventually have symptoms, complaining of shoulder pain (7). Women make up 70% of cases and are usually aged 50-70 with a bilateral presentation in up to 25% of cases (1,3).

    Advancement in imaging technology such as magnetic resonance imaging (MRI) and ultrasound (US) scans, has produced far more detailed anatomical examination. As such, this may have resulted in more cases being identified in recent years (6, 8).

    6. Assessment & Diagnosis

    Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.

    Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.

    7. Self-Management

    As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your rotator cuff calcific tendinopathy. This may include reducing/altering the amount or type of activity with the shoulder, as well as other advice aimed at reducing your pain.

    It is important that you try and complete the exercises you are provided to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant improvement (1, 3).

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    8. Rehabilitation

    This condition is managed like non-calcific rotator cuff tendinopathies which involve graded loading to stimulate healing, restore function and build resilience in the affected structures (1). Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing rotator cuff calcific tendinopathy. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.

    9. Calcific Tendinopathy Rehabilitation Plans

    Early Plan

    In the initial stages, the focus for rehabilitation is to manage pain levels and maintain range of motion, function and strength. Gentle range of motion strength exercises are recommended to help reduce pain, avoid soft tissue stiffness in the affected shoulder and increase strength. This should not exceed any more than 4/10 on your perceived pain scale.

    Early Plan - Rating

    Intermediate Plan

    As pain and range of motion improve, the emphasis shifts to progressively loading the affected tendon(s) and increasing shoulder strength and stability. Much like the early plan, a manageable pain level is allowable but should be monitored closely. With the focus shifting to strength, we recommend performing these exercises in just one session, 2-3 times per week with rest days in between. This programme aims to build the resilience of local structures whilst also tailoring the exercises towards everyday, functional movement patterns such as lifting and reaching. This should not exceed any more than 4/10 on your perceived pain scale.

    Intermediate Plan - Rating

    Advanced Plan

    The final phase begins when you are pain free and sufficient strength has developed. The focus for this plan is to heighten strength further and build resilience in both the affected tendon and the shoulder complex as a whole. Aim to complete these exercises 2-3 times per week; they should be challenging to perform in the sense that they work the articulating muscles hard. These exercises will offer novel stimulus and challenge your body to adapt to greater demands which will in turn, lower the likelihood of future occurrence and make you more efficient with everyday tasks. This should not exceed any more than 4/10 on your perceived pain scale.

    Advanced Plan - Rating
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    10. Return to sport/Normal Life

    Physiotherapy management typically comprises manual therapy and exercises which promote healing, reduce calcification, modulate pain and prevent stiffness, whilst strengthening the soft tissue structures (9). Whilst recovering you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment.

    11. Other Treatment Options

    In cases where symptoms remain unchanged despite conservative intervention, non-surgical options may be explored (10). Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment method that can benefit pain and function in those with chronic symptoms (2, 9).

    If your pain is ongoing despite physiotherapy and injection, you may be referred to an orthopaedic surgeon for a surgical opinion (10).

    12. Links For Further Reading

    British Elbow & Shoulder Society, patient resources for subacromial shoulder pain: www.bess.ac.uk/patient-resource-subacromialshoulder-pain/
    Chartered Society of Physiotherapy, shoulder pain information and exercises Shoulder pain | The Chartered Society of Physiotherapy (csp.org.uk)

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    Book an Appointment

    Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

    We have Pure Physiotherapy clinics across the country including Norwich, Great Yarmouth, Manchester, Stockport, Sheffield and Rotherham. Please view our clinics to find the closest physiotherapy clinic for you.

    References

    1. Sansone, V., Maiorano, E., Galluzzo, A., & Pascale, V. (2018). Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthopedic research and reviews, 10, 63.
    2. Simpson, M., Pizzari, T., Cook, T., Wildman, S., & Lewis, J. (2020). Effectiveness of non-surgical interventions for rotator cuff calcific tendinopathy: a systematic review. Journal of Rehabilitation Medicine, 52(10), 1-15.
    3. Le Goff, B., Berthelot, J. M., Guillot, P., Glémarec, J., & Maugars, Y. (2010). Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine, 77(3), 258-263.
    4. Sansone, V., Consonni, O., Maiorano, E., Meroni, R., & Goddi, A. (2016). Calcific tendinopathy of the rotator cuff: the correlation between pain and imaging features in symptomatic and asymptomatic female shoulders. Skeletal radiology, 45(1), 49-55.
    5. Chianca, V., Albano, D., Messina, C., Midiri, F., Mauri, G., Aliprandi, A., Catapano, M., Pescatori, L.C., Monaco, C.G., Gitto, S. & Mainini, A.P. (2018). Rotator cuff calcific tendinopathy: from diagnosis to treatment. Acta Bio Medica: Atenei Parmensis, 89(Suppl 1), 186.
    6. Kachewar, S. G., & Kulkarni, D. S. (2013). Calcific tendinitis of the rotator cuff: a review. Journal of clinical and diagnostic research: JCDR, 7(7), 1482.
    7. Louwerens, J. K., Sierevelt, I. N., van Hove, R. P., van den Bekerom, M. P., & van Noort, A. (2015). Prevalence of calcific deposits within the rotator cuff tendons in adults with and without subacromial pain syndrome: clinical and radiologic analysis of 1219 patients. Journal of shoulder and elbow surgery, 24(10), 1588-1593.
    8. Sansone, V. C., Meroni, R., Boria, P., Pisani, S., & Maiorano, E. (2015). Are occupational repetitive movements of the upper arm associated with rotator cuff calcific tendinopathies?. Rheumatology international, 35(2), 273-280.
    9. Duymaz, T., & Sindel, D. (2019). Comparison of radial extracorporeal shock wave therapy and traditional physiotherapy in rotator cuff calcific tendinitis treatment. Archives of rheumatology, 34(3), 281.
    10. Shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(1), 165-175.
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