What is calcific tendinopathy (also known as calcific tendinitis)?

Calcific tendinopathy, also known as calcific tendinitis, is characterised by sudden onset, severe pain in the shoulder that can refer down the arm and wakes you at night. It normally starts for no apparent reason and causes severe restriction to movement in all directions. Calcific tendinopathy most commonly occurs in the supraspinatus tendon. It is diagnosed using an ultrasound scan. You do not need an MRI or x-ray. Calcific tendinopathy is best managed with rest and anti-inflammatories,  If the pain does not settle, an ultrasound guided steroid injection and/or barbotage and lavage procedure are a very effective treatment option.

What are the symptoms of calcific tendinopathy?

The symptoms of calcific tendinopathy are:

  • Sudden onset, severe pain in the shoulder and into the arm
  • Pain that causes significant reduction in movement and inability to move the arm
  • Pain that is worse in the mornings and wakes you at night

If this sounds like your pain, read on…

What other conditions can mimic calcific tendinopathy

If this does not sound like your pain there are other conditions that can mimic the pain of calcific tendinopathy such as:

  1. acromio-clavicular (AC) joint osteoarthritis
  2. frozen shoulder
  3. shoulder impingement
  4. rotator cuff pain
  5. sub-acromial bursitis
  6. shoulder joint osteoarthritis

Calcific tendinopathy versus frozen shoulder?

Calcific tendinopathy is more common in the younger age groups, classically 20–40 years old, whereas frozen shoulder presents almost exclusively in those between 40-60 years old. Both calcific tendinopathy and frozen shoulder cause severe pain, particularly at night, and an associated reduction in arm movements. Calcific tendinopathy has a sudden, acute onset whereas frozen shoulder develops over a longer period of time.

Shoulder disorders are an incredibly common cause of pain and can occur at any age.  Research has shown that up to one third of people will suffer from shoulder pain during their lifetime (Dong et al., 2015).

Shoulder impingement syndrome is the most frequent cause of shoulder pain responsible for over 65% shoulder pathologies (Dong et al., 2015).

Calcific tendinopathy of the shoulder is a common and very painful condition. Chianca et al., (2018) reported calcific tendinopathy to be present in 2.5%-7.5% of healthy adult shoulders with 20% of all cases being non symptomatic.  Research has also revealed that up to 20% of calcific tendinopathy patients have bilateral (on both sides) calcifications.  Calcific tendinopathy can occur throughout the rotator cuff with 80% of cases involving the supraspinatus tendon, 15% infraspinatus tendon and 5% the subscapularis tendon (see below image).  Calcific tendinopathy of the shoulder is most common in the 4th and 5th decade of life with 70% of patients being female.

The term shoulder impingement is often used medical professionals to describe pain arising from the rotator cuff tendons or the surrounding bursa (small fluid filled sacs used to reduce friction during movement).

A multitude of different pathologies can result in shoulder impingement symptoms.  These include:

calcific tendinopathy ultrasound-guided_injection_shoulder_rotator-cuff

Symptoms associated with calcific tendinopathy of the shoulder include:

  • Acute/severe pain located at the side of your shoulder which may refer down towards the elbow.
  • Sudden onset of pain
  • Pain made worse when you lift your arm, especially overhead or away from the body.
  • Pain that is worse at night.  This may affect your ability to go to sleep or wake you up.
  • Sensations of weakness in your arm.
  • Lifting and carrying objects such as shopping bags can be painful.

What causes calcific tendinopathy?

Unfortunately, the pathophysiology of calcific tendinopathy is not fully understood however, it is believed to be caused by the transformation of tenocytes (cells used to produce tendon tissue) into chondrocytes (cells used to produce cartilage).  This results in the deposition of calcium within the tendon itself (Chianca et al., 2018).

The production of calcium within a tendon has been disused by Chianca et al., (2018) who subdivided its pathophysiology into 3 distinct stages:

  1. Pre calcification stage.  In this stage with tenocyte cells are converted into a fibrocartilage substance before being transformed into a calcific deposit.
  2. Calcific stage.  This phase is marked by increased pressure within the tendon causing inflammation and significant, acute pain.  During this phase conservative treatment including non-steroidal medication is often ineffective.
  3. Post calcific stage.  During the post calcific phase, the calcific deposits within the tendon are reabsorbed during a process called remodelling.  This can take many months to complete.

How is calcific tendinopathy diagnosed?

calcific tendinopathy Shoulder_injection_calcific_rotator cuff

A physiotherapist can provide a clinical diagnosis of shoulder impingement syndrome however, a clinical assessment alone is not able to reliably diagnose calcific tendinopathy

A diagnostic ultrasound scan is required to obtain a full and accurate diagnosis of the cause of your shoulder pain. Obtaining a correct diagnosis is essential, allowing for the most appropriate and effective treatment strategy to be implemented.

