Calcific tendonitis of the shoulder: treatment, causes and recovery

Most people start with non-operative treatment. The Whittington Health leaflet lists non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, physical therapy, stretching and strengthening, and steroid injections. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust likewise tells patients to take painkillers as prescribed during the very painful early stage, and says steroid injections can be used to settle pain if required.

If these do not work, there are more specialised options. The Whittington leaflet describes extracorporeal shock-wave therapy (a non-invasive sound-wave treatment) and ultrasound-guided needle lavage or needle barbotage, procedures that flush the joint or help remove calcium crystals. For some people, surgical decompression of the calcium deposits is an option.

NHS Borders' referral guidance for GPs says people should usually be referred to orthopaedics only after primary care management has failed. It describes primary care treatment as physiotherapy rehabilitation with strengthening over 6 months, up to two or three corticosteroid injections if a suitably trained provider is available, and activity modification.

The Doncaster leaflet says painful deposits will often resolve spontaneously after a period of one to six weeks, although the early stage can be very painful. The Whittington leaflet says that most of the time calcific tendonitis can be addressed and resolved quickly, and that regular checks with a healthcare provider are essential, particularly if you have had it before.

Recovery from surgery is longer. Whittington Health says that in most cases recovery after surgery takes about six weeks, and you may need a sling to keep the shoulder from moving too much. The NHS general shoulder pain page adds that it can take 6 months or longer to recover from shoulder pain overall.

The cause is not fully understood. The Whittington leaflet says ageing and wear and tear can eventually lead to calcific tendonitis, that healthcare experts are not sure why some people develop it and others do not, and that it is not associated with any particular activity.

It can happen anywhere in the body, but most often affects the shoulder or rotator cuff. People between the ages of 30 and 60 have a higher risk, and women are slightly more likely to be affected than men.

According to the Whittington leaflet, people may develop several different symptoms. NHS Borders adds that the pattern depends on the stage of the disease and the size and location of the deposit, and may resemble impingement, a persistent ache, or severe pain, tenderness and stiffness similar to an acute painful frozen shoulder.

• Sudden shoulder pain or stiffness.

• Intense pain with shoulder movement.

• Severe pain that disrupts sleep.

• Reduced range of motion.

• Tenderness over the rotator cuff.

A physiotherapist can diagnose shoulder impingement syndrome from the clinical picture, but Whittington Health states that a clinical assessment alone cannot reliably diagnose calcific tendinopathy. A diagnostic ultrasound scan is needed for a full and accurate diagnosis, which matters because it allows the right treatment to be chosen.

NHS Borders' guidance says calcium may be seen on X-rays, ideally using three views, and that ultrasound is the most useful scan because it lets the rotator cuff be assessed in three dimensions and in motion. It also helps to tell true calcific deposits from degenerative calcification, which is commonly seen on scans of the rotator cuff.

Other shoulder conditions can cause similar pain. The Whittington leaflet lists acromioclavicular joint osteoarthritis, frozen shoulder, shoulder impingement, rotator cuff pain, sub-acromial bursitis and shoulder joint osteoarthritis. It also compares calcific tendinopathy with frozen shoulder, as in the table.

The Doncaster leaflet says you may use the arm in the meantime and that it is important to keep the shoulder moving to prevent stiffness, without aggravating it. It says to use a sling, if provided, for comfort only and to wean off it as soon as possible, and that sleeping propped up with pillows may be more comfortable. The leaflet also gives staged exercises, starting with elbow, hand and posture exercises and gentle pendulum swings, then assisted movements from about 3 weeks and active movements from about 6 weeks.

The NHS general advice for shoulder pain is to stay active and gently move your shoulder, use pain relief such as paracetamol and ibuprofen, and use heat or cold packs for up to 20 minutes at a time. Do not completely stop using the shoulder, as this can stop it getting better.

The NHS says to see a GP if shoulder pain is getting worse or does not improve after 2 weeks, or if it is very difficult to move your arm or shoulder. Ask for an urgent GP appointment or get help from NHS 111 if you have sudden or very bad shoulder pain, cannot move your arm, the shoulder has changed shape or is badly swollen, pins and needles do not go away, the arm or shoulder is hot or cold to touch, the pain started after an injury such as a fall, or you feel feverish or unwell. The NHS says these can be signs of something serious, such as a broken or dislocated bone.

NHS Borders lists worsening symptoms after an injection, or suspicion of infection, as reasons for urgent referral. Seek advice promptly if symptoms worsen after an injection or you think it may be infected.

In many areas you can refer yourself to an NHS community musculoskeletal (MSK) service for physiotherapy without seeing a GP first. The NHS notes that waiting times for NHS physiotherapy can be long and that physiotherapy is also available privately.

Scans, injections and shock-wave therapy may be offered through NHS orthopaedic and MSK services or privately. Whichever you use, ask what the plan is if pain does not settle, and how the scan result will be shared with your GP.