Sudden Severe Shoulder Pain – Think of Shoulder Calcific Tendonitis
Every now and then I will see a patient who suddenly develops severe shoulder pain almost out of the blue and they have difficulties lifting up the painful shoulder.
One possible diagnosis to keep in mind is that of calcium crystal deposition into the tendons of the shoulder. We doctors call it “Calcific tendonitis of the Shoulder“.
The pain is commonly described as severe, sharp in nature and disturbs sleep.
Painter first described calcification in the shoulder in 1907. Codman established that the calcification was within the tendons of the rotator cuff. Calcifying tendinitis of the shoulder is characterized by the presence of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff.
How To Make The Correct Diagnosis?
The best way to make a diagnosis is to order some radiological tests.
A plain x-ray of the shoulder joint can show calcification of the tendons around the shoulder.
An ultrasound scan can also show calcium deposits in the rotator cuff tendon.
MRI scan when used to look for other problems in the shoulder, e.g. tendon tears, can also show the calcium deposits inside the tendons.
Why Is Calcium Deposited There?
Calcific tendonitis is due to a build-up of calcium in the rotator cuff tendons, and is often aggravated by an existing condition, such as Impingement or overuse tendonitis in the shoulder.
The cause of this condition is UNKNOWN. It usually occurs in people aged 30 to 40 years, and can occur in both shoulders in about 15% of people.
When calcium builds up in the area, pain results from acute inflammation. Calcium is deposited in the rotator cuff, between the humerus and acromion inhibiting the normal, friction-free movement of the joint. Impingement or tendonitis, which reduce the mobility of the joint leads to degenerative change and Calcium deposition.
Why Does It Cause Pain?
When calcium builds up in the tendon, it can cause a build up of pressure in the tendon, as well causing a chemical irritation. This leads to pain. The pain can be extremely intense. It is one of the worst pains in the shoulder and can be very acute in it’s presentation.
The calcium in the tendon makes the tendon swollen and this reduces the space between the rotator cuff and the acromion, as well as affecting the normal function of the rotator cuff. This can lead to impingement of the subacromial space between the acromion and the calcium deposit in the rotator cuff when lifting the arm overhead.
Three Stages of this Condition has been Described
- Precalcification Stage
Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
- Calcific Stage
During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky, it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins–this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.
- Postcalcific Stage
This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.
In over 90 percent of cases, the deposits disappear spontaneously, but this may take 12 to 18 months.
What is the Treatment?
Treatment of calcific tendinitis involves:
1. Painkillers and anti-inflammatory medications
2. Physiotherapy – keeps your shoulder muscles strong and flexible and reduce the irritation
3. Cortisone steroid injections – reduces inflammation and control the pain
4. Ultrasound guided aspiration of calcium – this can only work if the calcium is not solid yet
5. Arthroscopic excision – removal of the calcium from the tendon using keyhole surgery
This is a video which explains what this condition is and how it is treated arthroscopically. Credits to Dr Terry Hammond for the excellent educational video:
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