High Yield Overview

CALCIFIC TENDINITIS

Rotator Cuff | Calcium Hydroxyapatite | Phases | Self-Limiting

SupraspinatusMost common location

30-50yrsPeak age

Self-limitingNatural history

ResorptiveMost painful phase

PHASES

Pre-calcific

PatternFibrocartilage metaplasia

TreatmentObservation

Calcific (formative)

PatternCalcium deposition

TreatmentMay be asymptomatic

Resorptive

PatternVascular invasion, painful

TreatmentTreatment if severe

Post-calcific

PatternHealing, tendon reconstitution

TreatmentResolution

Critical Must-Knows

Calcium hydroxyapatite deposition
Supraspinatus most common (insertion zone)
Resorptive phase is most painful
Self-limiting condition in most cases
Ultrasound-guided barbotage is effective

Examiner's Pearls

"
Resorptive X-ray: fluffy, ill-defined calcium
"
Formative X-ray: dense, well-defined
"
Needling/barbotage is effective treatment
"
Shock wave therapy has evidence

Critical Calcific Tendinitis Concepts

Phases

Pre-calcific, Calcific (formative/resting), Resorptive, Post-calcific. Resorptive phase is most painful due to vascular invasion and inflammation.

Radiology

Formative: dense, well-defined. Resorptive: fluffy, ill-defined, may have bursitis. X-ray appearance helps predict phase and prognosis.

Natural History

Self-limiting in most cases. Calcium resorbs spontaneously. Most resolve within 1-3 years. Conservative treatment usually sufficient.

Treatment

Needling/barbotage most effective intervention. US-guided aspiration and lavage. Shock wave therapy also effective. Surgery rarely needed.

At a Glance: X-ray Appearance by Phase

Phase	X-ray Appearance	Symptoms	Prognosis
Formative	Dense, well-defined, homogeneous	May be asymptomatic or mild	May persist, needs intervention if symptomatic
Resting	Dense, well-defined	May have mild symptoms	Stable phase, monitor
Resorptive	Fluffy, ill-defined, irregular	Most painful, acute severe	GOOD - indicates resolution

Mnemonic

PCRPCalcific Tendinitis Phases

Pre-calcific

Fibrocartilage metaplasia

Calcific

Formative and resting

Resorptive

PAINFUL, vascular invasion

Post-calcific

Healing, resolution

Memory Hook:PCRP - Phases of Calcium Rotation Process!

Mnemonic

TEDRisk Factors - TED

Thyroid

Hypothyroidism association

Estrogen

Females 30-50yo predominant

Diabetes

Strong metabolic association

Memory Hook:TED causes Calcific Tendinitis!

Overview and Epidemiology

Pathophysiology

Calcium hydroxyapatite deposits in avascular zone of supraspinatus tendon (critical zone near insertion). Reason for deposition unclear. Cell-mediated process, not degenerative.

Pathophysiology and Mechanisms

Rotator cuff anatomy relevant to calcific tendinitis:

The supraspinatus tendon is most commonly affected (70-80% of cases), followed by infraspinatus (20%), teres minor, and subscapularis (rare).

Critical zone of supraspinatus:

Located 1-2cm from the greater tuberosity insertion
Area of relative hypovascularity
Watershed zone between osseous and tendinous blood supply
Site where calcium deposits typically form

Pathophysiology:

Cell-mediated process (not degenerative)
Chondrocyte metaplasia of tenocytes
Calcium hydroxyapatite crystal deposition
Unknown trigger but associated with hypoxia

Anatomical factors:

Tendon compression between acromion and humeral head
Repetitive microtrauma
Impingement may coexist

Critical Zone

The critical zone of the supraspinatus tendon is the watershed area 1-2cm from insertion - this is where calcification typically occurs due to relative hypovascularity.

Classification Systems

Gartner Radiographic Classification

Type	Description	Significance
Type I	Dense, well-defined, homogeneous	Formative phase, chronic
Type II	Dense but inhomogeneous or fragmented	Transitional
Type III	Fluffy, ill-defined	Resorptive phase, good prognosis

Gartner classification helps predict natural history and response to treatment.

