eMedicine Specialties > Orthopedic Surgery > Systemic Diseases

Calcifying Tendonitis

Author: Anthony H Woodward, MD, Consulting Surgeon, Department of Orthopedic Surgery, Private Practice
Contributor Information and Disclosures

Updated: Oct 23, 2007

Introduction

Painter described calcification in the shoulder in 1907. Codman established that the calcification was within the tendons of the rotator cuff. Calcifying tendinitis of the shoulder is characterized by the presence of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff.1 This article addresses only calcifying tendinitis as it occurs in the shoulder. (See also the eMedicine article Rotator Cuff Disease.)

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Tendinitis.

Problem

Even supraspinatus tendons that are macroscopically normal contain minute amounts of calcium deposits. Degenerative tendons that have ruptured contain more calcium deposits, but it is not always in the form of calcium phosphate. The increase in calcium deposits is due to degenerative calcification.2 In contrast, the calcium in tendons with radiographically visible calcification is in the form of crystalline hydroxyapatite. Calcifying tendinitis is a different condition from that of degenerative tendons in which there is a small increase in calcium content.

The diagnosis of calcifying tendinitis is made from imaging studies or from direct inspection of the affected tendon. Therefore, it is a description of a morphologic status. This condition may be an incidental finding in an asymptomatic shoulder, or it may be the cause of shoulder pain.3 However, calcification may be found in a painful shoulder and yet not be the cause of pain. Indeed, considering that calcific deposits are found in 3-20% of painless shoulders and 7% of painful shoulders, the calcific deposit may not be the cause of shoulder pain in many cases.

Frequency

The incidence of rotator cuff calcification without shoulder symptoms in the general population is 3-20% according to different reports. The highest incidence is in adults aged 30-50 years.4  The incidence of symptomatic calcifying tendinitis appears to have declined in the last 20-30 years.

The supraspinatus tendon is affected most often. Calcification is observed with decreasing frequency in the infraspinatus, teres minor, and subscapularis tendons. More than one tendon may be involved. Women are affected slightly more frequently than are men (housewives and clerical workers account for most cases), and the right shoulder is affected slightly more often than the left is. Both shoulders can have or develop calcific deposits in 13-47% of subjects, and the calcific deposit usually is described as being approximately 1-2 cm proximal to the tendon insertion on the greater tuberosity.

Etiology

The cause of calcifying tendinitis is not known. It is generally agreed that it is not caused by trauma, and it is rarely part of a systemic disease.

Pathophysiology

The pathophysiology of calcifying tendinitis is controversial. The early hypothesis of Codman and others was that the calcification is a consequence of age-related tendon degeneration; however, this is not supported by the following observations:

  • The peak incidence of calcifying tendinitis occurs at an earlier age than that of degeneration.
  • Calcifying tendinitis, in contrast to degenerative tendinopathy, may resolve, and the tendon heals spontaneously.
  • Calcifying tendinitis is rarely associated with tears of the rotator cuff.
  • The chemical composition of the calcium salts in degenerate tendons is different.
  • The calcific deposit of calcifying tendinitis consists of poorly crystallized hydroxyapatite.
  • Calcifying tendinitis appears to occur in viable, not necrotic, tissue, whereas dystrophic calcification appears to occur in necrotic tissue.

Uhthoff and Loehr proposed that calcifying tendinitis is a disease that progresses through correlating pathologic and clinical stages, as follows5 :

  • Formative phase: As a consequence of an unknown trigger, a portion of the tendon undergoes fibrocartilaginous transformation, and calcification occurs in the transformed tissue. The deposit enlarges; the calcific deposit resembles chalk.
  • Resting phase: Once formed, the calcific deposit enters a resting period. The calcific deposit may or may not be painful. If large enough, the deposit may cause mechanical symptoms.
  • Resorptive phase: After a variable period, an inflammatory reaction may ensue. Vascular tissue develops at the periphery of the deposit. Macrophages and multinuclear giant cells absorb the deposit during this phase. The calcific deposit resembles toothpaste and occasionally leaks into the subacromial bursa, which may result in very painful symptoms.
  • Postcalcific phase: Once the calcific deposit has been resorbed, fibroblasts reconstitute the collagen pattern of the tendon.

