Calcific Tendonitis of the Rotator Cuff: When It's Not Frozen Shoulder

Shoulder pain is a common complaint among patients presenting to primary care physicians. While a torn rotator cuff or frozen shoulder may be among the first diagnoses that come to mind, 10% to 20% of shoulder pain diagnoses turn out to be calcific tendonitis—a lesser-known pathology. The physiatrists and orthopedic surgeons of HSS at NewYork-Presbyterian Weill Cornell Medicine and the Weill Cornell Medicine Department of Rehabilitation Medicine offer the latest nonoperative treatments as well as minimally invasive surgical approaches for those in need. 

What is calcific tendonitis? 

In patients with calcific tendonitis, which can affect tendons in any part of the body, calcium salt deposits accumulate and cause inflammation and pain. In the shoulder, these deposits are most often found in the supraspinatus tendon of the rotator cuff and may also collect in the infraspinatus tendon.  

It is not known what causes calcific tendonitis of the rotator cuff, but it occurs in women more often than men and most commonly in people ages 40-60. People at risk of elevated blood calcium, such as those prone to kidney stones, may have an increased risk of this condition.  

Calcific Tendonitis Symptoms 

Patients presenting with calcific tendonitis often complain that their pain came on suddenly and significantly impairs range of motion. They may have woken up with severe pain one day without any prior injury explaining it. Others report previous low-energy or repetitive trauma. Patients may experience lateral shoulder pain when lifting the affected arm (most often the dominant arm) overhead. 

Most cases of calcific tendonitis of the rotator cuff are diagnosed in this acute phase. It is not unusual, however, for symptoms to subside with time and come and go over a period of many months or years, with the patient adjusting their movements to avoid discomfort before finally seeking a doctor's care. 

Making the Diagnosis 

Differential Diagnosis 

Shoulder conditions that may mimic the symptoms of calcific tendonitis of the rotator cuff include: 

  • Rotator cuff tear 
  • Frozen shoulder (adhesive capsulitis) 
  • Subacromial bursitis 
  • Shoulder arthritis 

Definitive Diagnosis 

To diagnosis the cause of a patient's shoulder pain, doctors employ: 

  • Medical history and physical examination to ascertain symptoms and range of motion.  Patients will have pain during overhead activities and pain at night when sleeping on the shoulder. Physical exam will demonstrate painful shoulder forward flexion and abduction, with pain during rotator cuff strength testing and impingement signs. 
  • Shoulder x-rays to look for areas of calcium deposits about the shoulder.  
  • Diagnostic ultrasound conducted in our office can visualize calcium deposits in the shoulder. 
  • MRI may be ordered to rule out other pathologies, such as a rotator cuff tear; ascertain the size and location of calcium deposits; and determine how much inflammation is present. 

Treatment of Calcific Tendonitis of the Rotator Cuff 

Nonoperative Therapies 

Most people with this condition can achieve relief of their symptoms using nonsurgical therapies such as: 

  • NSAIDs. Since most calcifications will eventually self-resorb, we initiate treatment with two weeks of a prescription NSAID to relieve inflammation as the calcium deposit shrinks. Exercises may be prescribed to help patients improve their range of motion as they heal. 
  • Barbitage and lavage. If NSAID treatment is not sufficient to ameliorate symptoms, a physiatrist can insert a needle under ultrasound guidance to break up and remove the calcification via a syringe. A steroid injection may also be given into the bursa to treat any inflammation from calcific pieces that come loose. The patient then needs to rest for two weeks and then slowly resume regular activities over the next six weeks.  
  • Percutaneous needle tenotomy (Tenex). This treatment is for patients with calcium deposits that are too big to be treated with barbitage and lavage. It works in a similar way by breaking up and removing larger calcium deposits. Patients require rest for four to six weeks followed by physical therapy. Resumption of heavy activity such as weightlifting is not permitted for about three months. 
  • Shockwave therapy. This treatment is not covered by insurance but may be preferred by patients who are not comfortable with needle therapies or who cannot take the required time off to recover from them. Similar to lithotripsy for kidney stones, high-intensity ultrasound is used to break up calcium deposits via mechanical impact. Patients only need to rest for 48 hours; treatment is given once a week for five weeks. (Needle-based treatments most often require only a single session.) 

Surgical Treatment 

Surgery may be necessary to remove calcium deposits that persist if nonoperative treatments are ineffective or if the deposits are too large for those therapies. Our orthopedic surgeons perform this procedure arthroscopically, using the device's camera as well as MRI results to identify the deposits and plan their removal. 

  • The surgeon cleans out the calcium deposit and the area where it resided.  
  • Removing a large calcium deposit may leave a defect in the tendon that may require repair. If a patient needs surgical repair of a torn rotator cuff after excision of the calcium deposit, they will be immobilized in a sling for six weeks, followed by physical therapy to regain range of motion and strength, with full return to sports and other activities four to six months after surgery. 
  • Patients who do not require a rotator cuff repair do not need to wear a sling, can begin physical therapy sooner, and return to their regular activities in two to three months. 

Most patients do not experience a return of the calcium deposits unless they have another condition that makes them prone to them. If you have a patient complaining of sudden unexplained shoulder pain and/or you see calcium deposits on a shoulder x-ray, refer them to HSS at NewYork-Presbyterian Weill Cornell Medicine for a comprehensive workup and the most effective therapies. 

Referring a Patient 

There's no reason to live with the pain of calcific tendonitis of the rotator cuff. Contact us at 212-746-4500 to refer a patient to HSS at NYP Weill Cornell Medicine.