Calcinosis of the Shoulder: Understanding, Causes, Symptoms, and Treatment

What is calcinosis of the shoulder?

Calcinosis of the shoulder refers to the abnormal deposition of calcium salts, primarily calcium hydroxyapatite crystals, within the soft tissues around the shoulder joint, most commonly affecting the rotator cuff tendons. This condition, often termed calcific tendinitis, can lead to significant pain and functional limitation.

Understanding Calcinosis

Calcinosis is a general term for the formation of calcium deposits in soft tissues where they don't normally belong. In the context of the shoulder, this typically involves dystrophic calcification, which occurs in damaged or degenerating tissues. The most prevalent form of calcinosis in the shoulder is calcific tendinitis, specifically affecting the rotator cuff tendons (supraspinatus, infraspinatus, subscapularis, and teres minor). These deposits are composed of calcium hydroxyapatite crystals, which are the same minerals found in bone, but here they form in non-osseous tissues.

The presence of these calcium deposits can range from small, granular formations to large, dense masses. While often asymptomatic, they can trigger a significant inflammatory response, particularly when the deposits are being resorbed by the body, leading to acute and severe pain.

Causes and Risk Factors

The exact cause of calcinosis in the shoulder is not fully understood, but it is believed to be a multifactorial process involving a combination of genetic predisposition, metabolic factors, and mechanical stress on the tendons. Key contributing factors include:

• Degenerative Changes: As tendons age or undergo repetitive stress, microscopic tears and areas of degeneration can develop. These damaged tissues may become sites for calcium deposition.
• Hypoxia: Reduced blood flow or oxygen supply (hypoxia) to the tendon, often due to compression or repetitive movements, might create an environment conducive to calcification.
• Metabolic Factors: While less common for localized shoulder calcinosis, systemic conditions that affect calcium metabolism, such as certain autoimmune diseases or kidney disorders, can sometimes contribute to more widespread calcinosis. However, calcific tendinitis of the shoulder is generally not linked to these systemic issues.
• Genetic Predisposition: Some individuals may have a genetic susceptibility that makes them more prone to developing calcium deposits.
• Age and Gender: Calcific tendinitis most commonly affects individuals between 30 and 60 years of age, with a slightly higher incidence in women.

Signs and Symptoms

The symptoms of calcinosis of the shoulder can vary widely, from being completely asymptomatic to causing debilitating pain. The severity often depends on the size and location of the calcium deposit, and whether it is in a formative or resorptive phase.

Common symptoms include:

• Shoulder Pain: This is the most prominent symptom. Pain can range from a dull ache to sharp, intense pain, especially during the acute resorptive phase. It often worsens with arm movement, particularly overhead activities.
• Stiffness: Reduced range of motion in the shoulder joint.
• Weakness: Difficulty lifting or moving the arm due to pain or impingement.
• Tenderness: The shoulder may be tender to touch, especially over the affected tendon.
• Clicking or Grinding Sensation: During movement, some individuals may feel or hear a clicking or grinding sensation.
• Night Pain: Pain that disrupts sleep, especially when lying on the affected side.

Diagnosis

Diagnosing calcinosis of the shoulder involves a combination of clinical evaluation and imaging studies.

• Medical History and Physical Examination: A healthcare professional will inquire about the onset, nature, and severity of pain, as well as any activities that worsen or alleviate it. A physical examination will assess range of motion, strength, and identify areas of tenderness.
• X-rays: This is the primary imaging modality for confirming the presence of calcium deposits. X-rays can clearly show the size, shape, and location of the calcifications within the soft tissues.
• Ultrasound: Ultrasound can provide detailed images of the tendons and surrounding soft tissues, allowing for assessment of the deposit's consistency (solid vs. liquid-like) and guiding procedures like barbotage.
• Magnetic Resonance Imaging (MRI): While not typically needed to identify the calcium itself (X-rays are superior for this), an MRI may be ordered to rule out other shoulder pathologies, such as significant rotator cuff tears, or to assess the degree of inflammation around the deposit.

Treatment Approaches

Treatment for calcinosis of the shoulder primarily focuses on managing pain and inflammation and restoring shoulder function. The approach depends on the severity of symptoms and the stage of the condition.

