Calcific Tendinopathy

Rotator cuff calcific tendinopathy (RCCT) of the shoulder is a condition in which calcium builds up within the rotator cuff tendons – usually near to where they attach to the humerus (upper arm bone) ^{(1, 2)}. Calcium deposits can be present in those without shoulder pain however, some will experience significant pain and disability.

Alongside the presence of calcium deposits, the size has been another key factor with calcifications of >1.5cm in diameter being correlated with symptomatic cases ⁽³⁾. Alternative evidence, however, suggests that deposits <1cm in diameter do not relate to symptoms but calcification within a specific tendon, the supraspinatus, is highly correlated with symptom development ⁽⁴⁾.

The supraspinatus tendon was thought to be the most affected in up to 80% of cases. However, conflicting evidence demonstrated the presence of calcium deposits within the infraspinatus (approximately 50%) and subscapularis (33%) tendons in 62 patients with painful and non-painful shoulders ⁽³⁾. Nonetheless, the presence of calcium deposits within the supraspinatus has been firmly linked to pain ⁽⁴⁾ and may suggest why it is more frequently observed in symptomatic cases.

The exact cause of calcific tendinopathy is unclear despite significant research. Several reasons have been suggested, including reduced blood flow, excessive compression and those with metabolic conditions (such as diabetes). When there is already poor blood supply to portions of these tendons, prolonged contraction of the rotator cuff muscles may cause a further reduction in blood supply, meaning healing capacity may be limited ⁽¹⁾.

The processes involved in developing rotator cuff calcific tendinopathy have been associated with cellular activity and the creation and elimination of calcium crystals, which is generally broken down into 3 phases:

• Pre-calcific – patients are typical without symptoms, metabolic and mechanical alterations within the affected tendon pre-dispose it to developing calcium deposits.
• Calcific – calcium is released from cells and, once calcified, goes into resting. After this, reabsorption begins which is typically the most painful phase.
• Post-calcific – as the calcium deposit is removed, symptoms tend to alleviate and tendon structure normalises ^{(5, 6)}.

The prevalence of rotator cuff calcific tendinopathy in adults ranges between 2.7% and 10.3% in healthy shoulders ⁽³⁾; approximately 42% of these patients eventually have symptoms, complaining of shoulder pain ⁽⁷⁾. Women make up 70% of cases and are usually aged 50-70 with a bilateral presentation in up to 25% of cases ^(1,3).

Advancement in imaging technology such as magnetic resonance imaging (MRI) and ultrasound (US) scans, has produced far more detailed anatomical examination. As such, this may have resulted in more cases being identified in recent years ^{(6, 8)}.

Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.

Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your rotator cuff calcific tendinopathy. This may include reducing/altering the amount or type of activity with the shoulder, as well as other advice aimed at reducing your pain.

It is important that you try and complete the exercises you are provided to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant improvement ^{(1, 3)}.

Physiotherapy management typically comprises manual therapy and exercises which promote healing, reduce calcification, modulate pain and prevent stiffness, whilst strengthening the soft tissue structures ⁽⁹⁾. Whilst recovering you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment.

In cases where symptoms remain unchanged despite conservative intervention, non-surgical options may be explored ⁽¹⁰⁾. Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment method that can benefit pain and function in those with chronic symptoms ^{(2, 9)}.

If your pain is ongoing despite physiotherapy and injection, you may be referred to an orthopaedic surgeon for a surgical opinion ⁽¹⁰⁾.

British Elbow & Shoulder Society, patient resources for subacromial shoulder pain: www.bess.ac.uk/patient-resource-subacromialshoulder-pain/
Chartered Society of Physiotherapy, shoulder pain information and exercises Shoulder pain | The Chartered Society of Physiotherapy (csp.org.uk)