What does it mean?
Calcify- calcium deposition, Tendin- tendon, itis- inflammation
Presence of macroscopic depositis of Hydroxyapatite crystals (crystalline calcium phosphate) in any tendon.
Which tendons are affected?
Any tendon which is under stress can be affected by calcium deposition in them but its very commonly seen with supraspinatus tendon (tendon of your shoulder joint).
Where exactly is this tendon?
Supraspinatus and other Rotator Cuff muscles
Is it normal to have calcium in tendons?
Even normally supraspinatus tendon may contain minute amounts of calcium deposits.
Calcific deposits are present in 3-20% of painless shoulders. Its mostly a chance finding. Out of these only 7% are painful.
Degenerative tendons which are ruptured contain more calcific deposits and are more painful.
Why does it occur?
Unknown. Not caused by trauma or any other systemic disease.
Whats the progress of these calcific depositis?
Most of them resolve spontaneously and heal. (hurray!!)
Its rarely associated with tears..(double hurray!!)
It occurs in viable non-necrotic tissue as against dystrophic calcification- which is a different etiology, presentation and treatment. (that’s where an ortho consult helps to differentiate it from other types of problematic calcifications).
Degenerated Tendon with calcium deposit
- Formative phase : Unknown trigger à portion of tendon undergoes fibrocartilaginous transformation à leads to calcification à deposits enlarge à resembles like chalk
- Resting phase : may or may not be painful. If deposits large enough then mechanical symptoms may occur.
- Resorptive phase : After variable period à inflammatory reaction present à macrophages and multinuclear giant cells (these are inflammatory cells) absorb deposits à toothpaste like consistency à it leaks into subacromial bursa à painful symptoms.
- Post calcific phase : calcific deposits resorbed and collagen pattern containing fibroblasts present.
What problems do they cause?
(Let me tell you again) It's mostly asymptomatic and can be a chance finding.
Common age group of patients is 30-50yrs.
Common in females
Right shoulder is commonly affected than left. 15-47% of time both shoulders may be affected.
- Chronic, mild pain, intermittent flares similar to presentation of impingement syndrome à formative phase.
- Mechanical symptoms : large deposits à block elevation of shoulder.
- Severe acute pain : its an inflammatory response of resorptive phase.
Pain pattern : Point of shoulder to deltoid insertion ; less frequently to neck ; pain increases on elevation of arm above shoulder level or lying on the same side. Pain may awake patient from sleep.
Complains of : stiffness/ snapping/ catching/ weakness.
Range of movement is reduced,
Painful arc – 70 to 110 degrees of forward elevation is painful.
Tests of impingement are painful.
Crepitus (crept like sound) may emit from shoulder on movement.
Pain may be extremely severe in some cases when movements are reduced and tenderness is marked.
What investigations are required?
X-ray : only if the deposits are calcified we see it on x-ray. (symptoms if deposit size >1.5cm is not always true)
X-ray showing calcifying tendinitis
Two types of deposits seen on an xray :
- Well defined limits à formative or resting phase
- Diffuse or homogenous, amorphous, fluffy à poorly defined periphery à acute symptoms à resorptive phase.
MRI : 95% accuracy in finding calcification.
(Reduced signal intensity on T1W images. T2W images : Resorptive phaseà oedema present showing as increased signal intensity—not to
confuse with oedema due to tear)
USG : finding depends on the skill of the radiologist.
Its more accurate than an x-ray for soft/fluffy calcific deposits (still to have calcium deposits)
- NSAID’s (anti-inflammatory medicines)- medicines help in reducing the inflammatory markers which give you pain in resorptive phase.
- Needling / aspiration / lavage- yes it involves needles. It helps to reduce pain as well as the calcium deposits can be completely removed in the resorptive phase.
Needling, lavage and aspiration
- Injection Depomedrol- a very mild steroid injections can be used in the resoptive phase to reduce the inflammation and pain.
- Formative phase/ resting phase- mild/ chronic pain à Extracorporeal shock wave therapy is useful (its just like therapy to use high frequency shock waves to break the kidney stones. It is painful so may require anaesthesia.)
- Physiotherapy – Accupuncture therapy helps in relieving the muscle spasm. Exercises help to maintain and regain range of motion and strength.
- Surgical removal of the calcium deposits. It can be done either by open surgery (rarely done nowadays) or by using an arthroscope.
Arthroscopic removal of calcific deposits
Newer studies have suggested the outcome of such tendinitis is very favourable without intervention as it’s a self limiting problem. Intervention is needed only when episodic pain is severe and frequent.