What is Rotator Cuff Calcific Tendonitis?
Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimetre size, calcium deposit within the tendons of the rotator cuff. These deposits are usually found in patients at least 30-40 years old, and have a higher incidence in diabetics. The calcium deposits are not always painful, and even when painful they will often spontaneously resolve after a period of one to four weeks.
What Causes Calcific Tendonitis?
The cause of calcium deposits within the rotator cuff tendon (calcific tendonitis) is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.
One of the most compelling arguments is delayed healing.
Normally, the tendon heals via the action of collagen forming cells known as fibroblasts. After a period of weeks or months, the fibroblasts become less numerous in the region and are replaced by osteoblasts (bone forming cells). These osteoblasts stimulate the growth of bone (calcium) in the tendon.
Hence the main reason for the development of calcific tendonitis appears to be delayed healing.
How Does Calcific Tendonitis Progress?
Calcific tendonitis usually progresses predictably, and almost always resolves eventually without surgery. The typical course is:
Pre-Calcification Stage
You usually do not have any symptoms in this stage. At this point in time, the site where the calcification tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
Calcific Stage
During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky, it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins--this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.
Post-Calcific Stage
This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.
Patients usually seek treatment during the painful resorptive phase of the calcific stage, but some patients have the deposits found incidentally as part of their evaluation impingement syndrome, usually on X-ray.
What is Rotator Cuff Impingement Syndrome?
Impingement (impact on bone into rotator cuff tendon or bursa) should not occur during normal shoulder function. When it does happen, the rotator cuff tendon becomes inflamed and swollen, a condition called rotator cuff tendonitis. Likewise if the bursa becomes inflamed, shoulder bursitis will develop.
Both these conditions can co-exist or be present independently.
While a traumatic injury can occur eg fall, it is repeated movement of your arm into the impingement zone overhead that most frequently causes the rotator cuff to contact the outer end of the shoulder blade (acromion).
When this repeatedly occurs, the swollen rotator cuff is trapped and pinched under the acromion.
What is the Impingement Zone?
Postures that significantly narrow the sub-acromial space are:
- Your arm directly overhead.
- Your arm working at or near shoulder height.
Who Suffers Impingement Syndrome?
Impingement syndrome is more likely to occur in people who engage in physical activities that require repeated overhead arm movements, such as tennis, golf, swimming, weight lifting, or throwing a ball.
Occupations that requires repeated overhead lifting or work at or above shoulder height are also at risk of rotator cuff impingement.
What are the Symptoms of Rotator Cuff Impingement?
Commonly rotator cuff impingement has the following symptoms:
- An arc of shoulder pain approximately when your arm is at shoulder height and/or when your arm is overhead.
- Shoulder pain that can extend from the top of the shoulder to the elbow.
- Pain when lying on the sore shoulder
- Shoulder pain at rest as your condition deteriorates
- Muscle weakness or pain when attempting to reach or lift
- Pain when putting your hand behind you back or head.
- Pain reaching for the seat-belt.
How is Impingement Syndrome Diagnosed?
In most cases, a thorough clinical examination will identify a rotator cuff impingement. Your physiotherapist will ask about your shoulder pain and its behaviour plus examine your shoulder with some specific tests that identify impingement signs.
Diagnostic tests may include X-rays, MRI or ultrasound scans to look for tears in the rotator cuff or signs of bursitis.
Shoulder pain can commonly be caused by a problem with your neck joints. Your physiotherapist will examine this area to rule out this cause or include its treatment in your care plan.
What Causes Rotator Cuff Impingement & Bursitis?
Rotator cuff impingement and the bursitis it causes has primary (structural) and secondary (posture & movement related) causes.
Primary Rotator Cuff Impingement – Structural Narrowing
Some of us are born with a smaller sub-acromial space. Conditions such as osteoarthritis can also cause the growth of sub-acromial bony spurs, which further narrows the space.
Because of this structural narrowing, you are more likely to squash, impinge and irritate the soft tissues in the sub-acromial space, which results in bursitis or rotator cuff tendonitis.
Secondary Rotator Cuff Impingement – Dynamic Instability
Impingement can occur if you have a dynamically unstable shoulder. This means that there is a combination of excessive joint movement, ligament laxity and muscular weakness around the shoulder joint.
This impingement usually occurs over time due to repetitive overhead activity, trauma, previous injury, poor posture or inactivity.