Diagnostic musculoskeletal ultrasound

Diagnostic ultrasound imaging is better than to magnetic resonance imaging (MRI) in the diagnosis of calcific tendinopathy (Ardic et al., 2006, Chianca et al., 2018). Diagnostic musculoskeletal ultrasound has also been proven to be excellent at visualising inflammation associated with tendon and bursal pathology.  It also has the unique ability to dynamically assess the movement of the tendon in real-time, not possible with x-ray or MRI.

How do we treat calcific tendinopathy?

calcific tendinopathy

A majority of calcific tendinopathy are self-limiting and will resolve with a period of rest, physiotherapy, and a short course of non-steroidal medication (Louwerens et al., 2016).

What if conservative treatment options fail?

If your pain remains persistent and conservative management techniques have not been successful, there are other treatment options are available to you.  Research has demonstrated that shockwave therapy and ultrasound guided steroid injections are effective at reducing pain and restoring shoulder function (Chianca et al., 2018).  Success of each treatment is intrinsically linked with the continued participation in a physiotherapy program.

At Complete Physio, we carry out both of these options at four of our conveniently located sites.

Shockwave treatment

Shockwave therapy is used to stimulate tendon healing.  It produces powerful sound waves that create an environment of controlled microtrauma to the region.  This directly targets the calcium within the tendon.  Evidence has revealed that shockwave therapy:

  • stimulates a healing response
  • causes fragmentation of calcium deposits within a tendon
  • encourages reabsorption of the calcium by the body
  • reduces pain by desensitising local nerve endings

(Chianca et al., 2018).

A course of 3 to 6 treatment sessions are required. This should be accompanied by a course of physiotherapy for optimum results.

Injection therapy

Ultrasound guided injection therapy is an accurate and effective treatment technique used to reduce pain and increased movement.  Current research has observed increased accuracy rates (Daniels et al, 2018, Aly et al., 2015), significant reduction in pain and reduced post injection complications with ultrasound guided injections.

Calcific tendinopathy requires a specific advanced injection technique called a barbotage & lavage procedure. Barbotage & lavage is a technique involving the use of both local anesthetic and corticosteroid. During the procedure, the calcium deposit will be broken up and aspirated (drawn up in the syringe) where possible. This procedure not only reduces the pain but also removes the calcific area in the tendon.

This procedure often results in a dramatic reduction in the patient’s pain symptoms. We also provide a graded exercise program to follow in order to help the shoulder return to normal strength and function in the days after the injection procedure.

Our clinicians are highly experienced injection physiotherapists, independent medical prescribers, and fully qualified musculoskeletal sonographers. We provide a comprehensive one-stop service which, includes a clinical assessment, ultrasound scan, and an ultrasound guided barbotage & lavage procedure for £250.

If you would like to book an appointment or would like more information before booking please call 020 7482 3875 or email info@complete-physio.co.uk

References:

Aly, A.R., Rajasekaran, S. and Ashworth, N., 2015. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British journal of sports medicine, 49(16), pp.1042-1049.

Ardic, F., Kahraman, Y., Kacar, M., Kahraman, M.C., Findikoglu, G. and Yorgancioglu, Z.R., 2006. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. American journal of physical medicine & rehabilitation, 85(1), pp.53-60.

Daniels, E.W., Cole, D., Jacobs, B. and Phillips, S.F., 2018. Existing evidence on ultrasound-guided injections in sports medicine. Orthopaedic journal of sports medicine, 6(2), p.2325967118756576.

Cheatham, S.W., Enseki, K.R. and Kolber, M.J., 2016. The clinical presentation of individuals with femoral acetabular impingement and labral tears: a narrative review of the evidence. Journal of Bodywork and Movement Therapies, 20(2), pp.346-355.

Chianca, V., Albano, D., Messina, C., Midiri, F., Mauri, G., Aliprandi, A., Catapano, M., Pescatori, L.C., Monaco, C.G., Gitto, S. and Mainini, A.P., 2018. Rotator cuff calcific tendinopathy: from diagnosis to treatment. Acta Bio Medica: Atenei Parmensis, 89(Suppl 1), p.186.

Dong, W., Goost, H., Lin, X.B., Burger, C., Paul, C., Wang, Z.L., Zhang, T.Y., Jiang, Z.C., Welle, K. and Kabir, K., 2015. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine, 94(10).

Louwerens, J.K., Veltman, E.S., van Noort, A. and van den Bekerom, M.P., 2016. The effectiveness of high-energy extracorporeal 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), pp.165-175.

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