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.

Calcific tendonitis of the Subscapularis tendon (arrow)

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:

For more information on shoulder pain and treatment, please call us at +65-683 666 36 or email us at hcchang@ortho.com.sg

Do visit us at http://www.ortho.com.sg

Comments
8 Responses to “Sudden Severe Shoulder Pain – Think of Shoulder Calcific Tendonitis”
  1. Tim says:

    Good info. I had this for a few weeks with the terrible pain. After laying off heavy lifting and heavy work it’s abated but anytime I do heavy work it flares up quickly.

    With the Arthroscopic excision, would it usually just re-occur in most people? Is this a simple surgery and how long is the recovery time? Thanks for any help.

    • Hi Tim, you can try 1 shot of cortisone into the subacromial space of your affected shoulder. It can be quite effective. However, if the pain recurs and surgery is needed, it is a simple procedure but your surgeon may have to repair the tendon at the end of the procedure to remove the calcium deposits inside the tendon. The recovery time may be slightly longer for this reason. Generally 6 to 12 weeks to feel pretty good. The calcium deposits, once removed, usually do not recur.

  2. Tim says:

    Hi again Dr. Chang Haw Chong,

    Thanks so much for the reply and advice. It’s actually in both shoulders when it occurs. I’d like to do more physical activities but I hesitate now knowing it will cause pain for days, even weeks, afterwards. It most definitely will re-occur as it has several times in the past year. I basically now am limited to certain exercises/activities I can do. If surgery would correct this, even with a 3-month recovery time I would think it’s very worth it, or am I missing some possible side effects or unwanted outcomes?

    • Mike Kemp says:

      I have had this problem for 18 months now in my right shoulder. I have had 1 injection 4 months ago which helped for a few weeks but the pain is back with a vengeance now especially in the evenings and it can be very very painful. The deposit shown to me on an ultrasound scan a couple of months back was quite large and in the toothpaste stage. I wish this would hurry up and resolve itself as it is a nightmare trying to get sleep at night. I expect I will end up under the knife if this does not improve soon.

  3. Suryasudheer says:

    Hi Doctor,

    I have the same problem described above. I am facing this problem frequently ( once in 3-4 months) with both the shoulders randomly.Some times left and some times right. The pain is unbearable for me and not able to lift hand itself due to this pain. I need to use my second hand to lift the hand to wear my vest. More over this problem goes off automatically with out any medication may be after 2-3 weeks. Once I consulted a doctor and he suggested me to use normal medicines prescribed,but problem persists. My father and paternal aunt has the same problem but they has it for one shoulder only unlike me. Currently I am working in UAE. Please suggest me in this regard.

    Regards
    Surya

    • Hi Surya,

      If there is x-ray confirmation of calcific tendonitis and your shoulder pain recurs often, surgical removal of the calcified deposits with arthroscopy is the best solution.

      Regards,

      hc

  4. TESS says:

    Hi Dr.CHANG,

    I have the same problem like the others, i have sharp pain on my right shoulder now I can’t move my arm or raising it up. What do u think the cause of this condition? I also have tennis elbow also or tendinitis on my right arm that most of the time I have pain too especially if I’m busy at work and used my arm. My job requires re-petitive motion in my arm and shoulder. I’ve been suffering with this pain on and off for the past 3-4 years now and mostly hot pack and aleve helps, but this time last Saturday I woke up with severe pain and it didnt go away. DO YOU THINK THIS CONDITION IS JOB RELATED??? I been at my work for 16 years same….. now I don’t know what treatment is best for my condition, I’m also diabetic but controlled by meds.THE ER doctor said my x-ray shows calcium builds up on my shoulder I dont know how severe it is so what is the best treatment for me and if this can be job related condition.

    Thank you,
    tess

    • Dear Tess,

      Repetitive overhead movements of the upper limbs can result in tendonitis of the shoulder joint.
      You may also be suffering from “impingement syndrome”. This is a condition where the bony spur of the acromion hits the rotator cuff tendons when the shoulder is elevated above 90 degrees.
      Repetitive injury from impingement syndrome to the tendons can result in deposition of calcium into the substance of the tendon.

      In this case, yes, your pain may be work-related.

      The treatment is to come to a correct diagnosis. I would do x-rays to look for spurs and calcium in the tendon. An MRI scan should be done to rule out any cuff tendon tear.

      Being a diabetic, you are at increased risk of frozen shoulder. A careful examination will help to rule this out.

      The treatment will depend on the cause of your pain.

      Regards,

      hc

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