Commonly asked questions about Calcific Tendinitis
Q: What causes calcific tendinitis?
A: We still do not know. There is evidence that the oxygen concentration and blood supply to the tendon may be decreased. It is certainly not related to diet, osteoporosis, exercise or injury.
Q: What symptoms do I get with this condition?
A: The pain can be constant and nagging and is felt in the shoulder and sometimes down the arm/hand. It is made worse by elevating the arm. Some patients also have excruciating attacks of pain, which then abate to a lower level after a few days. The calcium can spontaneously absorb and this process is associated with severe pain.
Q: What does a cortisone injection do?
A: It helps with the pain for a short term basis but it does not take away the calcium.
Q: How many injections can I have?
A: Most doctors would say a maximum of three. There is in fact no absolute maximum, especially if they are spaced weeks or months between the injections. However, if you need a lot of injections, then this is a sign that something definite ought to be done about it.
Q: Apart from surgery, are there any other treatments available?
- Non steroidal anti-inflammatory drugs
- Subacromial injection of steroid
- Needle aspiration and irrigation
- Extracorporeal shockwave therapy
Q: Can physiotherapy help?
A: The physiotherapist can help you to maintain the range of motion. Some patients also find therapeutic ultrasound to be of benefit. However, the evidence that it works is conflicting. The Cochrane Musculoskeletal Database Review of 26 trials found that both ultrasound and pulsed electromagnetic field therapy resulted in significant improvement in pain compared to placebo. However, a further meta-analysis of 35 randomised controlled trials found that only 2 studies supported the use of therapeutic ultrasound over placebo. The remaining 8 showed that therapeutic ultrasound is no more effective than placebo. Full references given at the end.
Q: What is Extracorporeal shockwave therapy?
A: Extracorporeal shock wave therapy utilises acoustic waves (sound waves) to induce fragmentation of the calcium crystals. It is the same technology used to break up kidney stones
Q: Would you recommend Extracorporeal shockwave therapy to?
A: Although this is used in some places, we do not recommend it. The recurrence rate following Extracorporeal shockwave therapy is relatively high and some patients also find the procedure very painful and can develop troublesome haematomas (blood blisters) on the skin afterwards.
Q: What is needling?
A: Needling refers to needle aspiration and irrigation. The aim of this procedure is to drain a substantial portion of the calcium deposit; thereby stimulating the body’s cell mediated resorption.
Q: What are the advantages of needling?
A: Needle aspiration has the advantages over arthroscopic treatment in that this can be readily done under local anaesthesia in the outpatient setting with ultra-sound control, thus avoiding the need for an operation and general anaesthesia.
Q: How is needling performed?
A: A local anaesthetic injection is given. Using a needle, the calcium deposit is punctured under direct ultrasound guidance (Figure 7,8). Sometimes the creamy calcium material can be aspirated from the needle. A second needle is introduced and saline is injected, thus creating an inflow-outflow irrigation system between the two needles. On completion of the procedure, one often gives a steroid injection.
Q: What is the success rate of needling and what happens if it does not
A: About 70% or more are successful. Increased pain observed within the first week after the needling is usually due to resorption of the calcium.
Q: Is needling suitable for everyone?
A: No. Generally speaking, the best results are obtained in patients with an acutely painful shoulder, typically during the resorption stage in which the calcium is of toothpaste like consistency. Patients with an active frozen shoulder and those with small (<1.5cm) ill defined deposits are probably not suitable.
Q: What does the actual operation to remove calcium entail?
A: It is usually done under a general anaesthetic. Using an arthroscope (keyhole surgery), the calcium is removed from the tendon. We take an x ray in theatre to make sure all the calcium is removed. Sometimes, we also have to repair the tendon at the same time if the defect left by the calcium is significantly large.
Q: How long does it take to recover from surgery?
A: Total pain relief may take up to 3-6 months. There is certainly no formal restriction on when you can return to work or do leisure activities. It has to be emphasised that recovery may talke long due to the fact that the “sick” tendon may take its time to recover and the time to recover may be frustating for the patient.
Q: What is the rehabilitation like after surgery?
A: Full motion and activities are permitted immediately, within pain limits. The physiotherapist will demonstrate the exercises.
Q: Are there any serious complications with surgery?
A: The most common complication is stiffness (approx 30%), sometimes referred to as Frozen shoulder. This is also more common in patients with diabetes and middle-aged ladies. If it does occur, it does not mean that further surgery is necessary. It just means the recovery may take a little longer.
Q. Is acromioplasty (shaving of the undersurface of the acromion bone) necessary when the surgery is done for the calcium deposits?
A: Usually not, except if the surgeon notices rotator cuff impingement during the operation to drain the calcium from the tendon. Impingement is not the cause of calcific tendinitis and the mainstay of the surgical treatment is the removal of the calcific deposit
Q. Suggestions for further reading?
- Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258
- Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies Phys Ther. 2001 Jul; 81(7): 1339-50
- P.E. Huijsmans, C.P. Roberts, K. van Rooyen, D.F. du Toit and J.F. de Beer. CLINICAL RESULTS OF ULTRASOUND-GUIDED NEEDLING OF CALCIFIC TENDINITIS OF THE SHOULDER. Presented at the South African Orthopaedic Association Meeting, Pretoria, South Africa – 6–10 September, 2004 Journal of Bone and Joint Surgery – British Volume, Orthopaedic Proceedings
Vol 87-B, Issue SUPP III, 275.