CALCIFIC TENDINOSIS OF THE SHOULDER
Calcific deposits in the soft tissues are commonly associated with pain in the shoulder. In acute calcific tendinitis and bursitis, the pain can be excruciating and is generally not difficult to diagnose and treat. On the other hand, shoulder pain associated with chronic calcification can be a diagnostic and therapeutic dilemma. Treatment should be dictated by the location, temporal phase of the calcification, and the clinical picture.
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- Incidence and Pathophysiology
- Clinical Presentation/Differential Diagnosis
- Operative Technique
- Postoperative Program
The incidence of calcification in the shoulder soft tissues varies with patient population and ranges from 2.7% in Bosworth’s series of 6,000 + office workers to 20% in Ruttimann series of 100 asymptomatic shoulders. Codman postulated that tendon degeneration and necrosis precedes dystrophic calcification and that tissue hypoxia plays a role in its formation. Uhthoff and Sarkar theorized a much more dynamic evolution of the calcification and its subsequent resorption, not characteristic of a degenerative process. They postulate a formative phase, in which an unknown trigger produces a localized area of lower oxygen tension. This portion of the tendon undergoes fibrocartilaginous transformation with chondrocyte deposition of poorly crystallized hydroxyapatite. Fluffy calcification occurs in the tendon tissue and enlarges. The calcific deposit, at this stage, resembles chalk. Once formed, the calcific deposit enters a resting phase. The calcified area may or may not be painful. If large enough, impingement symptoms may occur. After a variable period, an inflammatory response then occurs. Vascular tissue develops at the periphery, the oxygen level increases, and macrophages and micronuclear giant cells begin to resorb the calcium during this resorptive phase. The calcific material resembles “tooth paste” and can leak into the subacromial bursa. Pain at this time can be excruciating and this is usually when the patient presents to the office or emergency room in agony. With or without treatment, the inflammation subsequently subsides and the process enters the postcalcific phase where the calcium is replaced to varying degrees by new collagen. Pain may or may not persist and is more likely associated with mechanical factors. The clinician may have difficulty determining whether the calcification is playing a significant role than the clinical syndrome. The most common location for calcification is in the supraspinatus tendon near the tuberosity attachment. Calcification can also be seen in the infraspinatus, teres minor and subscapularis. Females appear to be affected more often than males and bilateral involvement is not uncommon. The highest incidences are in adults aged 30-50 years. No significant correlation seems to exist with trauma or rotator cuff rupture.
The clinical presentation of acute calcific bursitis/tendinitis is often very impressive. The onset of symptoms is usually spontaneous and is associated with the rapid development of excruciating shoulder pain and inability to sleep. The patient is exceedingly tender to palpation about the bursa and has extreme pain with any attempted motion of the shoulder. There may be warmth and fullness anterolaterally. Elbow and hand motion are normal and distal neurocirculatory examination is intact. Neck motion also is generally normal and careful neurologic exam should exclude cervical radiculitis and Parsonage-Turner syndrome. Infection must be ruled out with blood studies and aspiration if necessary. Milwaukee shoulder syndrome is associated with massive calcification in elderly women and severe glenohumeral joint degeneration and dissolution of the rotator cuff. The severe acute symptoms will usually subside in 3 to 7 days, often with the help of analgesic and anti-inflammatory medications and subacromial corticosteroid injections with local anesthetic. Motion gradually returns and the resolution of pain often correlates with the dissolution of the deposit and complete resolution of the syndrome or its containment in a cyst-like shell. Retained calcium may be associated with subacute and chronic calcific tendinitis. Symptoms in these stages often depend on the size and location of the calcific lesion and the morphology of the coracoacromial arch. Large supraspinatus lesions can be associated with anterior impingement while subscapularis lesions lead to anterior subcoracoid impingement. Acute symptoms may recur periodically when the calcific mass leaks or ruptures. As the calcific mass matures and hardens, mechanical symptoms such as painful snapping or catching can occur.
An AP in external rotation, true AP in internal rotation, axillary and outlet views are sufficient to demonstrate and characterize calcification in any tendon. Symptoms usually occur if the deposit is larger than 1.5 cm although Friedman found no correlation between the size of the deposit and the severity of the symptoms. The calcific deposits vary in appearance. Diffuse, heterogeneous, morphous fluffy deposits with poorly definite periphery are associated with acute symptoms and the resorptive phase. Localized homogenous deposits with well-defined limits have been identified with the formative or resting phases or the later chronic phase.
