Rotator Cuff Calcific Tendinopathy

Acute (resorptive) presentation: sudden onset of severe shoulder pain over hours, often waking the patient from sleep, with marked global restriction of movement due to pain. The shoulder may be warm and swollen from secondary subacromial bursitis. The picture can mimic frozen shoulder or septic arthritis.

Chronic (formative or resting) presentation: low-grade intermittent shoulder pain with a painful arc and overhead activity pain, easily mistaken for ordinary rotator cuff tendinopathy. Deposits may be incidental on imaging in asymptomatic patients.

Examination:

• •Acute phase: globally restricted movement due to pain; the patient guards the arm
• •Chronic phase: painful arc 60-120 degrees, positive impingement signs, tenderness over the affected tendon
• •True weakness is unusual and should prompt assessment for a concomitant cuff tear

Red flags to exclude:

• •Septic arthritis (fever, rigors, systemically unwell, red hot joint, raised CRP and WCC) - if it cannot be confidently excluded, arrange urgent same-day specialist assessment and aspiration
• •Crystal arthropathy in the glenohumeral joint itself - aspiration is diagnostic
• •Pathological fracture (cancer history, weight loss, low-energy mechanism)

The resorptive phase itself can produce a mildly raised CRP and low-grade temperature, which is why septic arthritis must be carefully ruled out clinically rather than dismissed on bloods alone.

Plain radiographs (AP in internal and external rotation) are first-line and usually diagnostic, showing the calcium deposit within the tendon. The Gartner radiographic classification gives prognostic information:

• •Type I: dense, well-defined, homogeneous - formative or resting; less likely to resolve spontaneously
• •Type II: mixed appearance with cloudy margins - transitional
• •Type III: ill-defined, fluffy, translucent - resorptive; highest chance of spontaneous resolution

Ultrasound is useful for confirming deposit size and consistency, identifying concomitant cuff tears, and guiding barbotage. MRI may show peritendinous oedema but plain X-ray remains more reliable for confirming the deposit itself.

Bloods in acute presentation: FBC and CRP to help differentiate from septic arthritis. If septic arthritis cannot be confidently excluded clinically, arrange same-day specialist assessment and aspiration regardless of laboratory values.

Acute resorptive phase:

• •Reassure: the acute flare signals the deposit is resolving and usually settles over days to weeks
• •Regular paracetamol and oral NSAIDs (e.g. naproxen 500 mg BD with gastroprotection); NSAIDs are particularly effective given the genuine inflammatory resorptive process
• •Ice and relative rest
• •Subacromial corticosteroid injection for severe pain not responding to oral analgesia - targets secondary subacromial bursitis. Avoid repeated frequent injections. Warn diabetic patients about 24-48 hours of temporary hyperglycaemia

Chronic or formative phase:

• •Mild or incidental deposits need no specific treatment
• •Physiotherapy: progressive rotator cuff and periscapular strengthening
• •Analgesia as required

Specialist interventional options (persistent symptoms beyond 3-6 months):

• •Ultrasound-guided barbotage: aspiration and lavage of the deposit. Most effective for Type I and II formative deposits and is the key intervention between conservative failure and surgery. Not indicated in the resorptive phase as the body is already clearing the deposit
• •Extracorporeal shockwave therapy (ESWT): NICE IPG645 (2020) found efficacy evidence inadequate and recommends use only in research settings
• •Arthroscopic excision (with or without subacromial decompression): reserved for refractory cases

Refer if symptoms persist beyond 3-6 months despite conservative management or if septic arthritis cannot be confidently excluded.

Acute flare: pain control and gentle movement within tolerance (pendular exercises); avoid pushing through severe pain.

Recovery phase: progressive ROM exercises as pain settles.

Strengthening: once pain settles, progressive rotator cuff and periscapular strengthening - isometric, isotonic, then functional loading.

Post-barbotage: guided return to exercise. A brief pain flare in the first 48-72 hours is common and self-limiting.

Post-arthroscopic excision: follows standard rotator cuff surgery rehabilitation principles, surgeon-led with protected ROM initially.

Most cases resolve over time. Recurrence is uncommon once the deposit has fully resorbed, and the condition does not progress to tear in the way degenerative cuff disease can.

• •Uhthoff & Loehr - Defined the three-phase lifecycle (pre-calcific, calcific, post-calcific) of calcific tendinopathy; underpins the paradox that acute severe pain reflects resorption rather than worsening disease.
• •Gartner & Heyer - Radiographic classification (Types I-III) linking deposit morphology to prognosis: Type III resorbing deposits carry the best spontaneous-resolution rate; Type I chronic deposits are least likely to clear without intervention.
• •de Witte et al (2013) JBJS - Ultrasound-guided barbotage with subacromial steroid injection was superior to steroid injection alone for chronic calcific tendinopathy.
• •NICE IPG645 (2020) - ESWT for refractory shoulder calcific tendinopathy: efficacy evidence inadequate; recommended only in the context of research.
• •BESS shoulder care pathways - UK framework directing referral to specialist intervention after conservative failure at 3-6 months.

• •Diagnosis is on plain X-ray showing the calcium deposit within the tendon - this is what distinguishes it from other shoulder pain causes
• •Gartner Type III (fluffy, translucent) = resorptive = acute severe pain = best prognosis; Type I (dense, well-defined) = chronic = least likely to clear without intervention
• •Supraspinatus is involved in over 50% of cases
• •Barbotage targets the deposit intratendinously; subacromial steroid injection targets the secondary bursitis - different procedures with different indications
• •Do not barbotage in the resorptive phase - the body is already clearing the deposit
• •Milwaukee shoulder (BCP arthropathy) is a destructive large-joint disease in older adults and is a distinct entity from calcific tendinopathy