• Conservative Management:
  • Rest and Activity Modification: Avoiding activities that aggravate the pain.
  • Ice Application: To reduce inflammation and pain.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Oral medications like ibuprofen or naproxen to reduce pain and inflammation.
  • Pain Relievers: Over-the-counter or prescription pain medications.
• Medical Procedures:
  • Corticosteroid Injections: Injections of corticosteroids into the subacromial space or around the affected tendon can provide significant, though often temporary, pain relief by reducing inflammation.
  • Barbotage (Needling and Lavage): This procedure involves using a needle, often guided by ultrasound, to puncture and aspirate the calcium deposit. Saline solution may be injected to help break up and wash out the calcium. It is effective for softer, more liquid-like deposits.
  • Extracorporeal Shockwave Therapy (ESWT): This non-invasive treatment uses high-energy sound waves directed at the calcium deposits to break them up, facilitating their reabsorption by the body. It can be effective, particularly for chronic, resistant cases.
• Surgical Intervention:
  • Arthroscopic Calcium Removal: If conservative treatments fail and severe symptoms persist, surgical removal of the calcium deposits may be considered. This minimally invasive procedure involves inserting a small camera and instruments through tiny incisions to visualize and remove the calcium.

Role of Physical Therapy and Rehabilitation

Physical therapy is a crucial component of managing calcinosis of the shoulder, whether as a primary treatment or following medical procedures. A physical therapist will develop an individualized program focused on:

• Pain Management: Utilizing modalities such as therapeutic ultrasound, electrical stimulation, or cold therapy to reduce discomfort.
• Restoring Range of Motion: Gentle stretching and mobilization exercises to improve shoulder flexibility and reduce stiffness. This might include pendulum exercises, wall slides, and passive/active assisted range of motion.
• Strengthening: Gradually progressing exercises to strengthen the rotator cuff muscles, scapular stabilizers, and surrounding shoulder girdle musculature. This helps improve joint mechanics, support the shoulder, and prevent recurrence. Examples include internal/external rotation with resistance bands, rows, and overhead presses (once pain allows).
• Posture Correction: Addressing any postural imbalances that may contribute to shoulder dysfunction.
• Activity Modification and Ergonomics: Guidance on proper body mechanics during daily activities and work-related tasks to reduce stress on the shoulder.
• Return to Activity: A progressive plan to safely return to sport, work, or recreational activities.

Prevention and Management

While complete prevention of calcinosis may not always be possible due to genetic and degenerative factors, certain strategies can help manage symptoms and potentially reduce the risk of recurrence:

• Regular Exercise: Maintaining shoulder strength and flexibility through a balanced exercise program.
• Proper Warm-up and Cool-down: Always preparing muscles for activity and aiding recovery afterward.
• Avoiding Overuse: Being mindful of repetitive overhead activities and taking breaks.
• Ergonomic Adjustments: Ensuring proper posture and workstation setup, especially for those with desk jobs or repetitive tasks.
• Managing Underlying Conditions: Addressing any systemic health issues that might indirectly impact musculoskeletal health.

Prognosis

The prognosis for calcinosis of the shoulder is generally good. Many cases resolve spontaneously or with conservative treatment over time, as the body often reabsorbs the calcium deposits. The acute painful phase, though severe, is often followed by improvement. However, some individuals may experience persistent pain or recurrent episodes, necessitating more aggressive interventions like barbotage, ESWT, or surgery. Full recovery of function is the typical outcome, although the timeline can vary significantly from weeks to several months.

When to Seek Medical Attention

It is important to consult a healthcare professional if you experience:

• Persistent or Worsening Shoulder Pain: Especially if it does not improve with rest or over-the-counter pain relievers.
• Significant Limitation in Movement: Inability to lift your arm or perform daily activities.
• Sudden, Severe Shoulder Pain: This could indicate an acute inflammatory phase of calcific tendinitis or another serious condition.
• Signs of Infection: Redness, warmth, swelling, or fever accompanying shoulder pain (rare for calcinosis, but important to rule out).