In an unstable shoulder, the rotator cuff has to work harder, which can cause injury.
An overworking rotator cuff fatigues and eventually becomes inflamed and weakens due to pain inhibition or tendon tears.
When your rotator cuff fails to work normally, it is unable to prevent the head of the humerus (upper arm) from riding up into the sub-acromial space, causing the bursa or tendons to be squashed.
Failure to properly treat this instability causes the injury to recur. Poor technique or bad training habits such as training too hard is also a common cause of overuse injuries, such as bursitis or tendonitis.
Poor Shoulder Blade (Scapular) Stability
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
Poor shoulder blade stability results in tipping and rotation of your scapular, which causes your acromion (bone) to pinch down into the subacromial structures (eg bursa and tendons) causing impingement leading to swelling or tears.
Normal shoulder blade-shoulder movement - known as scapulo-humeral rhythm - is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury.
How to Normalise Your Scapulo-Humeral Rhythm
Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm. Any deficiencies will be an important component of your rehabilitation.
Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder.
How to Treat Rotator Cuff Calcific Tendonitis
Rotator cuff calcific tendonitis is a common complaint that we see at PhysioWorks and it is unfortunately an injury that often recurs if you return to sport or work too quickly – especially if a thorough rehabilitation program is not completed.
Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents injuries such as bursitis, impingement, subluxations and dislocations.
We also know that your rotator cuff provides subtle glides and slides of the ball joint on the socket to allow full shoulder movement. Plus, your shoulder blade (scapular) has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall.
Did you know that your arm only has one bony joint articulation where your collarbone (clavicle) attaches to the acromion (tip of shoulder blade)?
The rest of your attachments are muscular, which highlights the importance of retraining and strengthening of your shoulder muscles.
Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate these injuries and prevent recurrence – these are:
Phase 1 - Early Injury Protection: Pain Relief & Anti-inflammatory Tips
As with most soft tissue injuries the initial treatment is RICE - Rest, Ice, Compression and Elevation.
In the early phase you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some active rest from pain-provoking postures and movements.
This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder.
You may need to be wear a sling or have your shoulder taped to provide pain relief. In some cases it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.
As you improve, supportive taping will help to both support the injured soft tissue and reduce excessive swelling.
Your physiotherapist will utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this painful phase.
Phase 2: Regain Full Range of Motion
If you protect your injured rotator cuff structures appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage.
Symptoms related to Rotator cuff calcific tendonitis may take several weeks to improve while we await Mother Nature to work her wonders. During this time it is important to create an environment that allows you to return to normal use quickly and prevent a recurrence.
It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, shoulder muscle stretches, and light active-assisted and active exercises.
Researchers have concluded that physiotherapist-assisted treatment will improve your range of motion quicker and, in the long-term, improve your functional outcome.
In most cases, you will also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement.
Signs that your have full soft tissue extensibility includes being able to move your shoulder through a full range of motion. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power.
Phase 3: Restore Scapular Control
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
Normal shoulder blade-shoulder movement - known as scapulo-humeral rhythm - is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury.
Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm.
Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an important component of your rehabilitation.
Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder blade.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
You may find it difficult to comprehend, but your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury.
Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can effect a nerve’s electrical energy supplying your muscles causing weakness and altered movement patterns.
Plus, painful spinal structures form poor posture or injury doesn’t provide your shoulder or scapular muscles with a solid pain-free base to act upon.
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your pain, improve your shoulder movement and stop pain or injury returning.
Phase 5: Restore Rotator Cuff Strength
It may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a structure is injured we need to provide nature with an opportunity to undertake promary healing before we load the structures with anti-gravity and resistance exercises.
Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles in a successful rehabilitation program. These exercises need to be progressed in both load and position to accommodate for which specific rotator cuff tendons are injured and whether or not you have a secondary condition such as bursitis.
Your physiotherapist will happily prescribe the most appropriate program for you.
Phase 6: Restore High Speed, Power, Proprioception & Agility
If your shoulder injury has been caused by sport it is usually during high speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions.
In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.
Phase 7: Return to Sport or Work
Depending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment.
Your PhysioWorks physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work.
Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor or employer.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury.
Summary
There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment.
You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.
It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration.
For more specific advice about your bursitis or rotator cuff injury, please contact your PhysioWorks physiotherapist.
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FAQs about Rotator Cuff Calcific Tendonitis
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