Calcific Tendinopathy
Calcific tendinopathy is a condition in which calcium deposits form within one of the rotator cuff tendons of the shoulder, most often the supraspinatus. It is also called calcific tendonitis or calcific tendinitis, and the calcium is sometimes described simply as a deposit or a calcium build-up in the shoulder.
Some deposits are found by chance on a scan and cause no trouble at all. Others produce significant shoulder pain and inflammation, sometimes including a sudden episode of extremely severe pain that comes on over hours rather than days.
What causes calcific tendinopathy?
The reason calcium develops within a tendon is not completely understood. It is not caused by having too much calcium in your diet or your blood, which is the first thing most people ask. The changes appear to happen locally, within the tendon itself.
The calcium also changes over time. Some deposits stay relatively firm and settled. Others soften as the body starts to break them down and reabsorb them, and it is this stage that can set off a very painful inflammatory reaction in the surrounding tissues and the subacromial bursa. That is usually what has happened when shoulder pain arrives suddenly and severely without an injury to explain it.
How is it diagnosed?
Calcific deposits can often be seen on an X-ray, which shows that calcium is present and roughly where it sits.
Diagnostic ultrasound adds more. It shows the location, size and appearance of the deposit along with the surrounding rotator cuff tendon and the subacromial bursa, so we can see whether the bursa is inflamed and whether the tendon itself is involved.
The appearance of the deposit on ultrasound also helps determine whether an ultrasound-guided procedure is likely to be appropriate, which is a question an X-ray cannot answer. A firm, well-organised deposit and a softening one look different on a scan and are managed differently.
Finding calcium does not automatically mean the calcium is causing your pain. Deposits are found in shoulders that have never hurt. The scan is read alongside your symptoms and examination, not on its own.
How is calcific tendinopathy treated?
Treatment depends on how severe your symptoms are, how long they have been going on, and what the deposit looks like on the scan. Most people start conservatively.
- Modifying the activities that provoke the pain
- Appropriate pain relief
- Physiotherapy and progressive shoulder rehabilitation
Where there is significant associated inflammation or bursitis, an ultrasound-guided steroid injection, sometimes called a cortisone injection, may be considered. This treats the inflammatory reaction rather than the deposit itself, which is an important distinction: it can settle a painful shoulder without changing the calcium.
Ultrasound-guided barbotage
For selected patients with persistent, symptomatic calcific tendinopathy, ultrasound-guided barbotage may be considered.
Barbotage is a minimally invasive procedure carried out under local anaesthetic. A needle is guided accurately into the calcium deposit and saline is used to help break down and wash out some of the calcium material. A steroid injection into the adjacent subacromial bursa may also be considered afterwards, to manage the inflammatory response the procedure can provoke.
Not every calcium deposit needs barbotage, and not every deposit is suitable for it. The decision rests on your symptoms together with the size, location and ultrasound appearance of the deposit. This is the main reason the scan matters before any procedure is discussed.
What happens afterwards?
The shoulder can be uncomfortable for a short period following barbotage. Relative rest is usually advised at first, followed by a gradual return to movement and rehabilitation.
Full aftercare guidance, including how long to rest and when to resume normal activity, is set out on the barbotage procedure page along with the risks and the consent form.
The aim throughout is to reduce pain and let normal shoulder movement and function return.
What to do next
An assessment and ultrasound examination will establish whether the calcium deposit is likely to be causing your symptoms, and whether physiotherapy, an injection, barbotage or another pathway suits your shoulder best. You do not need to know which of those you need before you come in — working that out is the purpose of the appointment.
Current fees for scans, injections and the barbotage procedure are listed on our prices page.
Written by Suegnet Meyer, Advanced Practice Musculoskeletal Physiotherapist and MSK Sonographer. HCPC registered [PH55635]. Chartered Society of Physiotherapy member [66175].