Calcific Tendonitis / Further Readings and References
Calcific tendinitis (CT) is a painful shoulder disorder characterised by either single or multiple deposits in the rotator cuff tendon or subacromial bursa. Incidence varies from 2.7 to 20 %, as reported by various authors. Incidence in women is higher. The peak age of presentation is about 40. About 1/5 of cases affect both shoulders. Association with diabetes and thyroid disease has been reported.
The aetiopathogenesis of CT remains elusive. Different mechanisms had been proposed.
Historically. Codman  hypothesised that overuse degeneration of rotator cuff leads to calcific deposits in the tendon in 1934.
Sandstrom  proposed that the degeneration in the tendon follows local ischaemia which led to calcium deposition in 1938.
Mohr and Bilger  considered that the process begins with necrosis of tenocytes due to apoptosis along with intracellular accumulation of calcium, but a more detailed description was given by Uhthoff et al.  in 1997.
Incorrect differentiation of stem cell
Rui et al.  postulated that incorrect differentiation of tendon-derived stem cells into osteoblasts or chondrocytes could be the basis of the calcification in 2011.
Xrays and ultrasound scans are the standard investigations. Xrays should include anteroposterior – neutral, internal, external rotations, axillary, and outlet views. Ultrasound scans are instrumental in detection of calcifications. Attempts been made to classify calcifications according to their shape, border, textures and shadow cones. Re-classifications have been proposed with more advanced scanning technology. Some types are found to be associated with shoulder pain such as the “fragmented” type.  CT scan and MRI scan not required.
1. Codman EA (1934) The shoulder. Thomas Todd, Boston
2. Sandstrom C (1938) Peridentinis calcarea: common disease of middle life. Its diagnosis, pathology and treatment. Am J Roentgenol 40:1–21
3. Mohr W, Bilger S (1990) Basic morphologic structures of calcified tendinopathy and their significance for pathogenesis. Z Rheumatol 49(6):346–355
4. Uhthoff HK, Loehr JW (1997) Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg 5:183–191
5. Rui YF, Lui PP, Chan LS, Chan KM, Fu SC, Li G (2011) Does erroneous differentiation of tendon-derived stem cells contribute to the pathogenesis of calcifying tendinopathy? Chin Med J (Engl) 124(4):606–610.
6. Le Goff B, Berthelot JM, Guillot P, Glémarec J, Maugars Y. Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine. 2010;77(3):258–263.
Many cases may resolve spontaneously and require no special treatment. Cases, which fail to follow this benign course, can be treated by several modalities. However, a gold standard therapy does not exist.
This involves rest, heat packs, physical therapy, oral analgesics, and NSAIDs.
Ultrasound-guided subacromial bursa steroid injections.
Multiple puncturing of the calcification with a needle under ultrasound guidance (needling).
Needling plus steroid injection.
One or two needles are applied to the calcification under USS and saline injected into the calcification in an attempt to wash out the calcium.
Extracorporeal shock wave therapy
ESWT has been used for medical treatment since the 1990s. Its use for calcific tendonitis is increasing. There is a lot of disparity, regarding the dosage (energy flux density), duration (impulses) and interval of administration of it. [7-13]
Surgery is considered a last resort. It usually consists of a combination of arthroscopic decompression, acromioplasty, debulking or removal of the calcification and trimming of the subacromial bursa.
7. Rompe JD, Kirkpatrick CJ, Kullmer K, Schwitalle M, Krischek O (1998) Dose-related effects of shock waves on rabbit tendo Achillis: a sonographic and histological study. J Bone Jt Surg Br 80(3):546–552
8. Farr S, Sevelda F, Mader P, Graf A, Petje G, Sabeti-Aschraf M (2011) Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder. Knee Surg Sports Traumatol Arthrosc 19(12):2085–2089. doi:10.1007/s00167-011-1479-z
9. Ioppolo F, Tattoli M, Di Sante L, Attanasi C, Venditto T, Servidio M, Cacchio A, Santilli V (2012) Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis: a randomized clinical trial comparing two different energy levels. Phys Ther 92(11):1376–1385. doi:10.2522/ptj.20110252
10. Albert JD, Meadeb J, Guggenbuhl P, Marin F, Benkalfate T, Thomazeau H, Chale`s G (2007) High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. J Bone Jt Surg Br 89(3):335–341
11. Hsu CJ, Wang DY, Tseng KF, Fong YC, Hsu HC, Jim YF (2008) Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. J Shoulder Elbow Surg Br 17(1):55–59
12. Krasny C, Enenkel M, Aigner N, Wlk M, Landsiedl F (2005) Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. J Bone Jt Surg Br 87(4):501–507
13. Daecke W, Kusnierczak D, Loew M (2002) Long-term effects of extracorporeal shockwave therapy in chronic calcific tendinitis of the shoulder. J Shoulder Elbow Surg 11(5):476–480
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