Clinical Assessment

History

Variable presentation
May be asymptomatic (incidental)
Chronic dull ache (formative)
Severe acute pain (resorptive)
Night pain common in acute phase
May mimic frozen shoulder

Acute severe pain suggests resorptive phase.

Examination

Painful arc
Impingement signs may be positive
ROM may be limited by pain
Tenderness over greater tuberosity
In acute phase, may be unable to move

Differentiate from rotator cuff tear.

Chemical Bursitis

When a calcific deposit ruptures into the subacromial bursa, it causes an intense inflammatory reaction (Acute Chemical Bursitis). The patient presents with a pseudoparalytic shoulder, severe pain, and warmth—mimicking septic arthritis. Always aspirate if in doubt.

Intratendinous Steroid Injection

NEVER inject corticosteroid directly into the tendon. Risk of tendon necrosis and rupture. Only inject into the subacromial bursa. Intratendinous injection also impairs the natural healing process.

Investigations

Plain Radiographs

Standard views: AP, supraspinatus outlet, axillary

Findings:

Calcium deposit in supraspinatus insertion area
Formative: dense, well-defined
Resorptive: fluffy, ill-defined

X-ray appearance predicts phase and prognosis.

AP X-ray of the shoulder showing calcific tendinitis with arrow pointing to dense calcific deposit in the supraspinatus tendon — AP X-ray of the right shoulder demonstrating calcific tendinitis in the supraspinatus tendon. The white arrow indicates a dense, well-defined, homogeneous calcific deposit located just superior to the humeral head in the supraspinatus insertion zone. This appearance is consistent with Gartner Type I (formative phase) - the deposit is dense and sharply delineated, indicating a chronic phase. In contrast, resorptive phase deposits appear fluffy and ill-defined. The supraspinatus is the most commonly affected tendon (70-80%), with calcification occurring in the critical zone 1-2cm from the greater tuberosity insertion. This patient was a 33-year-old female receptionist who underwent needle decompression and extracorporeal shock wave therapy.Credit: Pakos et al., SICOT-J 2018 / Annotated by Mikael Häggström, M.D. - CC BY 4.0

Management

First-Line Treatment

Acute resorptive phase:

NSAIDs
Ice
Subacromial injection (steroid)
Activity modification

Chronic/formative phase:

Physical therapy
Time (self-limiting)
NSAIDs as needed

Most resolve within 1-3 years spontaneously.

Surgical Technique

Arthroscopic Calcific Deposit Excision

Indications:

Failed conservative management (6+ months)
Failed ultrasound-guided barbotage
Failed ESWT
Large symptomatic deposit

Technique:

Beach chair or lateral position
Standard posterior viewing portal
Diagnostic arthroscopy - assess cuff, labrum, biceps
Locate deposit using spinal needle under fluoroscopy
Incise bursal surface over deposit
Curette and evacuate calcium (paste-like material)
Avoid excessive debridement of healthy tendon
Subacromial decompression if impingement present
Consider side-to-side repair if large defect

Key surgical pearls:

Calcium may be deep within tendon
Needle localization helpful
Do not repair small defects (heal spontaneously)
Repair defects greater than 1cm transverse dimension

Avoid Iatrogenic Cuff Tear

Minimize debridement of healthy tendon tissue. The goal is to evacuate calcium, not remove tendon. Small defects heal without repair.

Complications

Conservative treatment complications:

Prolonged symptoms (rare, condition usually self-limiting)
Frozen shoulder (may develop secondary stiffness)
Chronic pain if resorption does not occur

Barbotage complications:

Post-procedure pain flare (common, 24-48 hours)
Infection (rare, less than 0.1%)
Neurovascular injury (rare with proper technique)
Incomplete calcium removal

Surgical complications:

Rotator cuff tear (iatrogenic during debridement)
Incomplete excision (residual calcium)
Infection (less than 1%)
Stiffness/frozen shoulder (2-5%)
Failure to improve symptoms

Recurrence:

Recurrence is rare (less than 10%) after complete resolution
More common if calcium incompletely removed during surgery

Postoperative Pain Flare

Warn patients that pain may temporarily worsen after barbotage or surgery due to inflammatory response to calcium crystal release. This typically settles within 48-72 hours.

