Calcific Tendinitis of the Shoulder
Calcific tendinitis affects the rotator cuff tendons, especially the supraspinatus tendon. It causes severe pain, especially at night. It also limits the range of motion in the joint. Treatment may be medical (injections, lavage, physical therapy/rehabilitation) or surgical (arthroscopic removal of the deposits).
- Video of the procedure
- Description & progression
- Surgical indication
- Preparing for surgery
- Hospital stay & procedure
- After the surgery
- Potential complications
Calcific tendinitis of the rotator cuff tendons (calcification of the shoulder) is a common and very painful shoulder problem that affects mainly young women between the ages of 25 and 50. It may affect just one shoulder or both. The pain is caused by deposits of calcium inside one of more of the rotator cuff tendons. The tendon most commonly affected is the supraspinatus. The pain is severe and happens mainly at night. It can also affect everyday life as it makes it difficult to raise the arms.
The deposits may stay the same size or they may grow, piercing the tendon and getting resorbed into the subacromial space (between the tendon and the acromion). This resorption is actually part of the natural healing process, although the calcium in the subacromial space triggers an extremely painful inflammatory reaction that lasts 48–72 hours. The pain is so acute that it may require morphine and force patients to seek emergency treatment.
The time to spontaneous resorption varies from a few days to several years, but there is no way of predicting how long it will take. If the pain becomes too crippling, medical treatment maybe offered:
- Steroid injections into the subacromial space, combined with physiotherapy.
- X-ray-guided aspiration, lavage and injections. This is done by a radiologist who inserts a needle into the deposits, guided by x-ray images. As much calcium as possible is then aspirated from the space. This is followed by an injection of steroids to reduce any inflammatory reaction after the procedure.
Neither of these two procedures is 100% effective, especially when the calcification is extensive.
If necessary, Dr Lévy may offer to remove the remaining deposits arthroscopically.
If the deposits are too large, he may also suggest open surgery.
There are two surgical indications:
- Failure of correctly-applied medical treatment
- Calcium deposits are too large for medical treatment
SURGICAL CONSULTATION :
The aim of the preoperative consultation with the surgeon is to establish a diagnosis. Dr Lévy will examine the shoulder to determine which tendon or tendons are affected. This involves a comprehensive examination to test the tendons one by one and identify which ones are affected by the calcification.
X-rays can be used to confirm the size and number of the deposits. He will also use MRI images to make sure there are no torn tendons, and determine the extent to which the acromion is impinging on the rotator cuff. This information will be used to plan the surgery. Dr Lévy will explain what will happen during and after the surgery, as well as any potential complications. This will include advice on the length of remission and when you can resume any sports.
If the shoulder is stiff, you may be offered a few sessions of physiotherapy to loosen the joint and prepare the shoulder for the surgery.
Once the indications have been confirmed, one of Dr Lévy’s assistants will give you an appointment with the anaesthetist who will look after you during the surgery. The anaesthetist will examine you and prescribe any additional tests that may be needed before the surgery. He or she will also explain how the anaesthesia works. The procedure is always performed under general anaesthesia, together with locoregional anaesthesia to minimise any postoperative pain.
It is essential to stop smoking one month before and after the surgery. This is because a mass influx of nicotine reduces blood flow, slows down the healing process and makes it harder for the tendons to recover. You may use extended-release nicotine patches to help with the withdrawal symptoms.
The surgery will be performed as an outpatient procedure. It usually takes about 30 minutes.
The procedure begins with subacromial decompression, which involves shaving off the bony spur on the end of the acromion causing the impingement with the tendon. This is done arthroscopically, which means the surgeon does not fully open the joint but instead accesses the space using tiny incisions less than 1cm wide.
Arthroscopy means none of the anatomic structures are affected, and he can access the joint without causing any trauma to the muscles or ligaments. There are many proven benefits of this technique over traditional “open” surgery:
– Little or no visible scarring
– No muscle damage
– Faster functional recovery
– Little or no bleeding
– Less risk of infection.
