Soft Tissue Pain: Calcific Tendinitis
By Whitney Lowe, LMT
Soft Tissue Pain: Calcific Tendinitis
By Whitney Lowe, LMT
Calcific tendinitis in the shoulder is a soft-tissue pain complaint that may be acute but is usually chronic, and affects the rotator cuff tendons. Its symptoms somewhat mimic other conditions such as adhesive capsulitis, rotator cuff disorders, shoulder impingement syndrome, or traditional tendinitis characterized by tendon fiber inflammation. Because of these similar symptoms, knowing the evaluation procedures that will distinguish this condition from others is a priority for treatment. Treatment strategies also differ so attention to the particular treatment protocols for this condition is necessary for pain resolution or management.
Calcium deposits can accumulate in any tendon, but occur most often in the supraspinatus, but also the infraspinatus, teres minor, and subscapularis tendons (in that order) (Fig. 1). Calcium deposits develop for no apparent reason (idiopathically), and may disappear and reabsorb without intervention.
Sometimes the tendon tissue gradually returns to normal and the calcium deposits reabsorb. In chronic calcific tendinitis, the healing process is interrupted and the condition becomes exacerbated, prolonged, and deposits may continue to develop. In some cases, there may be compression of the supraspinatus tendon fibers against the underside of the acromion process. However, there is controversy about whether the impingement process contributes to tendon pathology.
Some cases of calcific tendinitis have an active inflammatory process, but research has yet to provide a cause. It may be that it is the inflammatory process that produces the calcium deposits, but inflammation may also result from their development. In either case, inflammation may not be apparent as it may reside under the acromion process. Anti-inflammatory medications, both oral and injected, are often successfully used to provide pain relief, so this would indicate some inflammatory process.
Calcific tendinitis can be mistaken for other shoulder pathologies including adhesive capsulitis, shoulder impingement, bursitis, rotator cuff tears, or other disorders. Evaluating for calcium deposits is usually done through the history and physical exam because they may not show up in X-rays. However, both X-ray and ultrasound are sometimes used for diagnosis.
The relationship between calcium deposits and pain is unpredictable, as there are people who have deposits yet no symptoms of pain or limitation in movement. Nor does there seem to be a direct correlation between the size of the calcium deposit and the amount of pain it produces. For those who do have symptoms, pain can present rapidly - frequently within 24-48 hours - and be severe. Pain is usually described as deep or throbbing in nature (similar to a toothache).
This presentation is in sharp contrast to overuse conditions in the shoulder where symptoms emerge gradually and are more clearly a result of repetitive overuse. Calcific tendinitis pain usually increases in a short period of time, and motion of the shoulder may aggravate the pain. In addition, resting the affected joint often resolves the pain of classic impingement and tendinitis complaints. With calcific tendinitis pain may persist even with a significant period of rest from activities that are painful.
With classic supraspinatus tendinitis, pain is most likely to be exaggerated with abduction of the shoulder, either with active motion or resisted abduction. In calcific tendinitis, pain is not as dependent on activity or movement; though movement can increase the pain, it can also occur when the arm is motionless at the client's side.
Particularly notable with calcific tendinitis is pain with palpation over the greater tuberosity of the humerus (Fig. 2). Pain is not predominant at the greater tuberosity of the humerus with other types of rotator cuff problems. For example, with shoulder impingement syndrome pain may be felt under the acromion process with the arm abducted. But if the greater tuberosity is palpated with the shoulder in a neutral position, there won't be as much discomfort if shoulder impingement is the problem. In contrast, palpation of this area is likely to be very painful with calcific tendinitis.
Calcific tendinitis can be distinguished from adhesive capsulitis or frozen shoulder as there is no capsular pattern with this condition. The capsular pattern of restriction (greatest motion limitations in lateral rotation and then abduction) is a primary criteria for evaluation in the frozen shoulder. Shoulder bursitis can produce pain with various motions, but is usually not aggravated with resisted shoulder abduction. The resisted abduction usually increases discomfort in calcific tendinitis.
Treatment for calcific tendinitis differs from treatment of other shoulder disorders. A predictable pathological process has not been identified, and natural resolution of the condition can take years (3 to more than 10, with sometimes no improvement). It is generally dealt with conservatively, using non-operative modalities and with many cases responding positively to some of these approaches. Anti-inflammatories and steroid injections are usually recommended, along with transcutaneous electrical nerve stimulation and physical therapy, but these have limited benefit for this condition. Rest from offending activities also doesn't result in much improvement.
Ultrasound has shown the most positive results, but recent research indicates higher levels of ultrasound are required for improvement and that little to no improvement results from lower levels. Another recent study resulted in complete dissolution of the calcium deposits in 86.6 percent of treatment subjects with application of radial shock wave therapy, which is an application of a low- to medium-energy shock wave to the affected tissues.1 These modalities both aim to break up the calcium deposits.
A role for massage for calcific tendinitis has not been determined at this point. A study from 1999 found deep friction massage treatment combined with phonophoresis to be beneficial.2 Phonophoresis uses ultrasound to drive medication (usually anti-inflammatory medication) into the skin. More research is needed to evaluate the two treatments individually. Even if deep friction massage could possibly function to break up calcification in the tissue, it would likely be uncomfortable for the client.
Further, massage could aggravate the client's condition. For this reason, applying direct massage on tendons with calcifications is not recommended. If calcific tendinitis is suspected, the massage practitioner should refer the client to a physician. However massage could be used for general pain relief in associated tissues and general relaxation, unless it produces pain. Because calcific tendinitis can lead to frozen shoulder from restricted mobility, massage (in the non-calcified tissues) and passive range of motion may be used as prevention by keeping the shoulder mobile.
Finally, complicated cases may be treated by a physician with a needling technique if conservative treatments have provided no pain relief or benefit. This is a technique in which a hypodermic needle is inserted into the calcium deposit. The needle is then used like a probe to break up the calcified deposits in the tendon tissue. A local anesthetic or corticosteroids are used in conjunction.
An individual with calcific tendinitis may seek the help of a massage practitioner believing they have some other type of pain condition in the shoulder. If the pain pattern for that individual is similar to that described above, calcific tendinitis should be considered. Thorough assessment and evaluation will be helpful to discriminate between calcific tendinitis and other soft-tissue disorders such as rotator cuff pathology, impingement, or adhesive capsulitis. Making these distinctions is important for this condition. Clients suspected to have calcific tendinitis should be referred to a physician, even if the client chooses to continue massage for mild pain relief.
- Cacchio A, Paoloni M, Barile A, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Phys Ther, May 2006;86(5):672-82.
- Gimblett PA, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. JMPT, 1999;22(9):622-7.