Shoulder pain is a common complaint affecting up to a third of the general population. One cause of shoulder pain is calcific tendonitis shoulder, a very frustrating condition causing high levels of pain that can last for months. Calcium deposits in the shoulder are irritating to the tendons. What should you do if you have shoulder calcification, and are treatments such as shockwave therapy and shoulder lavage effective?
What is Calcific Tendonitis Shoulder?
Calcific tendonitis shoulder occurs when calcium deposits form in a rotator cuff tendon. The rotator cuff tendons connect your upper arm to your shoulder. Typically, calcium deposits in the shoulder lead to severe shoulder pain and restricted movement.
Why do calcium deposits form in the shoulder?
We don’t know why some people develop calcium deposits in the shoulder.
Conditions that increase calcium deposition include hormonal disorders, such as thyroid abnormalities, and metabolic diseases, such as diabetes. Secondly, shoulder calcification is more common in women aged 40-60. People who use their arms, such as labourers and athletes, are more at risk. Finally, a fall on the shoulder can also precipitate a calcium deposit.
Calcification generally has three stages. The last stage, known as ‘resorptive,’ is usually the most painful.
How Do You Identify Calcific Tendonitis Shoulder?
Calcium deposits in the shoulder usually cause severe pain and stiffness. The pain is often so intense that sleeping is difficult. In addition, arm lifting in different directions is limited.
X-ray of the shoulder shows more extensive hard calcium deposits. However, ultrasound can detect smaller deposits that may be missed on an X-ray. Also, ultrasound can stage the calcification (i.e., resorptive stage) to know whether it’s likely to cause pain. Therefore, it is essential to recognise that the presence of calcification in the shoulder on X-ray does not necessarily indicate that the calcium is causing pain.
Calcium buildup in the shoulder vs. frozen shoulder
Sometimes, it can be challenging to differentiate between these two common shoulder problems—calcific tendonitis and frozen shoulder. However, calcific tendonitis of the shoulder typically presents acutely (though not always). Additionally, movement is restricted to a single plane, whereas all movements are limited in frozen shoulder. Nevertheless, it can be challenging to distinguish among these common shoulder conditions in the early stages. Sometimes an MRI is needed to aid diagnosis.
Treatment of Calcific Tendonitis Shoulder
Most calcium deposits in the shoulder improve with treatment. At least 75% of patients with calcification in the shoulder will respond to simple treatments.
Simple treatments:
The treatment of shoulder calcification mirrors that of other shoulder conditions. Generally, a combination of treatments is more effective than a single treatment.
- Medication: Anti-inflammatory tablets are the most effective and first-line treatments. Examples include ibuprofen and naproxen. You should consult your physician to see if you can take these tablets.
- Physiotherapy treatment for calcification in the shoulder: As shoulder calcification can cause loss of mobility, exercises can improve the range of motion. Additionally, exercise reduces the risk of developing another shoulder condition, frozen shoulder.
- Shockwave therapy for calcium deposits in the shoulder: This treatment uses sound waves to break down calcium deposits. Evidence suggests that high-power focused shockwaves are more effective. Often, we use 3 to 5 shockwave sessions to achieve better results for shoulder calcification. Studies comparing shockwave therapy to injections or surgery found similar results at a much lower cost.
Other treatments for shoulder calcification:
If simple treatments are unsuccessful, other therapies may be helpful. However, these treatments need more specialised equipment.
- Cortisone injection for calcific tendonitis: Cortisone is a potent anti-inflammatory and is more effective when administered to the site of pain. Usually, cortisone is injected into the bursa above the calcium deposits to reduce pain. Ultrasound is essential to guide the cortisone injection for calcific tendonitis into the correct location. Overall, cortisone injections are helpful, but you may need more than one.
- Orthopaedic barbotage: Overall, this procedure, also called shoulder lavage, is more invasive than a simple cortisone injection. After using a local anaesthetic, we use a larger, special needle to suck out or break down the calcium deposits. Generally, the aim is to remove or break down most of the calcification. Breaking down the calcification facilitates further degradation. You will be sore for 1-2 weeks, but should feel better after 2-4 weeks. Sometimes, you may need more than one barbotage. Evidence suggests that shoulder lavage treatment or calcification is more effective than other treatments, such as shockwave therapy. A recent review found that barbotage was better than shockwave therapy. Moreover, most people find benefits in lavage treatment. This video shows the lavage treatment using ultrasound to perfect the technique.
- TENEX procedure for shoulder calcification: TENEX is an advanced injection procedure that uses ultrasonic energy to disrupt pathological tissue. It is a suitable procedure for removing calcification by irrigating with water to flush it out.
- Surgery: In general, calcific tendonitis shoulder surgery is reserved for cases that fail other treatments. Most physicians agree that surgery should be considered only after six months. Surgery involves removing calcium deposits and creating space between the shoulder tendons and the bone. Overall, the risks of calcific tendonitis shoulder surgery include infection, ongoing pain, and a return of calcium deposits.
Frequently Asked Questions about Calcification in the Shoulder:
Why is calcific tendonitis so painful?
