What is Calcific Rotator Cuff Disease?
- Calcific Rotator Cuff Disease,
also known as calcific tendinitis, is characterized by the deposition
of calcium hydroxyapatite crystals within the tendons of the rotator
cuff.
- This condition is a common cause of shoulder pain and can lead to
significant discomfort and functional impairment.
- The exact
cause or pathophysiology of calcific tendinitis remains unclear, but it is
believed to be an active, cell-mediated process involving the
differentiation of tenocytes into chondrocyte-like cells, which then
produce calcium deposits [Darrieutort-Laffite et al, 2019; Darrieutort-Laffite et al, 2018; Suzuki et al, 2014].
- The
prevalence of calcific deposits in asymptomatic individuals is notable,
with studies indicating that up to 5% of healthy adults may have these
deposits without experiencing symptoms [Suzuki et al, 2014].
- When symptomatic, calcific tendinitis typically presents with
activity-related shoulder pain and can be associated with acute
inflammatory episodes, particularly during the resorptive phase when the
calcium deposits are being broken down and absorbed [Greis et al, 2015; Darrieutort-Laffite et al, 2018].
What are the most common symptoms of Calcific Rotator Cuff Disease?
- The most common symptoms of calcific rotator cuff disease include:
- Mild to moderate pain during the formation of calcium deposits: During the initial phase of calcific tendinitis, patients may experience mild to moderate pain or may be asymptomatic. This phase is often characterized by the deposition of calcium hydroxyapatite crystals within the rotator cuff tendons [Suzuki et al, 2014; Darrieutort-Laffite et al, 2018].
- Severe pain:
As the condition progresses, particularly during the resorptive phase
when the body attempts to break down and absorb the calcium deposits,
patients can experience severe pain. This pain is often activity-related
and can be debilitating [Suzuki et al, 2014; Darrieutort-Laffite et al, 2018; Hackett et al, 2016]. - Loss of shoulder motion resulting in frozen shoulder (adhesive capsulitis): The inflammation and pain associated with calcific tendinitis can lead to significant restriction in shoulder movement, potentially resulting in frozen shoulder (adhesive capsulitis). This condition is marked by stiffness and a substantial reduction in the range of motion [Alam et al, 2024; Greis et al, 2015]. Learn more about adhesive capsulitis here.
- Pain when lifting the arm: Patients with calcific rotator cuff disease often report pain when lifting their arm, which can interfere with daily activities and reduce overall shoulder function [Suzuki et al, 2014; Hackett et al, 2016; Greis et al, 2015].
How do you know if you have Calcific Rotator Cuff Disease?
- Radiographic imaging is used to confirm the presence of calcium deposits in the rotator cuff tendons, aiding in the diagnosis of calcific rotator cuff disease [Greis et al, 2015].
- Radiography (X-ray) is the most common method used to confirm the presence of calcium deposits in the rotator cuff tendons [Greis et al, 2015; Suzuki et al, 2014].
- X-rays are highly sensitivity and specificity for identifying calcifications. Radiography can reliably detect calcifications, with a sensitivity of 98% and specificity of 96% [Nörenberg et al, 2016].
- Magnetic Resonance Imaging (MRI) and ultrasound are also effective in visualizing calcific deposits and assessing the extent of inflammation and tendon involvement.
- Susceptibility-weighted imaging (SWI) in MRI has shown high sensitivity and specificity for detecting calcifications compared to standard MRI sequences [Greis et al, 2015; Nörenberg et al, 2016].
- SWI has a sensitivity of 98% and specificity of 96%, making it comparable to radiography for identifying calcifications. However, standard MRI sequences have lower sensitivity (59%) and specificity (67%) for detecting calcifications [Nörenberg et al, 2016].
- Ultrasound
is another effective imaging modality for diagnosing calcific rotator
cuff tendinopathy. It can assess the presence, size, and consistency of
calcific deposits with high accuracy.
- The sensitivity of ultrasound in detecting calcific rotator cuff tendinopathy is 100%. This high sensitivity indicates that ultrasound is highly effective in identifying calcific deposits within the rotator cuff tendons [Ottenheijm et al, 2010].
- The diagnostic performance of ultrasound is comparable to other imaging modalities such as radiography (X-ray) and magnetic resonance imaging (MRI), making ultrasound a reliable tool for diagnosing calcific rotator cuff tendinopathy.
What patient populations benefit most from ultrasound over other imaging modalities for this condition?
