Does calcific tendinitis always require surgery?

Usually not. The article notes that in studies about half of patients were symptom-free within three months and about 70% within a year after conservative treatment; these are trial results and do not predict any individual's outcome. Only about 10% who do not respond to conservative treatment, shockwave, or lavage, or who show no improvement beyond six months, are considered for arthroscopic surgery. Whether surgery is appropriate depends on your condition and a physician's assessment.

Why does my shoulder hurt so much that I can't sleep at night?

When the calcification enters the resorptive phase, calcium crystals leak into the overlying bursa and trigger inflammation, often causing severe acute pain that worsens at night and can make sleep difficult. However, the pain in this phase usually improves within one to two weeks.

Who is more likely to develop calcific tendinitis?

The article notes it most often affects women aged 30 to 60, is often unrelated to trauma or overuse, and may be associated with diabetes, kidney stones, and thyroid- and estrogen-related conditions. A small number have a hereditary tendency, and bilateral occurrence is more common in those cases.

Besides medication and injections, what other treatments are there?

When initial treatment fails, ultrasound-guided needling and lavage (barbotage) to aspirate the calcification, or extracorporeal shockwave therapy, may be considered; the latter tends to help refractory cases in the formative and resting phases. Dry needling, therapeutic ultrasound, and regenerative therapies such as PRP currently have less supporting evidence.

How is calcific tendinitis diagnosed?

Mainly with X-ray or ultrasound, which often show characteristic calcium deposits about one to one and a half centimeters above the tendon insertion. Ultrasound can also guide injections and, from changes in blood flow, help judge whether the deposit is in an inflammatory resorptive phase.

Calcific Tendinitis Explained: From Symptoms to Treatment

Calcific tendinitis can occur at any site but mainly affects the rotator cuff tendons of the shoulder. Its main symptoms are pain and functional impairment from limited range of motion, related to calcium deposits within the tendon that cause impingement, tendon irritation, and increased intratendinous pressure. Symptoms usually ease within three to six months.

Epidemiology

It typically affects women aged 30 to 60, with an incidence of about 3-10% in the general population.
Around 50% of calcium deposits cause no symptoms.
Bilateral occurrence is seen in 10-20% of cases.
Within the rotator cuff, the supraspinatus tendon is most often involved, accounting for about 51%, followed by the infraspinatus tendon at about 44.5%.
In 20% of cases the calcification may be asymptomatic.

Cause and pathophysiology

No definite cause has been established, and it is not necessarily related to trauma or overuse.

Calcific tendinitis passes through three phases:

Precalcific phase: the tendon undergoes fibrocartilaginous transformation, and calcification proliferates within the tissue. This phase is usually not painful.
Calcific phase: this can be further divided into three subphases.
Formative phase: not necessarily painful; calcium deposits begin to appear.
Resting phase: the calcium deposit is stable and does not necessarily cause pain, though a deposit large enough may produce mechanical symptoms.
Resorptive phase: an inflammatory response triggered by unknown factors, with vascular invasion around the deposit as macrophages and giant cells migrate in and resorb the calcification. This is the most painful phase.
Postcalcific phase: the calcium deposit is resorbed, and fibroblasts rebuild the tendon’s normal collagen pattern. Some people have a hereditary tendency, and bilateral occurrence is more frequent in those cases.

Risk factors

It is rarely part of a systemic disease, but it may be associated with diabetes, kidney stones, and thyroid- and estrogen-related conditions.

History and symptoms

Localized pain is the main symptom, and the clinical presentation varies by phase, with symptoms such as catching and joint friction.
The pain is often progressive and unrelated to trauma. Because calcium crystals leak from the deposit into the overlying bursa, severe acute pain often appears in the resorptive phase; the pain may improve within one to two weeks.
Pain worsens at night and can even make sleep impossible.

Physical examination:

Both active range of motion (AROM) and passive range of motion (PROM) are limited, with little difference between the two.
Shoulder impingement tests (Hawkins and Neer tests) are usually positive.