Calcification of tendons is common. Most cases are symptom-free. One study reported that approximately 25% of individuals had calcification in the shoulder, and most were painless. However, when the body removes calcification, it mounts an immune response that can be painful.
How long does calcific tendonitis last?
It is variable. Sometimes, the body mounts an intense immune response that immediately removes calcification. In other cases, the immune response is less intense and may take many months or years. Treatments for calcific tendonitis help the immune system to dissolve the calcification.
Causes of calcific tendonitis of the shoulder: Is it due to your diet?
Generally no. Diet or nutrition does not directly affect your risk of developing calcific tendonitis in the shoulder. However, we know that people who are overweight or have diabetes are more likely to get more severe pain from calcific tendonitis.
What is shoulder lavage treatment for calcific tendonitis shoulder?
Shoulder lavage treatment is similar to barbotage. However, we try to aspirate or suck out the calcium from the tendon in shoulder lavage treatment rather than break it up. Then, we inject cortisone into the shoulder bursa to help settle inflammation.
Lavage treatment is generally a more complex procedure and should be performed only by a physician experienced in advanced ultrasound-guided techniques.
A recent systematic review found that shoulder lavage was more effective than shockwave therapy for improving pain and shoulder function in patients with calcific tendonitis.
TENEX is a more advanced injection procedure which is effective at removing calcification. It uses ultrasonic technology and water irrigation to flush out and remove the calcification.
Should you have shockwave therapy for calcific tendonitis shoulder?
Recent evidence suggests that shockwave therapy is as effective as injections for calcific tendonitis shoulder. However, treatment often requires more sessions (1 weekly session over five weeks). Generally, we recommend a high-energy focused shockwave. A recent study found that high-energy shockwaves are more effective than low-energy shockwaves for calcific shoulder tendonitis.
How does surgery compare to other treatments for calcific tendonitis shoulder?
A recent study comparing surgery to non-surgical treatments (such as injections and shockwaves) found that surgery was slightly better, although both groups improved.
Therefore, you should only consider surgery after trialling other treatments such as shockwave and 1-2 injections – either barbotage or shoulder lavage.
Final Word from Sportdoctorlondon about Calcific Tendonitis Shoulder
Shoulder calcification is a common cause of sudden, severe shoulder pain. Overall, if simple steps are ineffective, then sucking out (aspirating) the calcification is usually adequate. However, you should consult a physician experienced in this advanced procedure. Many other therapists, such as physiotherapists, are doing injections but do not have the experience of doctors.
Is injection in shoulder is painful?
It doesn’t have to be painful if done with local anesthetic and performed by a practitioner with injection experience. LM
How painful is shockwave vs lavage? How long do you have movement restrictions after lavage?
Lavage can be painful if the calcification is acute – but we use local anesthetic, so the pain is short-lived. Shockwave is less painful overall – but you need up to 5 sessions.
Your shoulder is usually painful for 3-5 days after lavage. I suggest rest from overhead activities, including rehab for 7-10 days after lavage.
Would Calcium supplements help?
No calcification does not occur because of dietary influences
I developed this suddenly out of the blue one month ago. The pain was excruciating for 11 days and then suddenly greatly improved. I’ve had a deep ache in my deltoid since then and finally was given a cortisone shot 30 days after the acute attack. That has taken away most the pain. My local Dr doesn’t believe these deposits ever cause pain which is frustrating. I have my ROM back but I am afraid resuming my gym and outdoor activities will re-inflame my shoulder. Is it ok to do activates such as skiing right away or should I wait awhile? Just wondering if this is a one-time experience or something more chronic I need to worry about. I couldn’t take another severe attack of pain like that again – -it was horrible!
Hi Abby, As I describe in my blog, calcific tendonitis of the shoulder usually becomes very painful when the body decides to get rid of it ie the resorptive phase.
Generally, these ‘acute attacks’ are rare so your chances of another attack are low but not impossible.
If you experience the beginning of what you think is another episode, I suggest taking high-dose anti-inflammatories such as ibuprofen and making an appointment with a doctor experienced in musculoskeletal conditions.
LM
Thanks so much for validating what I’m going through and the advice! I hope it never happens again, but now I know what to expect and jump on it with NSAIDS. I hope this reabsorption phase acts quickly and can get rid of the deposits. I am making an appt with a shoulder specialist in a larger city that understands this condition. I always get the strange things ….
I had the Lavage procedure about a week ago to break up the calcium deposits in my shoulder. I usually have a low white blood cell count in my bloodwork, and see a hemotoligist, for many years, to keep track of it. Today was my appointment, and my white blood count was higher then it ever was. I am usually in the 2.8 to 3.4 range, and it was 4.5 which is in the normal range. I was wondering, could it be higher because I had the Lavage procedure last week?
Many thanks for your comments.
A cortisone injection can increase the white cell count for a few weeks. If your doctor used cortisone as part of the lavage procedure (most do), the increase in the white cell count could be attributed to the procedure. However, I’d expect the increase to be only temporary. I’d speak to your haematologist to clarify.
Lorenzo