Postoperative Care

After barbotage:

Sling for comfort only (24-48 hours)
Ice, analgesia (NSAIDs)
Resume normal activities as tolerated
Physiotherapy for ROM and strengthening
Review at 6-8 weeks with repeat imaging

After arthroscopic excision:

Rehabilitation Protocol

Protection phase: Sling for comfort, pendulum exercises, gentle passive ROM

Motion phase: Progressive active ROM, no resistance, avoid impingement positions

Strengthening phase: Rotator cuff strengthening, scapular stabilization, progressive resistance

Return to activity: Sport-specific training, full activities when strength recovered

If rotator cuff repair performed:

Standard cuff repair rehabilitation protocol
No active elevation for 6 weeks
Sling for 4-6 weeks

Outcomes

Prognostic Factors

Favorable: Resorptive phase (will resolve), soft deposits, smaller size.

Less favorable: Dense formative deposits, large deposits, associated cuff tears.

Evidence Base

Natural History

Multiple studies • JBJS/JSE (2019)

Key Findings:

Most resolve spontaneously
Resorptive phase indicates resolution
1-3 year natural history
10-20% need intervention

Clinical Implication: Counsel patients about self-limiting nature; conservative first.

Limitation: Varied follow-up.

Barbotage Effectiveness

RCTs • JSES (2020)

Key Findings:

Barbotage superior to injection alone
60-80% success rate
Best for soft/formative deposits
Safe and effective

Clinical Implication: Barbotage is first-line intervention for refractory cases.

Limitation: Technique variability.

ESWT for Calcific Tendinitis

Gerdesmeyer et al • JBJS (2003)

Key Findings:

High-energy ESWT superior to low-energy
67% success at 6 months
Calcium resorption in 86%
No serious adverse events

Clinical Implication: High-energy ESWT is effective for refractory calcific tendinitis before considering surgery.

Limitation: Optimal energy levels and treatment protocols vary.

Arthroscopic vs Conservative

Balke et al • KSSTA (2012)

Key Findings:

Arthroscopic excision effective for resistant cases
91% good/excellent outcomes
Low complication rate
Most improve without surgery

Clinical Implication: Reserve surgery for true failure of conservative measures including barbotage and ESWT.

Limitation: Observational study, selection bias.

Needling + Steroid vs Needling Alone

de Witte et al • AJSM (2013)

Key Findings:

Barbotage with and without subacromial steroid compared
Steroid group had significantly better pain relief at 6 weeks
Functional outcomes equal at 1 year

Clinical Implication: Always combine barbotage with a subacromial steroid injection for optimal short-term symptom control.

Limitation: Single-centre RCT.

Acromioplasty in Calcific Tendinitis

Marder et al • JSES (2011)

Key Findings:

Compared deposit removal alone vs removal + acromioplasty
No difference in outcomes between groups
Acromioplasty adds surgical morbidity without benefit

Clinical Implication: Do NOT routinely perform acromioplasty for calcific tendinitis - pathology is intrinsic to tendon.

Limitation: May be indicated if significant type 2/3 acromial spur present.

Cuff Repair After Excision

Yoo et al • Arthroscopy (2010)

Key Findings:

Studied outcomes of defects left open vs repaired
Small/medium defects heal spontaneously
Only repair if greater than 50% tendon width compromised

Clinical Implication: Do not suture every defect - only repair if structural integrity significantly compromised.

Limitation: Retrospective cohort.

