Keywords: Calcific Tendonitis, Calcuim deposit, tendon, shoulder pain, differential diagnosis, corticosteriod injection, physiotherapy.
This information has been displayed with the kind permission of Lennard Funk and SportsInjuryClinic. Parts of the pages have been copied from Shoulderdoc.co.uk and SportsInjuryClinic.net.
What is the likelihood?
As a student I always found differential diagnosis hard because until you have experience, how do you know which conditions are common, what they ACTUALLY look like and how can we improve our clinical reasoning skills and in the hope to become clinical experts as we gain experience? The following content offers a quick patient profile of what age you would expect, what symptoms and then possible treatments to consider. There is no black and white, no ‘definite’ patient however there are often common trends. Use your index of suspicion to guide likely diagnoses and try to treat what you find.
Acute calcific tendonitis 2–10% of the population (Rowe et al, 1985)
Calcific tendonitis refers to a build-up of calcium in the rotator cuff (calcific deposit). When calcium builds up in the tendon, it can cause a build up of pressure in the tendon, as well causing a chemical irritation. This leads to pain. The pain can be extremely intense. It is one of the worst pains in the shoulder (the other being Frozen Shoulder ).
Calcific deposit on x-ray[/column]
The use of imaging.
As with other conditions imaging must be used to minimise or strengthen an index of suspicion based on a clinical assessment. In other words treat the person not the scan! There is a growing body of evidence that demonstrates that you can have MRI, Xrays that show severe OA, multiple disc prolapses, tendon tears however these people are asymptomatic. Which shows us that these can exist without pain.
As clinicians it is our duty to build a clinical picture of the mostly likely causes of pain and base treatment on solid clinical reasoning and evidence where possible. It is thought that X-Ray may be good at identifying calcification however ultrasound has been found to be useful in diagnosing whether a calcification could be causing the pain (Goff et al, 2010). A research article found that calcification was more likely to be painful if:
- There was a fragmented appearance, which was twice as common for symptomatic calcifications as for asymptomatic calcifications
- The presence of a power Doppler signal was strongly associated with symptoms. None of the asymptomatic shoulders gave a positive Doppler signal, whereas 36% of the symptomatic shoulders yielded a clear power Doppler signal.
- There was subacromial-subdeltoid bursa thickening.
Goff et al (2010)
Advice for patient
- Rest. Particularly from aggravating factors such as lifting arm over head.
- Apply ice or cold therapy to reduce pain (20mins 2-3 x daily).
- See a doctor or physiotherapist for a clear diagnosis to ensure you are continuing with the correct management if symptoms persist.
- NSAID’s may help with pain – recommend that your patients speaks to their doctor for further information on this.
What can the health professional or physiotherapist do?
- The aim of physiotherapy is to keep the shoulder flexible and strong.
- Physiotherapy should be aimed at improving motor control (and where needed dynamic strength) of the posterior rotator cuff and scapula retractors and depressor to reduce any sub acromial pain syndrome (previously called subacromial impingement) which may cause compression of the tissues involved.
- Acupuncture can be used for pain management.
- TENs can be used for pain management.
Medical or surgical management
- Cortisone steroid injections – reduces inflammation and control the pain
- Ultrasound guided Barbotage – under ultrasound guidance the calcific deposit is injected with a salt water solution and the calcium is also sucked out into a syringe. The area is then repeatedly washed.
- Surgery for Calcific tendonitis: Surgery is required if the pain is not controlled with the methods above and/or the pain is extremely severe, with night pain. The goal of any surgery to reduce the effects of impingement, by increasing the amount of space between the acromion and the rotator cuff tendons, which will then allow for easier movement and less pain and inflammation. The calcium deposit is also debrided and released at the same time. The operation performed is Arthroscopic Subacromial Decompression & Excision of the Calcific Deposit .
Sure you know this inside out? Could you explain it to a patient/ formulate a problem list and provide appropriate management? Complete the quiz to check.
Goff, B., Berthelot, J., Guillot, P., Glemerac, J. and Maugars, Y. (2010) Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine 77: 258–263
Rowe CR.(1985) Calcific tendonitis. Instr Course Lect; 34:196–282.