- Ultrasoundis a highly effective imaging modality for diagnosing calcific rotator cuff tendinopathy, particularly in certain patient populations. Given its high sensitivity and specificity, ultrasound is especially beneficial for:
- Patients with contraindications to MRI: Ultrasound is advantageous for patients who cannot undergo MRI due to contraindications such as the presence of metallic implants, pacemakers, or severe claustrophobia [Feldman et al, 2022].
- Patients requiring dynamic assessment: Ultrasound allows for real-time, dynamic evaluation of the shoulder, which can be particularly useful in assessing tendon movement and identifying impingement during shoulder motion [Feldman et al, 2022].
- Cost-sensitive settings: Ultrasound is a cost-effective alternative to MRI, making it a preferred choice in settings where cost is a significant consideration. This is particularly relevant in primary care and sports medicine environments [Roy et al, 2015; Ottenheijm et al, 2010].
- Point-of-care diagnosis:
Ultrasound can be performed at the point of care, providing immediate
diagnostic information without the need for scheduling and waiting for
MRI appointments. This is beneficial in acute care settings and for
patients with sudden onset of shoulder pain [Jain & Khazzam et al, 2024]. - Patients with suspected calcific tendinopathy:
Given its high sensitivity (100%) for detecting calcific deposits,
ultrasound is particularly useful for patients with suspected calcific
tendinopathy, allowing for accurate diagnosis and guiding subsequent
management [Ottenheijm et al, 2010].
Treatments
Treatment options for calcific rotator cuff tendinopathy in the shoulder include both nonoperative and operative interventions.
- Nonoperative treatments are typically the first-line approach and include:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These are used to manage pain and inflammation [Suzuki et al, 2014].
- Physical Therapy: Aimed at improving shoulder function and range of motion [Suzuki et al, 2014].
- Corticosteroid Injections: These can provide significant pain relief and reduce inflammation [Suzuki et al, 2014].
- Extracorporeal Shock Wave Therapy (ESWT):
Shockwave can be effective in reducing pain, improving function, and promoting the
resorption of calcific deposits in patients with calcific rotator cuff
tendinopathy. The time to recovery varies, but it can take up to 3 to 12 months post-treatment to see significant improvement.- A Cochrane systematic review and meta-analysis by Surace et al. (2020) included 32 trials (2281 participants), comparing shockwave to placebo and other interventions found that ESWT significantly improved pain and function. At 3 months, the mean pain score was 0.78 points better with ESWT compared to placebo (moderate-quality evidence).
- Fatima et al. (2022) conducted a randomized trial with 42 patients, comparing high-energy shock wave to routine physical therapy. The ESWT group received eight sessions over six weeks and showed significant improvements in pain and function at 6 and 12 weeks after treatmen . The ESWT group showed greater reductions in calcification size and better quality of life scores compared to the control group.
- Xue et al. (2024) performed a systematic review and meta-analysis of 16 RCTs (1093 patients). The study reported that shock wave significantly improved pain and function compared to the control groups.
- Bannuru et al. (2014) reviewed 28 RCTs and found that high-energy shockwave was significantly better than placebo in reducing pain and improving function in patients with calcific tendinitis.
- Ultrasound-Guided Needling (UGN)/Fenestration:
Ultrasound-guiged needling involves the insertion of a needle into the calcific deposit to break it up. This procedure is typically combined with a subacromial corticosteroid injection to reduce inflammation.
- Outcomes: Angileri et al. (2023) reported approximately 67% of patients achieved complete radiographic resolution of calcific deposits [Angileri et al, 2023].
- Comparison to Other Treatments: Louwerens et al. (2020) found that UGN was more effective in eliminating calcific deposits compared to high-energy ESWT [Louwerens et al, 2020].
- Speed of Symptom Resolution: Significant improvements in pain and function are typically observed within 3 to 12 months after the treatment [Angileri et al, 2023; Louwerens et al, 2020].
- Ultrasound-Guided Barbotage/Lavage:
Ultrasound-guided barbotage or lavage involves the injection of saline and/or anesthetic solution into the calcific deposit, followed by aspiration of the fragmented material. This procedure can also be combined with a corticosteroid injection.
- Outcomes: Dumoulin et al. (2021) reported that good clinical outcomes at 3 months were associated with steroid injections after UGL, with significant improvements in DASH scores and calcification resorption. Sconza et al. (2024) found that UGL showed significant differences favoring UGL over ESWT in pain relief and calcification resorption at 52 weeks [Sconza et al, 2024; Dumoulin et al, 2021].
