Calcific Tendinitis of the Shoulder
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Direct answer
Calcific tendinitis of the shoulder is deposition of calcium hydroxyapatite within a rotator cuff tendon, most often the supraspinatus, which becomes painful when the deposit is resorbed. The resorptive phase causes sudden, severe pain that disturbs sleep, and radiographs show a dense, well-defined deposit about one centimetre above the greater tuberosity. Most cases settle with NSAIDs, physiotherapy and shockwave, while ultrasound-guided needling handles persistent symptoms.
What you must remember
- Phases: precalcific, formative (calcification), resorptive (inflammatory and most painful) and postcalcific (healing), each with a different pain pattern.
- Resorptive phase: macrophages and giant cells break down the deposit, producing acute inflammation and the severe pain that often brings the patient in urgently.
- Site: the supraspinatus insertion, typically about 1 cm above the greater tuberosity; infraspinatus and subscapularis are less often involved.
- Radiograph: a dense, well-defined calcific opacity on AP and outlet views, with ultrasound confirming size and vascularity.
- Demographics: middle-aged adults, with a female predominance reported in several series; it is a deposition process, not a degenerative tear.
- First line: NSAIDs, a short rest from heavy overhead work and physiotherapy, with a subacromial corticosteroid injection for severe pain.
- Escalation: extracorporeal shockwave therapy for persistent cases, then ultrasound-guided barbotage, with arthroscopic removal kept for refractory disease.
A staged route from deposit to decision
The pathway starts by confirming the deposit and then escalates only as far as the symptoms demand. Because most deposits resorb, the aim is patient management, though a painful resorptive phase needs faster relief.
- Confirm the deposit: AP and outlet radiographs show the calcific density, and ultrasound measures its size and blood flow.
- Identify the phase: sudden, severe night pain with a fluffy or resorbing deposit points to the resorptive phase, while milder pain with a dense deposit suggests a quieter phase.
- Calm the acute pain: NSAIDs, ice and temporary relief from overhead activity, with a sling used only briefly for comfort.
- Inject if needed: a subacromial corticosteroid injection is considered for severe pain that is not settling.
- Needle the deposit: ultrasound-guided barbotage, with two needles lavaging the calcific material, relieves pain that persists.
- Escalate or operate: extracorporeal shockwave therapy and graded rehabilitation come next, with arthroscopic removal kept for refractory cases.
Most deposits resorb over time, so the usual aim is to control pain and protect movement rather than to remove the deposit. Surgery therefore has a narrow indication in this condition.
Where the exam tries to catch you
The traps come from confusing the deposit with a tear or with frozen shoulder.
- Trap: assuming a calcific deposit means a massive cuff tear and operating early Correct: calcific tendinitis usually resolves with conservative care, and surgery is for refractory cases.
- Trap: calling resorptive pain a frozen shoulder Correct: resorptive pain is intense and inflammatory, whereas frozen shoulder is a capsular contracture diagnosed clinically.
- Trap: injecting steroid into the tendon itself when a deposit is present Correct: steroid goes into the subacromial space, and barbotage is performed under ultrasound guidance.
Frequently asked questions
Which phase of calcific tendinitis is the most painful?
The resorptive phase is the most painful, when macrophages and giant cells break down the deposit and provoke an acute inflammatory reaction. Pain at this stage often prompts urgent presentation and may need analgesia or needling.
What is barbotage in calcific tendinitis?
Barbotage is ultrasound-guided needle lavage that breaks up and aspirates the calcium deposit from the tendon. It is reserved for persistent symptoms that have not responded to conservative care.
Where is the calcific deposit usually located?
The supraspinatus tendon at its insertion, typically about 1 centimetre above the greater tuberosity, is the usual site. Infraspinatus and subscapularis deposits are less common and are seen on the same radiographs.
Does calcific tendinitis always need surgery?
No, most cases resolve with NSAIDs, physiotherapy, shockwave therapy and needling, and many deposits resorb naturally over time. Arthroscopic removal is reserved for refractory cases that fail prolonged conservative care.