Calcification Of The Shoulder

Calcification of the shoulder, often termed as calcific tendonitis, is caused by calcium buildup in tendons. These calcium deposits might accumulate in either one spot or appear in multiple locations. If the deposits get larger or inflamed, they may cause severe discomfort. Calcific tendonitis most commonly affects the rotator cuff in the shoulder, but it can affect any part of the body.³

Anatomy of the shoulder

The acromioclavicular joint and the glenohumeral joint are the two joints that make up the shoulder. The acromion, a portion of the shoulder blade (scapula), and the collar bone (clavicle) connect at the acromioclavicular joint. The ball (humeral head) and the socket (glenoid) meet at the glenohumeral joint. The rotator cuff connects the humerus to the scapula. Tendons are the connective tissue that connect muscle to bone. Muscles, in turn, pull on tendons to move bones. The rotator cuff muscles maintain the humerus firmly in the socket. The glenoid, or socket, is shallow and flat.⁹

The labrum, a soft tissue border around the humeral head, creates a deeper socket that conforms to suit the humeral head. The shoulder joint is encased in a joint capsule. It's a fluid-filled sac that keeps the joint lubricated. Ligaments make up the structure, which are a type of soft tissue that connect bones. Any component of the shoulder can sustain a shoulder injury. ⁹

What is shoulder calcification?

Calcification of the rotator cuff tendon at its insertion on the humeral head is known as shoulder calcification. This is a common source of shoulder pain that can be serious in some cases. These individuals have shoulder pain that appears out of nowhere, is usually moderate at night, and worsens over time.

Why does shoulder calcification occur?

Calcific shoulder tendonitis occurs when hydroxyapatite, a naturally occurring mineral found in the human body, starts accumulating within the tendons of the muscles that surround the shoulder (the rotator cuff). This illness is more common in people assigned female at birth (AFAB) than in people assigned male at birth (AMAB), and typically affects people between the ages of 30 and 60.

Long-term, slow-onset, or intermittent shoulder pain is common in patients with this ailment. The pain is induced by the body's inflammatory response to calcification resorption. This occurs as part of the calcific deposit's natural cycle, which includes three phases: formative, resting, and resorptive, the last of which is the most painful. A slight accident or repetitive movement might irritate the tendon, causing the shoulder to become extremely uncomfortable without any calcific crystal resorption.

How is shoulder calcification diagnosed?

To evaluate whether there is a painful posture when lifting your arm, the doctor will initially do a physical examination. In addition, an X-ray will be taken, which will clearly show the calcium spots. A shoulder X-ray reveals more extensive hard calcium deposits. 

Ultrasound, on the other hand, can detect tiny deposits that an X-ray would miss. Ultrasound can also determine the stage of the calcification (i.e., resorptive stage) to determine whether it is a potential source of pain. As a result, it's critical to realize that the appearance of calcification in the shoulder on an X-ray does not always imply that the calcium is causing pain.

Calcific tendinitis

Calcific tendinitis of the shoulder, also known as enthesopathy, is a self-limiting condition marked by the deposit of calcium phosphate crystals in the rotator cuff tendons. It is most frequent in people between the ages of 30 and 50, and it is uncommon in people above the age of 70. It affects around twice as many people AFAB as it does people AMAB, is more frequent in the right shoulder than the left, and affects both shoulders in 10% of patients.⁵

Fragments of calcium are seen in the tendons around the shoulder which appear as soft as toothpaste or slightly tougher. It is possible for the tendon to expand as a result of calcium buildup, thereby swelling the areas. When raising the arm, the tendon becomes caught below the shoulder cap. Calcium particles may escape from the tendon at some point. The body then responds with a strong inflammatory response that can result in excruciating pain.⁸

Frozen shoulder

If you've suddenly gotten shoulder pain, you may have frozen shoulder syndrome, also known as adhesive capsulitis. This is a painful shoulder condition for which the reason is not entirely known. It is certain that it can progress rapidly and result in a potentially disabling condition. 

In this condition, the capsule of the socket joint which holds the glenoid becomes inflamed due to various causes such as physical distress. The pain is caused by this acute inflammation. When the inflammation subsides, the capsule contracts and the capsule fibers shorten, resulting in joint stiffness and loss of movement. The capsule eventually stretches out again, and the joint regains its capability to move. This is a self-limiting and self-healing disorder. However, it can take a long time, sometimes up to 15 months to cure. The treatment is rather simple for this condition and the patient is often administered with exercise therapy, or they are injected with a low volume of cortisone and local anesthetic into the joint when some physical exercises are difficult to perform.⁴

Differentiating between these two prevalent conditions related to the shoulder – calcific tendonitis and frozen shoulder – can be difficult at times. In most cases, however, calcific tendonitis of the shoulder develops quickly (although not always). Furthermore, movement restriction is limited to one plane, whereas with a frozen shoulder, all movements are restricted. Nonetheless, distinguishing between these common shoulder conditions in the early stages might be difficult. An MRI may be required to aid in the diagnosis.⁶

Patients with calcific tendinitis commonly experience intense, incapacitating pain that arises out of nowhere, usually in the morning. Consequent stiffness can occur, resulting in a frozen shoulder-like clinical presentation.

