Calcific Tendonitis: The Shoulder Pain That Comes Out of Nowhere

Hi, I'm Dr. Patrick Denard. I'm a shoulder specialist at the Oregon Shoulder Institute where I do 100% shoulder in my practice. And here I'm going to talk about calcific tendinitis symptoms, causes, and treatment. So calcific tendinitis is a calcium buildup in the rotator cuff. Now, this condition is one of the more painful conditions I truly see in my practice. I would say calcific tendinitis and frozen shoulder are probably the conditions that are most painful, and a very small change can actually cause a lot of pain in the shoulder. Essentially what you see is calcium builds up in the rotator cuff tendon itself. This leads to inflammation, especially if you were to look inside the shoulder, and a lot of pain. Typically you're going to have pain at nighttime and pain with overhead activity. The pain from calcific tendinitis can be so severe, in fact, that I've seen people go to the emergency room for this pain. This is often what's termed a calcific flare or calcific crisis, One of the interesting things about this condition when you have that extreme of amount of pain is it's actually often followed by resolution. So people will come see me, they're really scared about what happened. The pain is so severe they have to go to emergency room. But interestingly, it's probably related to some sort of release of the calcium from the rotator cuff that causes this inflammation, and it's subsequently followed by resolution in most cases. So now, what are the causes of calcific tendinitis? Well, in most cases, we don't have a cause. What it's important to know is that calcific tendinitis is not caused by calcium levels in your blood. It's not related to calcium intake. The cells get some mis-signaling and they form this calcium-like substance within the rotator cuff. There's thought to be a genetic relationship when this occurs. Again, it's a very painful thing when it occurs. But it's also very common. In fact, some studies say it's up to 5% of people in the general population have calcific tendonitis. Just many of these people are not symptomatic. One of the common presentations I'll see is that somebody develops pain of calcific tendonitis after they've done a lot of overhead work. So somebody may go do some painting in their house or be doing a lot of moving, and then they will notice a lot of increase in pain afterwards. Now, what's occurred in that case is they've had calcific tendonitis, but it's been asymptomatic. In other words, it's not causing pain. And then they do something to irritate it, and then it becomes very, very inflamed. And that gets later, as I'll talk about treatment in terms of how you want to think about what the treatment options for are for calcific tendonitis. So let's talk about treatment next. So the first thing to know is that most people can get through calcific tendonitis without surgery. Somewhere between 70 to 80% of people are gonna be able to manage in a conservative manner without undergoing surgery. So what does that include? Well, the first mainstay is nonsteroidal anti-inflammatories. These are things like Advil, Motrin, Aleve, et cetera. So there's some limitations here because you can take 600 to 800 milligrams of ibuprofen up to 3 times a day. Aleve, you can take 500 milligrams twice a day, but you want to use those for brief periods of time. So typically I, I view this in terms of being on the orders of weeks or perhaps months, but you don't want this to go on for, for extended period time because anti-inflammatories on a chronic basis can have negative side effects. For instance, they can impact your stomach lining leading to ulceration. And if you take them for a very long period of time, they can also increase cardiac risk. So be judicious or careful in the amount of nonsteroidal anti-inflammatories you use, but they can be helpful for getting you through symptoms, especially if you know, for instance, that you're gonna go out and do an activity, and that's a lot of overhead activity that may incite the pain or make it worse. That's a good time to preemptively take nonsteroidal anti-inflammatories. If people have trouble with their stomach, that in other words, nonsteroidal anti-inflammatories upset their stomach, one of the medications I recommend, which is a prescription medication, is Celebrex. That tends to be easier on the stomach lining. In more severe cases, you can consider medications like a steroid dose pack. This is a 5-day course of steroids, methylprednisolone, that you can take. And so especially when it's really flared, that's an option that I'll consider for people. Or another consideration there would be if somebody's gonna go on a trip, they have this condition and they're sort of worried about, well, what happens if I'm outta the country or I'm away from my physician and I get a flare? And that'd be a nice time to sort of have that as a backup option. The next line of treatment is injections. So injections. Injections we've been much more careful about, but one of the nice things about injections for calcific tendinitis, in particular steroid injections, is you get two benefits. One is the steroid itself is a powerful anti-inflammatory. Now you don't want to do this over and over again, but if you're going to do one or two injections, for instance, that's a reasonable way to bring down the inflammation inside the shoulder. Because again, if you look inside the shoulder in the setting of calcific tendinitis, there's often a lot of bursitis because you get this calcium forming within the rotator cuff tendon itself. Between the acromion bone and the bursa gets very irritated. So you're essentially calming that down with the steroid injection. The second benefit of steroid injections in particular is that if you do this under ultrasound guidance or image guidance, the calcium deposits can be needled. And there's data showing that about 50% of people will have improvement in the radiographic appearance of calcific tendinitis after they have needling of the calcium deposit. So that means it gets better on X-ray. To that point, one of the things I like to do is follow this on X-ray because then we can watch the symptoms over time. We can watch the symptoms, that is, in concert with seeing what it's actually looking like. Again, it's typically pretty small. You're talking about 5 to 10 millimeters in size in the rotator cuff. Uh, but you can follow this over time and