Calcific Tendonitis: Well, I Would Manage This Shoulder Pain
Key Takeaway
Here are the crucial details you must know about Calcific Tendonitis: Well, I Would Manage This Shoulder Pain. For chronic calcific tendonitis causing shoulder impingement, initial treatment often involves subacromial steroid injections to reduce bursitis. However, if symptoms are persistent or long-standing, well I would consider arthroscopic excision of the calcium deposits. This surgical approach directly removes the calcification, aiming to alleviate pain and restore function, especially for active individuals like golfers seeking to resume overhead activities without discomfort.
This is a radiograph of a 63-year-old gentleman’s right shoulder. He complains of gradual onset pain over the last 2 years, worse with overhead activities. Proceed with your assessment.
Candidate: I see an AP radiograph of the right shoulder showing a normal glenohumeral and AC joint. I note sclerosis on the undersurface of the acromion and amorphous calcium deposits in the supraspinatus tendon. Given the patient's age and the chronic duration (2 years), this is likely chronic degenerative calcific tendinopathy with associated subacromial impingement, rather than acute calcific tendonitis. I would like to see an axillary view to assess for posterior subluxation, and I would request an ultrasound to confirm the integrity of the rotator cuff.
Candidates often label this as "acute calcific tendonitis" and propose surgical excision immediately. They fail to interpret the chronic nature (2-year history) or recognize that the calcium is a chronic, degenerative finding. Missing the distinction between symptomatic impingement and the presence of incidental calcium is a common reason for failing this station.
A structured response: (1) Radiographic description (acromial morphology and site of calcification). (2) Differential diagnosis highlighting the chronic nature of the pathology. (3) Justifying management based on impingement symptoms rather than the calcium itself. (4) Prioritizing conservative treatment (subacromial injection as a diagnostic tool) to confirm the source of pain before surgical intervention.
The patient returns 8 weeks post-subacromial steroid injection. He reports that the pain relief lasted only 3 weeks and he is now back to his baseline pain. How do you manage this?
Candidate: The diagnostic injection provided temporary relief, confirming subacromial impingement as the primary driver of his symptoms. Given the failure of non-operative management (physiotherapy and injection) and his continued functional impairment, I would discuss the option of arthroscopic subacromial decompression (ASD). I would clarify to the patient that the goal is to treat the impingement; I would not specifically target the calcium deposit for excision unless it was causing mechanical symptoms or failing conservative management.
Candidates often suggest "arthroscopic removal of the calcium." The examiner will then ask why you are removing it if the patient has had it for 2 years without issue. A failing candidate struggles to justify why they are abandoning the calcium, whereas the gold standard identifies the impingement as the primary indication for surgery.
State that the transient relief from the injection validates the clinical diagnosis of subacromial impingement. Proceed to discuss surgical indications clearly: failure of a structured 3-6 month physiotherapy program. Emphasize that the impingement is the pathology being treated, and prophylactic excision of chronic degenerative calcification is not standard practice.
