Calcific Tendinitis
What is calcific tendinitis?
Calcific tendinitis is a condition in which calcium deposits form within a tendon — most commonly the supraspinatus tendon of the rotator cuff in the shoulder — causing pain that ranges from a persistent dull ache through to one of the most acutely severe pain experiences in musculoskeletal medicine. During the acute resorptive phase, when the calcium deposit is breaking down and being reabsorbed by the body, the resulting chemical and mechanical irritation of the surrounding tissue can produce sudden onset, excruciating shoulder pain that feels quite out of proportion to what patients expect from a tendon problem.
It is far more common than most people realise — estimates suggest calcific tendinitis affects three to eight percent of the adult population, with the majority of deposits occurring in the supraspinatus tendon. It predominantly affects women between the ages of 30 and 60, though it can occur at any age in either sex.
What causes calcium deposits in tendons?
The exact mechanism is not fully understood, but the current evidence points to a process of cell-mediated calcification — where areas of tendon tissue with poor blood supply or previous micro-damage undergo a transformation in which specialised cells deposit calcium hydroxyapatite crystals within the tendon substance. This is distinct from the calcium deposits that form in arthritic joints, and from the bony spurs that form at tendon attachments.
The condition typically progresses through recognisable phases. In the formative phase, calcium is deposited within the tendon and the patient may have mild to moderate pain or no symptoms at all — this is often when calcific tendinitis is incidentally discovered on imaging done for another reason. In the resting phase the deposit sits quietly. In the resorptive phase — which can be triggered spontaneously, by activity, or by treatment — the deposit begins to break down, releasing a chalky fluid into the surrounding tissue and triggering an intense inflammatory response. This is the phase associated with the severe acute pain that drives many patients to emergency departments or urgent care. After resorption the deposit typically shrinks significantly or disappears entirely, and most patients experience substantial relief.
What are the symptoms?
The symptom experience varies dramatically depending on the phase. In the formative and resting phases, symptoms may range from nothing at all through to a moderate, activity-related aching in the shoulder — similar to shoulder impingement or rotator cuff tendinopathy. In the acute resorptive phase, the onset of pain is often sudden — sometimes waking patients from sleep — and the intensity is frequently described as the worst pain the person has experienced. The shoulder is exquisitely tender, movement is severely limited and even the weight of the arm can be unbearable. This phase typically lasts days to a few weeks before beginning to resolve.
Between acute episodes, many patients experience a chronic low-grade aching that limits overhead activity, lying on the affected side, and sustained arm use.
How is it diagnosed?
Plain X-ray is usually sufficient to identify calcific deposits in the shoulder — the calcium appears as a bright white opacity overlying the rotator cuff on the X-ray. Ultrasound provides more detailed information about the deposit's characteristics, its relationship to the surrounding structures, and whether it is in a formative or resorptive phase — the consistency of the deposit (hard, soft or fluid) affects both the natural history and the response to treatment. MRI may be used to assess the surrounding rotator cuff for co-existing pathology such as partial or full-thickness rotator cuff tears.
How can physiotherapy help?
The natural history of calcific tendinitis is broadly favourable — the majority of deposits eventually resorb spontaneously, and most patients achieve significant pain relief without surgery. The challenge is managing symptoms through the process, which can take months to years, and addressing the underlying shoulder mechanics that may have contributed to the development of the condition.
In the acute phase, physiotherapy focuses on pain management — appropriate activity modification, positioning advice to reduce pain at rest and during sleep, and gentle range-of-motion exercises within comfortable limits to prevent the shoulder stiffness that can develop rapidly when a painful shoulder is not moved. Anti-inflammatory strategies coordinated with your GP may also be relevant during this phase.
As the acute phase settles, physiotherapy shifts toward restoring full range of motion, rebuilding rotator cuff and periscapular strength, and correcting any biomechanical factors — poor scapular control, rounded posture, rotator cuff weakness — that increase impingement load on the supraspinatus tendon. This work matters both for symptom management and for reducing the risk of recurrence.
Dry needling of the surrounding musculature can assist with pain management and muscle relaxation in the shoulder region. Real time ultrasound guided needling of the calcific deposit itself — barbotage — is a more specialised intervention performed by some practitioners that can accelerate resorption, though this falls outside standard physiotherapy scope and would be performed by an appropriately qualified medical practitioner or radiologist.
For patients who do not respond to conservative management and whose symptoms are significantly affecting quality of life, referral for consideration of ultrasound-guided aspiration, corticosteroid injection, extracorporeal shockwave therapy or surgical removal of the deposit may be appropriate. Physiotherapy plays an important role in optimising shoulder function both before and after any of these interventions.
Clinical Pilates integrates well into the rehabilitation phase, providing a controlled environment for rotator cuff and periscapular strengthening in positions that minimise impingement load on the healing tendon.
