Shoulder Resources

Calcific tendinitis (R) Calcific tendinitis (R)


Definition
Dystrophic calcification within the rotator cuff resulting in tendonitis .

Epidemiology
The condition usually affects 30-50 year olds.

Pathology
The calcification is dystrophic and occurs with a normal [Ca ][ PO4] product , as opposed to metastatic calcification where the calcium-phosphate product is elevated. The calcium is deposited as calcium hydroxyapatite crystals . It usually lies superficially within the supraspinatus tendon, adjacent to the bursa .

Aetiology
Not known.
Theories:
• Vascular (Codman) – degeneration in the critical area of hypovascularity. Note: Moseley has demonstrated no evidence of inadequate perfusion to the so-called critical zone.

Clinical
Corresponds to the three phases of Sarkar and Uhthoff.
• Precalcification stage – painless
• The site of predilection for calcification undergoes fibrocartilaginous metaplasia
• Calcification stage – this is divided into three sub stages:
• Phase of formation
• i. Calcium is laid down in matrix vesicles which coalesce to form calcium deposits.
• Resting phase
• i. The pain is minimal and the radiographic appearance is of well marginated, mature appearing deposits.
• Resorptive phase
• i. This is THE PAINFUL STAGE
• ii. The shoulder is hot, painful and red, over a period of only a few hours. This stage can be confused with sepsis.
• iii. Vascular channels surround the deposit and the calcium is gradually reabsorbed. At this stage the deposit is like toothpaste.
• Post calcific stage
• The granulation tissue laid down in the void matures and reconstitutes the tendon.
• Pain subsides a lot
The natural history of the disease is for complete resolution . All patients will eventually recover and the initial treatment of choice is nonoperative.

Imaging
May be helpful to obtain images in internal and external rotation , as the calcification may only be apparent on one view .
Calcification is seen just above the greater tuberosity . The deposit is initially well demarcated but then becomes wooly, ill defined and disappears.

Treatment

Nonoperative
Physical therapy , anti-inflammatories and steroid injections into the area of maximal tenderness. Note that one authority ( Lippmann) believes that steroids may abort the resorptive phase which may predispose to a recurrence .

Surgical treatment

Indications
Ongoing severe pain
Progression of symptoms
Absence of improvement after conservative therapy
There are three main options for treatment:
 • Aspiration under local or general anaesthetic
• Arthroscopic bursal debridement and needling of the area – decompresses the calcific deposit into the bursal space.
• Surgical excision via a deltoid splitting approach.

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