Natural History Study

Ogon et al • Clin Orthop (2009)

Key Findings:

65% spontaneous resorption at mean 3 years
Resorptive phase deposits resolve faster
Formative deposits may persist longer
Symptom resolution precedes radiographic resolution

Clinical Implication: Reassure patients about favorable natural history; symptoms often improve before calcium disappears on X-ray.

Limitation: Variable follow-up intervals.

Mnemonic

CALCIFCALCIF - Calcific Tendinitis Essentials

Calcium hydroxyapatite

Type of crystal deposit

Avascular zone

Critical zone location

Location: supraspinatus

Most common tendon

Conservative first

Self-limiting condition

Injection/barbotage

First-line intervention

Fluffy = favorable

Resorptive phase has good prognosis

Memory Hook:CALCIF - Remember the essentials of CALCIfic tendinitis!

Mnemonic

TREATTREAT - Treatment Ladder

Time

Self-limiting, watch and wait

Rest and NSAIDs

Conservative measures

ESWT

Extracorporeal shock wave therapy

Aspiration (barbotage)

US-guided needling

Theatre (surgery)

Arthroscopic excision last resort

Memory Hook:TREAT - the treatment ladder for calcific tendinitis!

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Acute Severe Shoulder Pain

EXAMINER

"A 45-year-old woman presents with sudden severe shoulder pain starting last night. She cannot move her shoulder. X-ray shows a fluffy, ill-defined calcific deposit at the supraspinatus insertion with surrounding soft tissue swelling. What is your diagnosis and management?"

EXCEPTIONAL ANSWER

This is calcific tendinitis in the resorptive phase. The acute severe onset, inability to move the shoulder, and X-ray appearance (fluffy, ill-defined calcium) are classic for the resorptive phase when the body is actively resorbing the calcium deposit, causing an intense inflammatory response. Paradoxically, this is actually a good prognostic sign as the deposit is resolving. My management: This is primarily conservative as resorptive phase resolves spontaneously. Analgesia (paracetamol, NSAIDs), ice, and rest. I would offer a subacromial corticosteroid injection for pain relief, which can be very effective. I would counsel her that this phase typically resolves within days to weeks as the calcium is resorbed. If symptoms persist beyond 2-3 weeks, I would consider ultrasound-guided barbotage. Surgery is rarely needed. I would explain this is a self-limiting condition and the acute severity does not indicate a poor prognosis - quite the opposite.

KEY POINTS TO SCORE

Resorptive phase = most painful but good prognosis

Fluffy X-ray appearance indicates resorption

Conservative treatment usually sufficient

Will resolve spontaneously

COMMON TRAPS

✗Offering immediate surgery

✗Misdiagnosing as rotator cuff tear

✗Not recognizing favorable prognosis

LIKELY FOLLOW-UPS

"What if it was dense and well-defined?"

"When would you offer barbotage?"

"When would you consider surgery?"

VIVA SCENARIOChallenging

Scenario 2: Chronic Shoulder Pain with Dense Calcification

EXAMINER

"A 50-year-old male desk worker has chronic shoulder pain for 18 months. X-ray shows a dense, well-defined calcific deposit in the supraspinatus. He has had physiotherapy and two steroid injections without relief. What is your management?"

EXCEPTIONAL ANSWER

This is calcific tendinitis in the formative/chronic phase based on the dense, well-defined X-ray appearance. The failed conservative treatment warrants escalation. My next step would be ultrasound-guided barbotage (needling) as the first-line intervention for refractory cases. Success rates are 60-80%. I would discuss that the deposit may be more amenable to aspiration if it has soft/paste-like consistency on ultrasound. If barbotage fails, I would offer ESWT as an alternative before considering surgery. Arthroscopic excision is reserved for failed barbotage and ESWT, and has over 90% success. I would counsel him that while this is taking longer than usual, most cases eventually resolve and surgery is rarely needed.

KEY POINTS TO SCORE

Dense deposit indicates formative/chronic phase

Barbotage is first-line intervention for refractory cases

ESWT before surgery

Arthroscopic excision for failed conservative measures

COMMON TRAPS

✗Jumping straight to surgery

✗Not knowing barbotage technique

✗Ordering unnecessary MRI

LIKELY FOLLOW-UPS

"Describe barbotage technique"

"When would you repair the tendon?"

