Calcific Tendinitis

A 52-year-old woman presents with severe shoulder pain without history of trauma or repetitive use. (Figure from Craig EV. Master Techniques in Orthopaedic Surgery: The Shoulder. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)

CLINICAL PRESENTATION

Calcifying tendinitis, or calcific tendinopathy of the rotator cuff, is a common disorder of unclear etiology in which multifocal, cell-mediated calcification of a tendon is usually followed by spontaneous resorption (Fig. 37-1). The clinical presentation of calcific tendinitis is variable. Patients may have minimal or no symptoms during the formative phase, while some may have acute symptoms during the resorptive phase.¹^,² The resorptive phase, which occurs later in the cycle of calcifying tendinitis, is commonly characterized by acute symptoms such as pain. However, some patients have deposits that are found incidentally as part of a workup for impingement syndrome.

The pain seen in the resorptive stage is related to the increase in intratendinous pressure from vascular proliferation, influx of inflammatory cells, edema, and swelling. As tendon volume increases, the restrictive dimensions of the subacromial space may lead to additional pressure on the involved tendon and even to secondary impingement. During the acute phase, pain can be intense; patients can also have a sensation of painful catching caused by a localized impingement of the calcified mass on the coracoacromial arch.

PHYSICAL FINDINGS

The physical examination should help to confirm or refute the initial diagnosis.

A careful examination of the cervical spine should first be performed to rule out any abnormalities.
Next, the shoulder is inspected and palpated, and the muscle strength as well as the range of motion are assessed.
Range of motion of the shoulder is performed actively and passively and compared to the asymptomatic side.3
Again, the physical examination characteristics are dependent on the phase of presentation of calcific tendinitis.
With the subacute or chronic phase, examination findings often mimic subacromial impingement, with decreases in range of motion and a positive impingement sign.
In the chronic phase of calcifying tendinitis, the patient may also present with supraspinatus and infraspinatus atrophy.¹ In this phase, the severe pain leads to guarding against any motion.
Even if the patient allows motion, the glenohumeral motion and even the scapulothoracic motion may be severely limited secondary to muscle spasm.
Strength testing is prohibited by the pain and can be misleading to the novice examiner.
During this phase, provocative tests such as the impingement sign can be nearly impossible to perform due to the significant loss of motion.¹