see if it's resolving or not, and that can help guide treatment. The next option for treatment that's used quite often is physical therapy. Now, When it comes to physical therapy for calcific tendinitis, this is not the same as rotator cuff. This is why it's really important to know the condition or get the right diagnosis. You'll sometimes see calcific tendinitis missed on X-ray, and one of the reasons is because if it's in the supraspinatus tendon on the top of the shoulder, the top rotator cuff, that's very easy to see. But in other cases, it's in the subscapularis, which is in the front of the shoulder, or in the infraspinatus in the back of the shoulder. In those cases, it can kind of hide behind the ball. And in my practice, I get what are called axillary radiographs, meaning I'm looking straight down at the ball and socket joint. And for that reason, I can always see and determine if somebody has calcific tendinitis. But not all specialists, or orthopedic surgeons for that matter, get axillary radiographs, unfortunately. And sometimes this will be missed. But when it comes to actually considering physical therapy for this, this is, again, is not like rotator cuff. With rotator cuff, you want to strengthen the rotator cuff muscles, and that allows you to compensate for the rotator cuff tear. But as we talked about with calcific tendonitis, this is a chemical irritation or inflammation. So I will see people who have gone to a therapist, they're working really, really hard, and it's just getting worse and worse and worse. My advice in the setting of calcific tendonitis, arthroscopic excision is an option, is to first calm down the inflammation. Again, that's anti-inflammatories, injections as needed. And then second, work on mobility. Work on stretching first, gentle range of motion. Check out my stretching exercises on the rehab playlist to give you some guidance, but I'm not a big advocate of, of doing aggressive strengthening cuz that'll just make the symptoms worse and worse. Now, other options you can consider, it's kind of in the injection topic, but barbotage where you needle the rotator cuff, but in that case also fluid is injected into the rotator cuff. Now, This sounds interesting based on some of the studies which have suggested that it leads to improvement. My problem with barbotage is I have the benefit of looking inside the shoulder. That is, I do arthroscopic surgery, so I look inside shoulders. And when you needle a rotator cuff and you push fluid into the rotator cuff, you're actually creating damage to the rotator cuff. Essentially, you're creating tearing. And if you put a lot of fluid, you'll even create defects in the rotator cuff. So my preference with The needling aspect is to needle the calcific tendinitis under direct visualization to give some stimulation for the body to recognize that area and perhaps resolve the calcific tendinitis. But I do not advocate injecting extensive amounts of fluid into the rotator cuff. Now, what happens if you don't get better with these first line treatments? So again, my first line is calm down the inflammation. I almost always try an injection. Usually people will get better within a few months with that approach. The problem with calcific tendinitis though, is sometimes it's very difficult to determine who who's going to go on to resolution. Some people are gonna get beyond this within 3 to 6 months. Others are gonna have symptoms for a couple of years. In either case, you know, depending on the time and what they've tried, what I do here is I put a camera inside the shoulder and essentially localize where the calcium deposit is in the rotator cuff. And we make a little slit or a controlled tear. I call this a flap, elevate the rotator cuff, shave out the calcium with a device that helps excise it, and then I repair the rotator cuff back down. What we don't want to do is create a large hole in the rotator cuff, just burr down the rotator cuff tissue itself. So I like to elevate the rotator cuff again, pull out the calcium, and then seal it back down. What does that look like? That's a procedure that typically takes 30 to 45 minutes. People go home the same day because it's a controlled tear or flap that's made. That has to be repaired. But since it's very stable, typically somebody's only going to be in a sling for a couple of weeks if that occurs. Now, there is data that shows that actually perhaps people who have surgery do better than conservative treatment of calcific tendonitis. However, I don't jump to that for everybody because there are many people, again, who will resolve without surgery at all. So it comes down to the extent of the symptoms and what somebody has tried. If you do consider surgery for calcific tendonitis, one of the things that's important to know is that because there is this inflammatory process, there can be a slightly higher risk of stiffness after the operation. So typically if we do a rotator cuff repair, the rate of stiffness is going to be 1 to 2%. What do I mean by that? Somebody who really struggles with getting the range of motion back from surgery, who needs injection, or who even goes on to having a license of adhesions. In the setting of calcific tendinitis, that rate is higher. It's probably around 5% based on one study. Now we limit that by moving people early and only being in a sling for a couple of weeks, whereas a standard rotator cuff repair, you're typically in a sling for a bit longer. However, sometimes even then it occurs because of this response from the release of calcific tendinitis. Most of the time we can manage that with things like injection and stretching after the procedure, but in some cases you have to actually go back, re-release adhesions that have formed from that inflammatory process. That typically takes care of the problem because in that setting, the calcium's already gone. You're just dealing with the adhesions that have occurred afterwards, and you do not need to be immobilized at all after that procedure. Again, very rare, but definitely something to be aware of if you're going into treatment for calcific tendonitis. So hopefully that overview helps you understand calcific tendonitis, the symptoms, causes, and potential treatment options in your case. And again, very importantly, get the right diagnosis because that's what it really comes down to. It's really important to distinguish calcific tendinitis from rotator cuff tears, and that's done on x-ray.