"What is your surgical approach?"

VIVA SCENARIOStandard

Scenario 3: Calcification Found Incidentally

EXAMINER

"A 42-year-old woman had a shoulder X-ray for trauma (normal result). Incidentally, a 1cm dense calcific deposit is seen in the supraspinatus. She has no shoulder pain. How do you manage this?"

EXCEPTIONAL ANSWER

This is incidental calcific tendinitis in the formative phase. The key point is that she is asymptomatic. I would reassure her that this is a common finding, occurring in 3-7% of the adult population, and is often asymptomatic. No treatment is required for asymptomatic deposits. I would counsel her that the deposit may cause symptoms in the future, particularly if it enters the resorptive phase, but many deposits remain asymptomatic and may even resorb without symptoms. I would not recommend any intervention at this stage. I would discharge her with advice to return if she develops shoulder pain. No follow-up imaging is needed for asymptomatic deposits.

KEY POINTS TO SCORE

Asymptomatic deposits are common

No treatment required if asymptomatic

Counsel about potential future symptoms

No follow-up imaging needed

COMMON TRAPS

✗Recommending prophylactic treatment

✗Ordering follow-up scans

✗Alarming the patient unnecessarily

LIKELY FOLLOW-UPS

"What if she returns with acute severe pain?"

"Would you ever treat an asymptomatic deposit?"

MCQ Practice Points

Most Painful Phase

Q: Which phase of calcific tendinitis is most painful? A: Resorptive phase. Vascular invasion and inflammation cause severe pain.

X-ray Appearance

Q: What is the X-ray appearance of resorptive phase? A: Fluffy and ill-defined. Formative phase is dense and well-defined.

Effective Treatment

Q: What is the most effective non-surgical intervention? A: Ultrasound-guided barbotage (needling). 60-80% success rate.

Gartner Classification

Q: Which Gartner type has the best prognosis? A: Type III (fluffy, ill-defined) - indicates resorptive phase with active resolution.

Location

Q: What is the most common location for calcific tendinitis? A: Supraspinatus tendon (70-80%), specifically in the critical zone 1-2cm from insertion.

Intratendinous Injection

Q: Why should you avoid intratendinous steroid injection? A: It increases the risk of tendon necrosis and rupture and impairs healing. Only inject into the subacromial bursa.

Differential Diagnosis

Q: How do you differentiate acute calcific tendinitis from septic arthritis? A: Both present with severe pain and pseudoparalysis, but calcific tendinitis patients are typically afebrile with normal inflammatory markers (CRP/ESR). Aspiration is definitive if in doubt.

Acromioplasty Role

Q: Does acromioplasty improve outcomes in surgical excision of calcific tendinitis? A: No. Level 1 evidence (Marder et al.) shows no benefit. The pathology is intrinsic tendon metaplasia, not extrinsic impingement.

Australian Context

Calcific tendinitis is commonly encountered in Australian general practice and orthopaedic clinics. The condition affects the working-age population (30-50 years), with implications for workplace productivity.

Access to treatment in Australia:

Conservative management: Widely available through GPs and physiotherapists under Medicare
Ultrasound-guided barbotage: Available in most radiology practices and sport medicine clinics; typically performed by musculoskeletal radiologists or experienced sports physicians
ESWT: Available in larger physiotherapy practices and pain clinics, though access varies by region
Arthroscopic surgery: Performed by shoulder surgeons and orthopaedic surgeons; available in public and private hospital systems

Medicare and private health considerations:

US-guided interventions attract Medicare rebates
Arthroscopic surgery covered under Medicare with private health insurance gap payments
ESWT not currently on Medicare Benefits Schedule in most states

Workers' compensation: While calcific tendinitis is typically not work-related, exacerbation through occupational overhead activities may be compensable in some circumstances.