Presentation

Calcifying tendinitis is a morphologic condition. It may be discovered serendipitously by an imaging study and cause no symptoms. If and when this condition is symptomatic, calcifying tendinitis may present in the following 3 ways:

  1. Chronic, relatively mild pain with intermittent flares, similar to shoulder impingement syndrome, is believed to indicate that the condition is in the formative phase.
  2. Mechanical symptoms may arise from a large calcific deposit, which may block elevation of the shoulder.
  3. More severe acute pain is attributed to the inflammatory response of the resorptive phase.

The pain commonly radiates from the point of the shoulder to the deltoid insertion and, less frequently, to the neck. It is often aggravated by elevation of the arm above shoulder level or by lying on the shoulder. Pain may waken the patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder.

Physical examination

Patients with chronic or subacute symptoms may demonstrate loss of range of motion, a painful arc of motion from 70-110 º of forward elevation, or impingement signs. Catching or crepitus may be noted. In the acute phase, the pain may be so severe that only little movement is allowed, and the tenderness is very marked. Laboratory studies are not required for the diagnosis of calcifying tendinitis.

Indications

The indications for surgical treatment of calcifying tendinitis are progressive symptoms, failure of conservative care, interference with the activities of daily living, and the patient's request.

Contraindications

The presence of local infection is a contraindication to invasive treatment. Allergies to medications contraindicate the use of the offending agents.

More on Calcifying Tendonitis

Overview: Calcifying Tendonitis
Workup: Calcifying Tendonitis
Treatment: Calcifying Tendonitis
Follow-up: Calcifying Tendonitis
References
[ CLOSE WINDOW ]

References

  1. Gärtner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res. May 1990;254:111-20. [Medline].

  2. Riley GP, Harrall RL, Constant CR, Cawston TE, Hazleman BL. Prevalence and possible pathological significance of calcium phosphate salt accumulation in tendon matrix degeneration. Ann Rheum Dis. Feb 1996;55(2):109-15. [Medline]. [Full Text].

  3. Re LP Jr, Karzel RP. Management of rotator cuff calcifications. Orthop Clin North Am. Jan 1993;24(1):125-32. [Medline].

  4. Rupp S, Seil R, Kohn D. [Tendinosis calcarea of the rotator cuff] [German]. Orthopade. Oct 2000;29(10):852-67. [Medline].

  5. Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg. Jul 1997;5(4):183-191. [Medline].

  6. Farin PU. Consistency of rotator-cuff calcifications. Observations on plain radiography, sonography, computed tomography, and at needle treatment. Invest Radiol. May 1996;31(5):300-4. [Medline].

  7. Loew M, Sabo D, Mau H, Perlick L, Wehrle M. [Proton spin tomography imaging of the rotator cuff in calcific tendinitis of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1996;134(4):354-9. [Medline].

  8. Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. J Shoulder Elbow Surg. Jul-Aug 1996;5(4):314-9. [Medline].

  9. Wittenberg RH, Rubenthaler F, Wölk T, et al. Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients. Arch Orthop Trauma Surg. 2001;121(1-2):56-9. [Medline].

  10. Wölk T, Wittenberg RH. [Calcifying subacromial syndrome--clinical and ultrasound outcome of non-surgical therapy] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1997;135(5):451-7. [Medline].

  11. Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. Apr 1997;78(4):379-84. [Medline].

  12. Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. J Bone Joint Surg Br. Sep 1999;81(5):863-7. [Medline]. [Full Text].

  13. Rompe JD, Bürger R, Hopf C, Eysel P. Shoulder function after extracorporal shock wave therapy for calcific tendinitis. J Shoulder Elbow Surg. Sep-Oct 1998;7(5):505-9. [Medline].

  14. Seil R, Rupp S, Hammer DS, et al. [Extracorporeal shockwave therapy in tendionosis calcarea of the rotator cuff: comparison of different treatment protocols] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1999;137(4):310-5. [Medline].

  15. Heller KD, Niethard FU. [Using extracorporeal shockwave therapy in orthopedics--a meta-analysis] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1998;136(5):390-401. [Medline].

  16. Henningan SP, Rome AA. Calcifying tendinitis. In: Ianotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Managament. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.

  17. Uhthoff HK, Sarkar K. Calcifying tendonitis. In: Rockwood CA, Matsen FA III, eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1990.

