Shoulder Calcification: comprehensive guide from a physical therapist

What is shoulder calcification concretely? Definition

Like everyone, calcium is present throughout your body and various tissues.

Sometimes, this calcium accumulates excessively in certain areas of the body.

Calcification refers to the abnormal buildup of calcium crystals in tendons or soft tissues of a body part.

This is why terms like tendinitis, enthesopathy, or calcific tendinopathy are used: because tendons are often affected.

The shoulder is particularly prone to this phenomenon, especially in:

• Tendons of the rotator cuff muscles: +++ supraspinatus, infraspinatus, subscapularis, long head of biceps;
• Entheses: where the tendon inserts into the bone;
• Subacromial bursa.

How can you be sure it’s calcification? Symptoms

Know that calcification is the main cause of shoulder pain [Kim 2020].

If you have shoulder pain during the day or night, are between 40 and 60 years old [de Carli 2014], and it is not due to a blow or sudden movement, there is a nonzero probability that calcification could explain this pain.

However, 2 out of 10 people with shoulder calcification visible on imaging experience no pain at all: this problem is often asymptomatic.

Pain is not necessarily present with shoulder calcification. This is reassuring because it means there is hope for less or no pain, even if calcium continues to accumulate.

Generally, diagnosis involves ruling out other conditions that could explain the pain, such as shoulder fracture, septic arthritis, or shoulder osteoarthritis.

Calcification is visible on X-ray, ultrasound, MRI, or arthroscopy. There are classifications to categorize calcification based on the size of the calcium deposit, measurable during imaging, whether it is more or less than 15 mm.

The shoulder may sometimes be red, swollen, but these are not very characteristic signs.

Source: Kim 2020

Why do some people have calcifications and others don’t?

Here are the common characteristics often found in people with shoulder calcifications:

• Gout attacks;
• Diabetes;
• Endocrine or autoimmune diseases;
• Rotator cuff tear;
• Stiff shoulder due to shoulder trauma.

This doesn’t necessarily mean these conditions cause calcification, just that they are frequently present. Calcifications can also occur without any of the listed pathologies.

Source: Kim 2020; Compagnoni 2021

What happens to calcification if left untreated?

An Italian research team 🇮🇹 followed up with 35 individuals 10 years after being diagnosed with shoulder calcification.

Among these 79 individuals:

• 7 received corticosteroid injections,
• 8 underwent shockwave therapy,
• 11 received both corticosteroid injections and shockwave therapy,
• 1 was treated with ultrasound-guided percutaneous lavage,
• 8 did not receive any specific treatment.

4 individuals no longer had any calcification, including those without treatment: indicating that calcification can disappear without intervention!

Another positive finding: in 30 cases, there was a reduction in calcification diameter.

The team concludes as follows:

Calcific tendinitis is a condition that resolves on its own, without tears in the rotator cuff or glenohumeral arthritis during long-term follow-up.

In 4 cases, the calcification increased in size, and in 1 case, the size did not change.

These changes were not statistically different whether there was treatment or not.

See also: What is the recovery time for shoulder tendinitis?

What are the treatments?

Treatments may aim to simply relieve symptoms (pain, stiffness of the shoulder) or reduce or eliminate the calcification altogether.

Since calcification can improve on its own without specific intervention, some people may choose to let things run their course without intervening specifically.

List of possible treatments

If you are considering treatments, most of the time conservative treatment is suggested. This includes one or more of the following modalities, with my personal preference initially leaning towards options 1 and 2:

1. Adjust the level of shoulder use by reducing or eliminating activities that worsen or trigger pain, such as certain sports or manual activities.
2. Find more comfortable positions, especially for sleeping or resting the shoulder. For example, using pillows for support or using an elbow brace.
3. Physical therapy: stretching, muscle strengthening, massage, manual therapy, therapeutic ultrasound, TENS (transcutaneous electrical nerve stimulation), shockwave therapy, supervised progressive reintegration of activities that trigger pain, cryotherapy, etc.
4. Medical treatment: taking anti-inflammatory drugs (NSAIDs), corticosteroid injections, mesotherapy.
5. Home remedies, natural treatment: application of essential oils, acupuncture, green clay poultice, dietary supplements like vitamin K or omega-3 fatty acids, etc. These options often rely on less solid theoretical foundations than those mentioned previously.
6. Less commonly, surgical treatment may be proposed. This is usually done arthroscopically and involves removing the calcification and possibly repairing damaged tendons.

There are few high-quality controlled and randomized clinical trials comparing the effectiveness of one or more of these treatments to placebo or natural progression.

Which treatment is most widely accepted?

Here is the opinion of a team of orthopedic surgeons from Korea regarding the management of shoulder calcification [Kim 2020]. Their opinion is based on reviewing around twenty academic publications, in addition to their clinical experience:

Patients with acute calcifying tendinitis [lasting less than 3 months] respond well to conservative treatment and rarely require surgical intervention.
However, patients suffering from chronic calcifying tendinitis often do not respond to conservative treatment and may require surgical intervention.

Clinical improvement takes time, even after surgical treatment.

What’s interesting is comparing this opinion to that given by other types of healthcare professionals accustomed to seeing calcifications. Not surgeons, but doctors or physical therapists.

Here is the management recommended by a team specializing in physical medicine and rehabilitation:

This figure recommends as first-line treatment the oral intake of anti-inflammatory drugs (even injected under the acromion) combined with physiotherapy sessions. According to the authors, 7 out of 10 individuals find sufficient relief with this approach within a maximum of 6 to 8 weeks of treatment.

If this proves insufficient and individuals seek alternative treatments to try, shock wave therapy or ultrasound-guided percutaneous lavage is proposed. If results still prove unsatisfactory, surgery may be considered after 6 months of continuous pain without improvement.

All studies consulted agree that surgical treatment should be the last option considered due to the higher risk of adverse effects compared to other treatments, along with uncertain outcomes. [Loew 2021]