- Comparison to Other Treatments: Zhang et al. (2019) found that UGL had better pain relief and calcification clearance compared to ESWT, with higher calcification disappearance rates [Zhang et al, 2019].
- Speed of Symptom Resolution: Significant improvements are typically observed within 3 months post-treatment, with sustained benefits at 5 year follow up [Zhang et al, 2019; Sconza et al, 2024; Dumoulin et al, 2021; de Witte et al, 2017].
- Ultrasound-Guided Tenotomy/Barbotage using TENEX: Traditional barbotage involves repeated needle insertion and aspiration to break up and remove calcific deposits, often combined with a corticosteroid injection to reduce inflammation. The Tenex device uses ultrasonic energy to help fragment and aspirate the calcific deposits.
- Outcomes:
Berrigan et al. (2022) conducted a retrospective comparison of
traditional barbotage and a barbotage using the Tenex device. Both techniques significantly improved
pain with high patient
satisfaction rates. There was no statistically significant difference in
pain improvement between the two techniques [Berrigan et al, 2022].
- Resolution of Calcifications:
Barbotage using the Tenex device resulted in a higher rate of calcification resolution compared
to traditional barbotage and faster symptom resolution.
- Speed of Symptom Resolution:
Barbotage using the Tenex device showed faster symptom resolution compared to traditional barbotage,
with significant improvements observed within 8 weeks post-treatment.
- Operative treatments are considered when nonoperative measures fail. Traditional operative treatments
for rotator cuff calcifications primarily involve arthroscopic
procedures. These include arthroscopic removal of calcific deposits,
with or without additional rotator cuff repair or subacromial
decompression.
- Arthroscopic Removal of Calcific Deposits: The procedure is performed under general anesthesia and incisions are made to insert an arthroscope and surgical instruments. Then the calcific deposit is localized and an incision is made in the affected tendon. The calcium deposit is then removed using a shaver, curette, or suction device. If a large defect is left in the tendon after deposit removal, a suture anchor repair may be performed.
- A high percentage of cases that are brought to sugery end up with a rotator cuff repair with approximately 50%
of surgical procedures for treating calcific rotator cuff tendinopathy
involve the removal of calcific deposits and are combined with a rotator cuff
repair.
- Lorbachet al. (2021) conducted a retrospective cohort study with 44 patients, where 22 patients received additional rotator cuff repair after the removal of calcific deposits, while the other 22 patients underwent simple debridement without repair. This study highlights that rotator cuff repair is often performed at the same time as the removal of calcific deposits because the surgical procedure can result in creating a significant tendon defects.
- Yoo et al. (2010) evaluated 35 patients undergoing arthroscopic treatment for chronic calcific tendinitis. Eighteen patients required rotator cuff repair due to complete tears resulting from the removal of calcific deposits, while the remaining 17 patients received either side-to-side repair or simple debridement.
- Chen et al. (2024) also noted that rotator cuff tears occurred in 30% of patients with calcific tendinitis, indicating that rotator cuff repair is a common adjunct to the removal of calcific deposits in surgical management.
- Recovery Times:
- Calcific Deposit Removal Alone:
Recovery times are generally shorter. Significant improvements in pain
and function are typically observed within 3 to 6 months post-surgery,
with complete recovery taking up to 12 months. [1-2]
- Calcific Deposit Removal with Rotator Cuff Repair:
Recovery times are longer due to the additional repair. Lorbach et al.
(2021) reported that patients undergoing combined procedures had better
clinical outcomes but required a longer recovery period, often extending
beyond 6 months for significant improvements, with complete recovery
potentially taking up to 12 months.[1]
- Complications:
- Calcific Deposit Removal Alone:
Complication rates are generally low. Risks include infection,
bleeding, and damage to surrounding structures. El Shewy (2011) reported
a 3.7% incidence of rotator cuff tears over a 7-year follow-up period.
Youn et al. (2023) found that even without repairing the rotator cuff
defect, patients had significant improvements in function and pain, with
a low rate of persistent interstitial defects.[3]
- Calcific Deposit Removal with Rotator Cuff Repair:
The addition of rotator cuff repair can increase the risk of
complications such as infection, stiffness, and re-tear of the repaired
tendon. Lorbach et al. (2021) found that patients who underwent
additional rotator cuff repair had significantly better clinical results
but also faced a higher risk of postoperative complications, including
tendon re-tear.[1]
Learn more about non-surgical treatment options at:
(781) 591-7855
info@BSBortho.com
20 Walnut St
Suite 14
Wellesley MA 02481