  18. Farin PU, Räsänen H, Jaroma H, Harju A. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage. Skeletal Radiol. Aug 1996;25(6):551-4. [Medline].

  19. Pfister J, Gerber H. Chronic calcifying tendinitis of the shoulder-therapy by percutaneous needle aspiration and lavage: a prospective open study of 62 shoulders. Clin Rheumatol. May 1997;16(3):269-74. [Medline].

  20. Boyer T. [Arthroscopic treatment of calcifying tendinitis of the rotator cuff] [French]. Chir Main. Nov 2006;25 Suppl 1:S29-35. [Medline].

  21. Jacobs R, Debeer P. Calcifying tendinitis of the rotator cuff: functional outcome after arthroscopic treatment. Acta Orthop Belg. Jun 2006;72(3):276-81. [Medline].

  22. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy. May 2006;22(5):521-7. [Medline].

  23. Kayser R, Hampf S, Seeber E, Heyde CE. Value of preoperative ultrasound marking of calcium deposits in patients who require surgical treatment of calcific tendinitis of the shoulder. Arthroscopy. Jan 2007;23(1):43-50. [Medline].

  24. Rupp S, Seil R, Kohn D. Preoperative ultrasonographic mapping of calcium deposits facilitates localization during arthroscopic surgery for calcifying tendinitis of the rotator cuff. Arthroscopy. Jul-Aug 1998;14(5):540-2. [Medline].

  25. Rubenthaler F, Wittenberg RH. [Intermediate-term follow-up of surgically managed tendinosis calcarea (calcifying subacromion syndrome--SAS) of the shoulder joint] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1997;135(4):354-9. [Medline].

  26. Weber SC. Arthroscopic treatment of calcific tendonitis. Presented at: The 16th Annual Meeting of the San Diego Shoulder Arthroscopy Course; June 1999; San Diego, Calif.

  27. Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg. May-Jun 1998;7(3):213-7. [Medline].

  28. Albert JD, Meadeb J, Guggenbuhl P, et al. High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. J Bone Joint Surg Br. Mar 2007;89(3):335-41. [Medline].

  29. Sabeti M, Dorotka R, Goll A, Gruber M, Schatz KD. A comparison of two different treatments with navigated extracorporeal shock-wave therapy for calcifying tendinitis - a randomized controlled trial. Wien Klin Wochenschr. 2007;119(3-4):124-8. [Medline].

  30. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy. 1992;8(2):183-8. [Medline].

  31. Jim YF, Hsu HC, Chang CY, Wu JJ, Chang T. Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study. Skeletal Radiol. 1993;22(3):183-5. [Medline].

  32. Perlick L, Korth O, Wallny T, et al. [The mechanical effects of shock waves in extracorporeal shock wave treatment of calcific tendinitis--an in vitro model] [German]. Z Orthop Ihre Grenzgeb. Jan-Feb 1999;137(1):10-6. [Medline].

  33. Rompe JD, Zöllner J, Nafe B, Freitag C. [Significance of calcium deposit elimination in tendinosis calcarea of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 2000;138(4):335-9. [Medline].

  34. Sistermann R, Katthagen BD. [Complications, side-effects and contraindications in the use of medium and high-energy extracorporeal shock waves in orthopedics] [German]. Z Orthop Ihre Grenzgeb. Mar-Apr 1998;136(2):175-81. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

calcifying tendinitis, calcific tendinitis, calcified tendinitis, calcareous tendinitis, tendinosis calcarea, calcific tendinopathy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Anthony H Woodward, MD, Consulting Surgeon, Department of Orthopedic Surgery, Private Practice
Anthony H Woodward, MD is a member of the following medical societies: American Association of Orthopaedic Medicine and Oregon Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jegan Krishnan, MBBS, FRACS, PhD, Chair, Senior Clinical Director, Department of Orthopedic Surgery, Flinders Medical Centre and Repatriation General Hospital, Flinders University of South Australia
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul E Di Cesare, MD, Chair and Professor, Department of Orthopedic Surgery, University of California Davis School of Medicine
Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and Sigma Xi
Disclosure: stryker Consulting fee Consulting; smith and nephew Consulting fee Speaking and teaching

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.