Differential diagnosis

Rotator cuff tear
Osteoarthritis of the shoulder or acromioclavicular joint
Adhesive capsulitis
Biceps tendinitis
Cervical radiculopathy
Gout

Diagnostic tools

X-ray or ultrasound: characteristic calcium deposits, usually about one to one and a half centimeters above the tendon insertion.
X-ray: can be taken from multiple angles to fully assess location, size, and morphology.
Resting phase: dense, uniform calcification with clear borders.
Resorptive phase: fluffy, ill-defined, possibly with increased central density.
Ultrasound: a tool for both diagnosis and guiding injection.
Resting phase: a hyperechoic lesion with acoustic shadowing.
Resorptive phase: fluffy and fragmented, cystic, or nodular; power Doppler imaging shows increased vascularity around the deposit.

Initial treatment

Initial treatment options include oral anti-inflammatory drugs, painkillers, corticosteroid injection, and rehabilitation with physical therapy.
Subacromial bursa (SAB) corticosteroid injection: suitable for clinically evident acute inflammatory symptoms.
Ultrasound-guided needling and lavage (barbotage): consider this if initial treatment fails. In most cases ultrasound-guided aspiration of the calcification is possible, but sometimes it is too hard to aspirate. When the calcification has a toothpaste-like consistency, aspiration is easiest — most often in the severely painful resorptive phase. Some studies disagree on whether lavage is needed, arguing that lavage does not affect long-term pain or functional outcomes.
Extracorporeal shockwave therapy: most useful for refractory calcific tendinitis in the formative and resting phases; in terms of results, the improvement in clinical outcome scores is greater with medium-to-high energy than with low energy.
Treatments with less supporting evidence: dry needling, therapeutic ultrasound, and regenerative therapies such as PRP.

Surgery

About 10% of patients do not respond to conservative treatment, ESWT, or barbotage and may need surgery; surgery is also considered for patients who do not respond to conservative treatment beyond six months.
The surgery is arthroscopic and includes removal of the calcification, possibly with acromioplasty.

Follow-up

After an acute pain flare:

Early follow-up assessment within one to two weeks after treatment.
If the corticosteroid injection was effective at the last visit (pain reduced or resolved), continue with a gentle rehabilitation program.
If the patient’s symptoms improved only mildly and imaging shows no change in the calcification, barbotage treatment is advised.
If significant pain persists, a second injection is given, supplemented with oral painkillers.

Follow-up for conservative treatment:

Follow up four months later or after completing treatment, assessing mobility and strength; for patients with persistent symptoms, repeat ultrasound or X-ray follow-up.
If symptoms and calcium deposits remain on imaging, consider barbotage or ESWT in preference to surgery; consider a second barbotage treatment for calcium deposits larger than 5 mm.

Prognosis

50% are symptom-free within three months after conservative treatment.
70% are symptom-free within one year of onset.
Symptoms persist for several years in 30%; of these, 66% improve with barbotage or ESWT.
The remaining 10% with persistent symptoms are referred for surgery.
Unfavorable prognostic indicators include female sex, bilateral involvement, the dominant hand, and large or multiple calcifications. For these particular patients, more aggressive treatment early in the disease may improve long-term outcomes.

Complications

Adhesive capsulitis
Rotator cuff tear: may render routine conservative treatment ineffective.
Acromial tuberosity osteolysis: very rare.
Ossifying tendinitis: very rare, associated with arthroscopic surgical intervention.
Osteonecrosis: extremely rare.

References

Calcific Tendonitis - Shoulder & Elbow - Orthobullets
J Orthop Traumatol. 2016 Mar;17(1):7-14. doi: 10.1007/s10195-015-0367-6. Epub 2015 Jul 12.
BMJ. 2023 Oct 11:383:2248. doi: 10.1136/bmj.p2248.
Radiol Med. 2021 Apr;126(4):608-619. doi: 10.1007/s11547-020-01300-0. Epub 2020 Nov 5.