Ortho Dx: Severe shoulder pain without prior injury

This patient has calcific tendinitis. The cause of calcific tendinitis of the rotator cuff is unknown. The typical presentation includes an acute onset of severe shoulder pain without a known injury or precipitating event. Patients will avoid overhead motion as...

Submit your diagnosis to see full explanation.

This patient has calcific tendinitis. The cause of calcific tendinitis of the rotator cuff is unknown.

The typical presentation includes an acute onset of severe shoulder pain without a known injury or precipitating event. Patients will avoid overhead motion as the pain is associated with subacromial impingement.

X-rays will commonly show a 1.5 cm to 2 cm calcific deposit near the insertion of the superior rotator cuff and area of decrease tendon vascularity.  X-rays alone are sufficient to confirm the diagnosis. MRI has little diagnostic value unless patients have failed a period of conservative treatment and/ or a rotator cuff tear is suspected.

Calcific tendinitis is divided into three stages of calcification: precalcific, calcific, and postcalcific. The calcific phase is further divided into the formative phase, the resting phase, and the resorptive phase. Pain becomes the most intense during the resorptive phase and is usually when patients seek treatment.  

The calcium deposit will look cloudy and have a toothpaste consistency during the resorptive phase.  In most cases the calcific deposit eventually disappears and is replaced with normal rotator cuff tendon.

Conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy for passive range of motion exercises is recommended initially.

A subacromial injection is often performed prior to physical therapy to help relieve pain and improve motion. Failure of nonsurgical management, defined as persistent symptoms beyond six months, is estimated to occur in up to 30% of patients.

Factors that increase rate of failure include the size of the calcification, density of the deposit, and if the deposit extends medial to the acromion.

Additional nonsurgical options include extracorporeal shock wave therapy, guided needle lavage, and acetic acid iontophoresis. 

Extracorporeal shock wave therapy involves two sessions of high frequency shock waves directed toward the calcium deposit. The shock waves provide significant pain relief by reducing the size and increasing the resorption rate of the deposit.

Ultrasound or fluoroscopic guided needle lavage involves directing a needle into the calcium deposit under guidance to confirm placement. Saline, or a mixture of saline and anesthetic, is injected into the deposit to break it up.

For the single injection technique, an 18 gauge needle is used to pierce the calcific deposit approximately five times while aspirating the debris. Two needles may be used as well — one to inject while the other aspirates.  The acetic acid iontophoresis aims to increase the pH making the calcium deposit more water soluble.

Shoulder arthroscopy is the gold standard surgical option for removal of calcium deposits that fail to resolve with conservative treatment. Surgical removal is very effective with an overall success rate of over 90%. Patients should be aware that removing the calcium deposit may require a large debridement and a rotator cuff repair may be necessary.

Dagan Cloutier, MPAS, PA-C, practices in a multispeciality orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants (JOPA).