Calcific Tendonitis



Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia


Supraspinatous CalciumSupaspinatous Large Deposits




2 groups of patients


1.  Degenerate Calcification


Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller


These patients do not have calcific tendonitis

- older patient group

- different histology


2.  Calcific Tendonitis




Reactive Hypoxic Calcification Theory


Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium


Codman proposed cuff hypoxia as the causative factor




1.  Pre-Calcific stage


Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia


2. Calcific Stage


A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

- crystals may be in the form of phosphates / carbonates / oxalates / hydroxyapatite


B. Resting Stage

- fibrocartilage surrounds deposits


C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma


3. Post-Calcific Stage


Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I




Accounts for 10% all consultations for painful shoulder


Peak 40 years

- diabetes

- F > M 


SS most common tendon

- IS less common

- SSC rare


Asymptomatic patients can have cuff calcium on xray


Clinical Presentation


Usually acute pain

- Resorption Stage

- background of absent to mild chronic pain of the Formative Stage


Patients may present to ED

- severe pain


DDx infection




Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD





Calcific Tendonitis APCalcific Tendonits Lateral


Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size


ER AP Xray

- shows SSC


Subscapularis CalciumSubscapularis Calcium Lateral


IR AP Xray

- shows IS & Tm


Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak


Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density




Low signal on T1 

Oedema on T2


Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2



- more sensitive than Xray ~100%


Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous




Check serum glucose / uric acid & iron




Non operative Management





- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration


Extracorporeal shock wave therapy


Extracorporeal Shock Wave Machine


Peters Skeletal Radiol 2004


- 90 patients

- treatment group complete resolution in 86%, reduction in size in 13.4%

- control group 0 disappeared completely, 9% partial reduction

- significant reduction in pain and improvement in function at 4 weeks

- no adverse affects


Effectiveness directly related to energy

- 0.44 mJ/mm3


Needle aspiration and irrigation



- drain a substantial portion of the calcium

- stimulate resorption of remainder



- resorption phase (soft, toothpaste material)



- small deposits

- formative phase (hard, chalky material)



- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive



- very painful for first 2-3 days




Aina et al Radiology 2001

- excellent results in 74%


Serafini et al Radiology 2009

- non randomised controlled trial

- patients treated better at 1 month / 3 months and 1 year

- no difference long term


Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone


Operative Management



- severe disabling symptoms > 6 months

- failure of needling / ECSW





- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement


Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

- SAD much longer time to return to non painful shoulder activity





Arthroscopic and mini open



Arthroscopic Technique


Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit


Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon


Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness


May need to remove entire diseased section and repair


Calcific Tendonitis Arthroscopy 1Calcific Tendonitis Arthroscopy 2Calcific Tendonitis Arthroscopy 3Calcific Tendonitis Arthroscopy 4




Secondary stiffness



- secondary to calcium deposits

- careful shoulder washout at the end of the case