Two-three tiny incisions will be made around the shoulder, each measuring 5–10mm. An arthroscope (tiny camera) is inserted into one of the incisions so that the surgeon can look at the whole joint, and in particular check there are no torn tendons. Very small instruments are then inserted into the other incisions to perform the surgery. During the procedure, the surgeon will check the long head of biceps tendon, the tendon that passes over the shoulder joint. The shoulder does not depend on this tendon for movement, but it can cause severe pain if it is damaged. Dr Lévy then decides whether to perform a tenotomy (careful cutting of the tendon) to alleviate the pain but without affecting the function of the shoulder.
Removal of the calcium deposits can now begin. The video below demonstrates the different stages of the procedure.
The surgeon inserts a needle into the tendon and uses it as a probe to determine where the deposit is located. The calcification can often be seen through the transparent tendon. Once the deposit has been located, he uses a scalpel to make a tiny nick in the direction of the tendon fibres, creating an outlet for the deposits. Using a hook or a curette, Dr Lévy then dislodges the deposits from the tendon. The calcium moves into the subacromial space, where it is then sucked up using another instrument to avoid it triggering an inflammatory reaction after the surgery. The surgeon then washes the joint thoroughly before closing the incisions.
You should keep your arm in a sling night and day for 2–3 weeks after the surgery. If you are very careful or when taking a shower, you can remove your arm from the sling and hold it against your body. You should not raise the arm or actively move it away from the body. Within a few days you can begin a few exercises by yourself that involve gently swinging the arm in a pendulum movement. Dr Lévy will explain how to do these exercises properly. He will also prescribe you some sessions of strictly passive physiotherapy, from day 10 after the surgery. The sutures are resorbable and should fall out within 15–20 days. You should then massage the scars to prevent any subcutaneous adhesions from forming.
POSTOPERATIVE CHECK-UPS :
30-DAY CHECK-UP :
By the time you attend this first check-up, the majority of patients say that the spontaneous night-time pain has disappeared. You should still avoid sleeping on the shoulder, but sleep on your back or on your other side. This appointment is the last time you will need to wear the sling. Dr Lévy will make sure the wounds are healing well and check your passive movement. You will have an x-ray to check the calcium deposits have gone and that the tip of the acromion was cleanly removed. At this point the surgeon will decide whether you can begin active assisted physiotherapy, and increase your passive then active range of motion, depending on the pain. You must continue to massage the scars to prevent any subcutaneous adhesions from forming.
4-MONTH CHECK-UP :
At this appointment, Dr Lévy will check the range of motion in all sectors of mobility. It should have increased since the last appointment. By now, the shoulder will usually have recovered its normal range of motion. The scars should be soft and you can finally sleep on this side. He will prescribe you further physiotherapy to strengthen the muscles and continue improving your passive range of motion. You will also be shown some exercises that you can do at home every day to stretch the joint.
6-MONTH CHECK-UP :
By now the shoulder should be supple and pain-free. You can resume any sports, but should not force the shoulder in case of any residual pain.
A wide range of complications can occur with surgery. Fortunately, they are very rare and the various appointments before and after the surgery are designed to avoid them, or detect them early if they do appear.
As well as the risks common to all types of surgery and the risks of the anaesthesia, there are some specific risks associated with this procedure.
The following complications may occur with surgery to treat calcific tendinitis of the shoulder :
SURGICAL WOUND INFECTION :
Despite all the precautions taken by the operating team, bacteria may still enter the wound either during the surgery or afterwards, before it is fully healed. Signs and symptoms of an infection are compromised healing with severe pain, more redness around the wound than normal, a purulent discharge and a persistent fever.
You must tell the surgeon if you see any of these signs and seek emergency treatment.
COMPLEX REGIONAL PAIN SYNDROME :
Complex Regional Pain Syndrome, also known as algodystrophy, is a condition involving pain and other symptoms usually in a limb following trauma or surgery, even if only minor. The syndrome may have a neurological cause such as damage to the peripheral nervous system, affecting either the small fibres which protect from pain or heat stimuli, and/or the large fibres which detect tactile stimuli. It causes pain and severe stiffness that can last for up to 18 months. Patients always recover fully. Dr Lévy will diagnose the condition using scintigraphy (a scan) and will support you throughout, in order to treat the painful and unpleasant symptoms.
This list does not cover all the possible risks.
Ask Dr Lévy if you want more information, especially if you have any questions about your particular situation and the advantages, disadvantages and risk/benefit ratio of each procedure.