Our physiotherapists Bethany Kippen and Emma Cameron both have experience in shoulder rehabilitation and rotator cuff conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Calcific tendinitis is a condition in which calcium deposits form within a tendon — most commonly the supraspinatus tendon of the rotator cuff in the shoulder — causing pain that ranges from a persistent dull ache through to one of the most acutely severe pain experiences in musculoskeletal medicine. During the acute resorptive phase, when the calcium deposit is breaking down and being reabsorbed by the body, the resulting chemical and mechanical irritation of the surrounding tissue can produce sudden onset, excruciating shoulder pain that feels quite out of proportion to what patients expect from a tendon problem.
It is far more common than most people realise — estimates suggest calcific tendinitis affects three to eight percent of the adult population, with the majority of deposits occurring in the supraspinatus tendon. It predominantly affects women between the ages of 30 and 60, though it can occur at any age in either sex.
What causes calcium deposits in tendons?
The exact mechanism is not fully understood, but the current evidence points to a process of cell-mediated calcification — where areas of tendon tissue with poor blood supply or previous micro-damage undergo a transformation in which specialised cells deposit calcium hydroxyapatite crystals within the tendon substance. This is distinct from the calcium deposits that form in arthritic joints, and from the bony spurs that form at tendon attachments.
The condition typically progresses through recognisable phases. In the formative phase, calcium is deposited within the tendon and the patient may have mild to moderate pain or no symptoms at all — this is often when calcific tendinitis is incidentally discovered on imaging done for another reason. In the resting phase the deposit sits quietly. In the resorptive phase — which can be triggered spontaneously, by activity, or by treatment — the deposit begins to break down, releasing a chalky fluid into the surrounding tissue and triggering an intense inflammatory response. This is the phase associated with the severe acute pain that drives many patients to emergency departments or urgent care. After resorption the deposit typically shrinks significantly or disappears entirely, and most patients experience substantial relief.
What are the symptoms?
The symptom experience varies dramatically depending on the phase. In the formative and resting phases, symptoms may range from nothing at all through to a moderate, activity-related aching in the shoulder — similar to shoulder impingement or rotator cuff tendinopathy. In the acute resorptive phase, the onset of pain is often sudden — sometimes waking patients from sleep — and the intensity is frequently described as the worst pain the person has experienced. The shoulder is exquisitely tender, movement is severely limited and even the weight of the arm can be unbearable. This phase typically lasts days to a few weeks before beginning to resolve.
Between acute episodes, many patients experience a chronic low-grade aching that limits overhead activity, lying on the affected side, and sustained arm use.
How is it diagnosed?
Plain X-ray is usually sufficient to identify calcific deposits in the shoulder — the calcium appears as a bright white opacity overlying the rotator cuff on the X-ray. Ultrasound provides more detailed information about the deposit's characteristics, its relationship to the surrounding structures, and whether it is in a formative or resorptive phase — the consistency of the deposit (hard, soft or fluid) affects both the natural history and the response to treatment. MRI may be used to assess the surrounding rotator cuff for co-existing pathology such as partial or full-thickness rotator cuff tears.
How can physiotherapy help?
The natural history of calcific tendinitis is broadly favourable — the majority of deposits eventually resorb spontaneously, and most patients achieve significant pain relief without surgery. The challenge is managing symptoms through the process, which can take months to years, and addressing the underlying shoulder mechanics that may have contributed to the development of the condition.
In the acute phase, physiotherapy focuses on pain management — appropriate activity modification, positioning advice to reduce pain at rest and during sleep, and gentle range-of-motion exercises within comfortable limits to prevent the shoulder stiffness that can develop rapidly when a painful shoulder is not moved. Anti-inflammatory strategies coordinated with your GP may also be relevant during this phase.
As the acute phase settles, physiotherapy shifts toward restoring full range of motion, rebuilding rotator cuff and periscapular strength, and correcting any biomechanical factors — poor scapular control, rounded posture, rotator cuff weakness — that increase impingement load on the supraspinatus tendon. This work matters both for symptom management and for reducing the risk of recurrence.
Dry needling of the surrounding musculature can assist with pain management and muscle relaxation in the shoulder region. Real time ultrasound guided needling of the calcific deposit itself — barbotage — is a more specialised intervention performed by some practitioners that can accelerate resorption, though this falls outside standard physiotherapy scope and would be performed by an appropriately qualified medical practitioner or radiologist.
For patients who do not respond to conservative management and whose symptoms are significantly affecting quality of life, referral for consideration of ultrasound-guided aspiration, corticosteroid injection, extracorporeal shockwave therapy or surgical removal of the deposit may be appropriate. Physiotherapy plays an important role in optimising shoulder function both before and after any of these interventions.
Clinical Pilates integrates well into the rehabilitation phase, providing a controlled environment for rotator cuff and periscapular strengthening in positions that minimise impingement load on the healing tendon.
Our physiotherapists Bethany Kippen and Emma Cameron both have experience in shoulder rehabilitation and rotator cuff conditions and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