The calcific deposit causes decreased signal intensity on T-1 weighted images. If edema is present around the deposit, as in the resorptive phase, increased signal intensity around the calcium may show on T-2 weighted images. This increased area of signal intensity should not be misinterpreted as a rotator cuff tear. MRI is not necessary to detect calcific tendinitis, although its accuracy for finding calcification is more then 95% and it can be helpful in detecting concomitant pathology in chronic stages.
Acute calcific bursitis/tendinitis
Patients presenting with this extremely painful syndrome require immediate treatment for pain relief. Modalities include:
- An intramuscular injection of narcotic, followed by oral analgesics and nonsteroidal anti-inflammatory medications.
- Sling for 1 or 2 days for pain.
- Subacromial cortico-steroi local anesthetic injection, to ameliorate the raging bursal inflammation.
- Gradual shoulder mobilization.
Since the calcification, noted at presentation, is likely in the resorptive phase and may resolve completely on its own, controversy exists over whether the subacromial injection should include a needling of the lesion under fluoroscopy in the acute phase. Generally this needling and lavage is reserved for more persistent symptoms in the subacute phase.
Subacute calcific tendinitis
One week to three to six months. Less severe inflammatory and/or mechanical inflammatory symptoms continue with persistent maturing calcification on x-ray. Treatment is directed towards relieving the mechanical abutment of the calcium impinging on the acromion or coracoid and the inflammatory irritation of the still soft calcium leaking into the surrounding tissues. Physical therapy directed at scapulothoracic strengthening and acromial posture are extremely important at this juncture, along with continued oral anti-inflammatories. Other PT modalities such as electroanalgesia, heat, ice have shown unknown effectiveness. Ultrasound was found ineffective in a controlled study by Perron and Malouin. In a controlled study, acetic acid iontophoresis combined with ultrasound provided no better clinical result or shrinkage of calcium deposits than did no treatment. If symptoms persist after a well performed scapulothoracic strengthening program, therapy may need to be directed at the persistent calcification. Nonoperative techniques may be more utilized in the subacute phase and operative intervention in the more chronic cases. Breaking up the calcific deposit by repeatedly puncturing it with a needle and aspirating and injecting saline under fluroscopic control has been commonly used in the past. Farin reported excellent results in 45 of 61 patients (74%) at one year follow up and resolved or diminished calcification in 74%. Pfister and Gerber reported 76% significant improvement in 62 shoulders. More recently, extracorporeal shock wave therapy has been used in Europe, Australia and Canada to treat resistant calcific tendinitis in the shoulder. A review of five randomized controlled trials with both high and lower energy ESWT by the Australian Safety and Efficacy Register of New Interventional Procedures/Surgical showed improved functional assessment in all patient groups. Disintegration of calcium ranged from 32% to 77%, depending on the study group and the intensity of the ESWT. Although interesting and encouraging, the role of ESWT at this time for calcific tendinitis is unknown and awaits further study.
Chronic calcific tendinitis
Three to six months and unresponsive to conservative/nonoperative care. These patients demonstrate persistent pain and persistent calcification in the subacromial space with associated mechanical symptoms. Correlation of the symptoms to the calcification can often be confirmed with an examination under fluroscopy. Demonstration that the symptoms can be produced by abutment or impingement of the calcium on the acromion or coracoid, more readily leads to successful surgical results. Ellmann et al reported on an international multicenter study to evaluate arthroscopic treatment of calcific tendinitis. Of 131 patients treated, the average global score was 69.4 out of a possible 75 with the nonoperative other shoulder rating 73.7. The good results had no correlation with age of the patient, size or type of calcification or duration of symptoms. There was no apparent benefit to acromioplaty in this series.
- Image intensifier and rotator cuff repair instrumentation.
- Anesthetic Options: General anesthesia versus interscalene block.
- Patient Position: Lateral decubitus position with arms suspended at 30 degrees of abduction and 10 degrees of flexion. Beach chair is not as convenient in terms of utilization of the C-arm.
- The patient is placed in the lateral decubitus position with the head supported in neutral and the arm suspended at 30 degrees of abduction and 10 degrees of flexion.
- C-arm is brought over the superior aspect of the shoulder with a sterile drape after the arm has been prepped. Calcification is localized with an 18 gauge needle utilizing the C-arm. The needle is left in position.
- C-arm is moved cephalad but kept sterile.
- Arthroscopy is performed through a standard posterior superior portal and a standard anterior superior portal. A systemetic diagnostic exam is performed. Articular side abnormalities of the rotator cuff such as a capillary blush are localized with an 18 gauge needle and suture marker technique.
- Subacromial bursoscopy is performed and the area that was penetrated by the 18 gauge needle under fluro is thoroughly examined. The undersurface of the anterior acromion is also examined for calcification and fraying and indication of impingement.
