Rotator Cuff Calcific Tendinitis
Article by John Miller
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:
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.
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.
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:
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.
What are the Symptoms of Rotator Cuff Impingement?
Commonly rotator cuff impingement has the following symptoms:
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.
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.
Poor Shoulder Blade (Scapular) Stability
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
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.
As you improve, supportive taping will help to both support the injured soft tissue and reduce excessive swelling.
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.
Phase 3: Restore Scapular Control
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
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.
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.
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.
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.
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.
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