Degenerative vs Reactive Calcification

Degenerative calcification and reactive calcification are the two kinds of calcific tendonitis of the shoulder. Degenerative calcification is mostly caused by the wear and tear of the shoulder. As we grow old, blood flow to the rotator cuff tendons diminishes. The tendon becomes weaker as a result of this. The fibers of the tendons rip and tear when we utilize our shoulders in our everyday life, similar to a worn-out rope. As part of the healing process, calcium deposits accumulate in the injured tendons.¹

Reactive calcification is distinct from other types of calcification. It's unclear why this happens. It doesn't appear to be related to degeneration, yet it is more likely than degenerative calcification to induce shoulder pain. 

Reactive calcification is divided into three stages. 

1. Pre-calcific stage: The tendon transforms, which results in the formation of calcium deposits. 
2. Calcific stage: Calcium crystals are deposited in the tendons. They then start to disintegrate such that the calcium deposits are simply reabsorbed by the body. Pain is most likely to occur during this stage. 
3. Post-calcific stage: The body heals the tendon in this stage, and the tendon is reconstructed with tissue formation.¹

It is unknown what causes the deposits to be reabsorbed by the body. However, as this happens and the tissue begins to rebuild, the discomfort usually subsides or disappears entirely.

Signs and symptoms

Patients with shoulder calcification experience a variety of symptoms, which vary depending on the stage of the disease, and the size and location of the calcific deposit. In the early stages of shoulder calcification, those who are affected frequently have no indications or symptoms.⁷ Calcific tendonitis would occur if you have acute discomfort in a resting position or if the pain gets worse with movement. Signs and symptoms of calcific tendinitis include:

• Shoulder stiffness or pain
• Pain is concentrated on the front or rear of your shoulder, and it travels down your arm.
• Pain may worsen suddenly or gradually due to the accumulation of calcium deposits.
• In serious circumstances, discomfort might render the arm immobile and disrupt the sleep pattern

Causes and risk factors

The specific aetiology of this syndrome is unknown, but thyroid gland malfunction, metabolic diseases (such as diabetes), and genetic susceptibility have all been suggested as factors that increase the likelihood of being affected with the calcification of the shoulder.⁷

The clinical picture varies from patient to patient depending on the stage of the deposit, but discomfort is unmistakably associated with this illness. Such discomfort can be extremely intense at times, causing sleep and daily activities to be disrupted. A sensation of ‘catching’ in the shoulder may also be present, which might be mistaken for shoulder impingement, a condition that overlaps calcific tendonitis in numerous aspects. As a result, it is critical to obtain a precise diagnosis of the problem so that it can be adequately treated.⁷

The following are some risk factors for developing calcific tendinitis of the shoulder.²

• Playing sports that involve frequent overhead arm movements, such as basketball and tennis.
• Heavy lifting and other jobs that require repeated overhead arm movements
• Injury to the shoulder in the past, such as a dislocation or impingement
• Weak shoulder muscles
• Trauma to the shoulder joint, such as banging or slamming your shoulder into anything
• Inflammatory diseases such as gout and rheumatoid arthritis 
• Osteoarthritis
• Gender - people AFAB are more likely to have it.
• Predisposition due to genetics
• Abnormal cell proliferation
• Abnormal thyroid gland activity 

Treatment of shoulder calcification

Treatment for shoulder calcification is similar to that of other shoulder disorders. In most cases, a combination of treatments is more beneficial than a single treatment.⁶

• Medication: The most effective and first-line treatment is an anti-inflammatory medication. Ibuprofen and naproxen are two examples. You should consult your doctor to see if these medications are suitable for you.
• Treatment for calcification in the shoulder with physiotherapy: Exercises can help with range of motion loss caused by shoulder calcification. Exercise also lowers the risk of getting a second shoulder issue like frozen shoulder.
• Calcium deposits in the shoulder are treated using shockwave therapy. Sound waves are used to break down calcium deposits in this treatment. According to research, a targeted shockwave with a high power of 3 to 5 provides a better result for shoulder calcification.

Alternative shoulder calcification treatments: If simple treatments fail, other therapies may be able to help. These therapies, however, necessitate the use of more specialized equipment:

• Cortisone injection for calcific tendonitis: Cortisone is a powerful anti-inflammatory that works best when administered directly to the cause of the discomfort. In most cases of shoulder calcification, a cortisone injection into the bursa above the calcium deposits relieves pain. An ultrasound is required to direct the cortisone shot for calcific tendinitis to the correct location. Cortisone injections are often beneficial, although you may require more than one.
• Orthopedic barbotage, also known as shoulder lavage, is a more intrusive surgery than a simple cortisone shot.
• After administering a local anesthetic, the calcium deposits are sucked out or broken down with a bigger needle. The goal is to eliminate or break down the majority of the calcification. Breaking down the calcification aids the body in further breaking it down. For the first 1-2 weeks, you will experience soreness, but after 2-4 weeks, you should feel better. You may require more than one barbotage. According to research, shoulder lavage appears to be more successful than alternative therapies for calcification, such as shockwave therapy. 
• Surgery: Calcific tendonitis shoulder surgery is typically reserved for those that have failed to respond to conventional therapies. Surgery should only be considered after 6 months, according to most doctors. The calcium deposits must be removed, and the area between the shoulder tendons and bone must be opened. Infection, chronic pain, and a return of calcium deposits are all hazards associated with calcific tendonitis shoulder surgery.

Summary

Calcification of the shoulder is a condition that results in the buildup of calcium in the tendon. This condition is also called calcific tendonitis, and it most commonly affects the rotator cuff in the shoulder, but it can affect any part of the body. Physical distress is the main cause of such a condition. Although there are many treatments for calcification of the shoulder, it is important to opt for a healthy lifestyle to prevent this disorder.