- The needle is removed and if calcium exudes as tooth paste from the tendon, it is multiply punctured and balloted with a shaver, as the calcium is suctioned from the joint. This shaver is introduced from a lateral portal.
- Once all the calcium has been milked from the tendon, the image intensifier is redeployed and utilized to confirm removal of the offending calcium.
- If the calcification is firm and doesn’t extrude, the extent of the calcification should be localized with multiple 18 gauge needles. This localization can be confirmed with the fluroscopy. Through the lateral portal, a blade is utilized to incise the tendon longitudinally within the confines of the 18 gauge needles. Probes, shavers, and curettes are then utilized to remove the calcification.
- Depending upon the size of the defect in the tendon, side to side rotator cuff repair may or may not be necessary. This is performed with the scope lateral and the suture passing devices coming from posterior and anterior.
- Determination for the necessity of acromioplasty is based on both preoperative and operative factors. If the patient demonstrates a Type II or III acromion with anterior calcification in the coracoacromial ligament and preoperative impingement symptoms, it is likely that an acromioplasty would be a valuable adjunct to the calcium removal. This is confirmed at surgery by the arthroscopic appearance of the undersurface of the acromion.
- Other associated pathology of the glenohumeral joint or the AC joint are treated as appropriate.
- Calcium deposits within the infraspinatous, subscapularis or biceps tendon can be removed with similar technique. Significant loss of biceps tendon integrity should be treated with soft tissue or bony biceps tenodesis.
- Postoperative restrictions are based on the degree of rotator cuff involvement. If the calcium demonstrated “tooth paste” consistency and could be massaged and extruded from the tendon without significant loss of tendon tissue, the shoulder can be mobilized without sling or restriction.
- If rotator cuff tendon loss from excision of calcium treated with rotator cuff repair necessitates protection. Three weeks with a shoulder immobilizer with gentle passive range of motion and Codman’s exercises followed by gradual mobilization, depending on the magnitude of cuff repair, is indicated.
- Arthroscopic subacromial decompression and/or Mumford distal clavicle excision require no immobilization. Progressive activity, as tolerated.
- Ark J, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic Treatment of Calcific Tendinitis of the Shoulder. Arthroscopy 1992; 8(2): 183-8.
- Bosworth BM: Calcium Deposits in the Shoulder in Subacromial Bursitis: A Survey of 12,122 shoulders. JAMA. 1941; 116: 2477.
- Codman E: The Shoulder. Boston, Todd Printing 1934.
- Esch JC, Baker C: Calcific Tendinitis and Esch JC, Baker C, EDS: The Shoulder and Elbow. Philadelphia, JB Lippincott. 1993. 1995.
- Ellmann H, Bigliani LU, Flatow E, et al: Arthroscopic Treatment of Calcific Tendinitis: The American Experience. Paper presented at the 5th International Conference on the Shoulder. Paris, France 1992 July.
- Farin, PU: Consistency of Rotator-Cuff Calcifications. Observations on Plain radiography, sonography, computed tomography, and at needle treatment. Invest Radiol. 1996 May; 31 (5): 300-4.
- Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V: Shock-Wave Therapy is Effective for Chronic Calcifying Tendinitis of the Shoulder. J Bone Joint Surg 1999; 81-B: 863-7.
- Perron M, Malouin F: Acetic Acid Iontophoresis and Ultrasound for the Treatment of Calcifying Tendinitis of the Shoulder: A Randomized Control Trial. Arch Phys Med Rehabil. 1997 April; 78(4): 378-84.
- Pfister J, Gerber H: Chronic Calcifying Tendinitis of the Shoulder: Therapy by Percutaneous Needle Aspiration and Lavage. A Prospective Open Study of 62 Shoulders. Clinical Rheumatology, 1997 May: 16(3): 269-74.
- Rompe JD, Berger R, Hopf C, Eysel P: Shoulder Function after Extra Corporal Shock Wave Therapy for Calcific Tendinitis. J Shoulder Elbow Surg, 1998 Sept-Oct; 7(5): 505-9.
- Snyder SJ, Eppley RA, Brewster S: Arthroscopic Removal of Subacromial Calcification. Arthroscopy (Abstract) 1991; 7: 320.
- Uhtoff HK, Sarkar K: Calcifying Tendinitis. In Rockwood CA, Matson FA eds. The Shoulder. Philadelphia, WB Saunders 1990; 774.
- Weber SE: Techniques and Results of Arthroscopic Treatment of Calcified Tendinitis of the Rotator Cuff using Fluroscopic Localization. Arthroscopy (Abstract) 1991; 7(322)