Calcific tendinitis

Overview
Calcific Tendinitis (also calcific/calcifying/calcified/calcareous tenonitis/tendonitis/tendinopathy, and tendinosis calcarea) is a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body, but most commonly in the tendons of the rotator cuff (shoulder), causing pain and inflammation.

Pain is often aggravated by elevation of the arm above shoulder level or by lying on the shoulder. Pain may waken the patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder.

The condition is related to and may cause frozen shoulder.

The calcific deposits are visible on X-ray as discrete lumps or cloudy areas. The deposits look cloudy on X-ray if they are in the process of re-absorption, and this is also when they cause the most pain. The deposits are crystalline when in their resting phase and like toothpaste in the re-absorptive phase. However, poor correlation exists between the appearance of a calcific deposit on plain x-rays and its consistency on needling.

Dietary calcium restriction
A controversial topic, this conservative treatment can be very effective for some patients, and reports of pain cessation with strict dietary calcium restriction have been documented. Dietary restriction applies to all milk products, nuts that have a high calcium content, calcium-fortified products and high calcium vegetables and snacks. Food nutritional labels are helpful in determining foods to restrict. If no improvement is noted after three months, other treatment modalities should be tried.

It is assumed the body scavenges the pathological calcium deposits when dietary calcium is restricted. Studies are required in this area.

Magnesium supplementation
Low magnesium levels can result in calcium deposition in soft tissues. Therefore magnesium supplementation may prevent the formation of calcifications.

Extracorporeal shock wave therapy (ECSW)
ECSW uses sound waves focused onto the deposit. It works by an unknown mechanism in this disorder. In some German studies, 30-70% of patients obtained pain relief, and, in 20-77% of cases, the calcific deposit disappeared or disintegrated.

Medications
Analgesics and non-steroidal anti-inflammatory drugs (NSAID) are useful to a limited extent.

Physical therapy
Electroanalgesia, ice therapy, and heat offer symptomatic relief. The benefit of ultrasound in calcific tendinitis is debated; most studies are negative but a study by Ebenbichler et al (1999) showed resolution of deposits and clinical improvement.

Iontophoresis
In studies, acetic acid iontophoresis combined with ultrasound provided no better clinical results or shrinkage of the calcific deposits than did no treatment.

Injections, needling, and lavage
Under local anesthetic, the calcific deposits can be mechanically broken up by puncturing them repeatedly with a needle and then aspirating the calcific material with the help of a sluice of saline. About 75% of patients are helped by this procedure.

Corticosteroid injections
These are not generally useful.

Surgery
Removing the deposit/s either with open shoulder surgery or arthroscopic surgery are both difficult operations, but with a high success rates (around 90%). About 10% require re-operation.