Calcific Tendinitis of the Shoulder

The incidence of calcification in the shoulder soft tissues varies with patient population and ranges from 2.7% in Bosworth’s series of 6,000 + office workers to 20% in Ruttimann series of 100 asymptomatic shoulders.

Codman postulated that tendon degeneration and necrosis precedes dystrophic calcification and that tissue hypoxia plays a role in its formation. Uhthoff and Sarkar theorized a much more dynamic evolution of the calcification and its subsequent resorption, not characteristic of a degenerative process. They postulate a formative phase, in which an unknown trigger produces a localized area of lower oxygen tension. This portion of the tendon undergoes fibrocartilaginous transformation with chondrocyte deposition of poorly crystallized hydroxyapatite. Fluffy calcification occurs in the tendon tissue and enlarges. The calcific deposit, at this stage, resembles chalk.

Once formed, the calcific deposit enters a resting phase. The calcified area may or may not be painful. If large enough, impingement symptoms may occur.

After a variable period, an inflammatory response then occurs. Vascular tissue develops at the periphery, the oxygen level increases, and macrophages and micronuclear giant cells begin to resorb the calcium during this resorptive phase. The calcific material resembles “tooth paste” and can leak into the subacromial bursa. Pain at this time can be excruciating and this is usually when the patient presents to the office or emergency room in agony.

With or without treatment, the inflammation subsequently subsides and the process enters the postcalcific phase where the calcium is replaced to varying degrees by new collagen. Pain may or may not persist and is more likely associated with mechanical factors. The clinician may have difficulty determining whether the calcification is playing a significant role than the clinical syndrome.

The most common location for calcification is in the supraspinatus tendon near the tuberosity attachment. Calcification can also be seen in the infraspinatus, teres minor and subscapularis. Females appear to be affected more often than males and bilateral involvement is not uncommon. The highest incidences are in adults aged 30-50 years. No significant correlation seems to exist with trauma or rotator cuff rupture.

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7/8/2006

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