|
Synonyms
Tendonitis calcarea, shoulder calcium, calcification deposit in the shoulder joint, shoulder calcification,
Definition
Tendinitis calcarea deals with a malady in the region of the shoulder tendons, especially in the region of the Supraspinatus tendon, but sometimes also at the insertions of other tendons of the rotator cuff. The term rotator cuff is a general designation for the muscles that participate in rotating the shoulder. Within the scope of Tendonosis calcarea with very acute, inflammatory complaints, also called Tendinitis calcarea, reactive calcium deposits occur at the sites of tendon insertions due to a reduced perfusion of the rotator cuff. These calcium deposits can be recognized on the basis of an X-ray image; thus, they can be diagnosed relatively easily.
Cause and development
As already briefly mentioned above, a reduced perfusion of the rotator cuff is regarded to be the cause of Tendinitis calcarea. Thus, an increased pressure occurs in the region of the tendon tissues, whereby the oxygen partial pressure is reduced.
In a comparison between sexes, one can determine that females suffer more than males from this malady.
Often Tendinitis calcarea is diagnosed by chance, since it has a rather painless course of development. Perhaps many patients have a „calcified shoulder“, without leading to any complaints. The course of illness and the development of Tendinitis calcarea can be divided into individual phases. On the basis of the phasiform course of the illness, acute pains normally occur in intermittent attacks. The duration of an illness phase differs from patient to patient and it cannot be predicted. Phases of inflammatory shoulder pain revert to phases that are nearly completely pain-free. One differentiates four phases of Tendinitis calcarea:
1st Phase: Phase of the cellular conversion:
Within the first phase, a cellular conversion occurs. Thereby, the tendon tissue is converted to fibrous cartilage. The patient usually experiences very slight pain or none at all. This phase cannot be diagnosed yet by an X-ray, since a calcification has not yet taken place.
2nd Phase: Phase of calcification:
Within the second phase, the fibrous cartilage perishes partially and calcium is deposited. This phase can be diagnosed ultrasonically, but also by means of X-ray examinations. If the shoulder tendon is very elevated by the calcium deposit, it can lead to a constriction of the shoulder tip upon raising the arm. This, in turn, leads to an irritation of the tendons that pass under the shoulder tip, especially the Supraspinatus tendon as well as the bursa of the shoulder tip (Bursa subacromialis). Thus, the painful clinical picture of an impingement syndrome can be created.
3rd Phase: Phase of the reabsorption:
This phase is indicated by the reabsorption (resolution) of the calcium deposit. The process of the calcium resolution is linked to an intensive inflammatory reaction, which can cause significant pain. In addition, individual calcium deposits extend into the bursa of the shoulder tip (Bursa subacromialis) and they cause an inflammation of the bursa there (bursitis).
4th Phase: Phase of repair:
The calcium deposit has been significantly reduced and it no longer can be demonstrated by ultrasonic or X-ray diagnosis. The tendon tissue recovers.
Not every Tendinitis calcarea illness runs completely through this cycle. Tendinitis calcarea can persist in each stage of the illness and eventually not reach the next stage at all.
However, if a calcium deposit has once been resolved, then a reoccurrence of calcium deposits (relapse) is extremely rare.
Symptoms
The complaints of a patient with Tendinitis calcarea can vary considerably. This depends primarily on the size of the calcium deposit and the stage of the illness.
Large calcium deposits can therefore cause affected tendons to impact under the shoulder tip, especially when raising the arm sideways (abduction).
The patient experiences acute inflammation pain during the resolution of the calcium deposit or if the calcium deposit has penetrated the bursa beneath the shoulder tip. The sharp, crystalline calcium structures lead to intensive inflammation of the bursa with very significant pains. The following can accompany the clinical picture:
- Pain when lying on the affected shoulder
- Shoulder pain with stress
- Pains when performing work above the head
- Shoulder pain that suddenly occurs (without any accident)
- Inability to move the arm (pseudo-palsy/ pseudo-paralysis).
Diagnosis
Ultrasonic
As soon as calcification has occurred, it can be demonstrated ultrasonically. The calcium deposit leads to a sonic obliteration behind it, which can be detected. An advantage with the ultrasonic examination is the determination of the exact site of the calcium deposit, which facilitates the localization of the calcium deposit when a surgical procedure is planned.
X-ray
As soon as calcification has occurred, it can be demonstrated by an X-ray image. Thereby, calcifications can normally be seen easily. However, limitations exist with regard to the exact location of the calcium deposit.
Magnetic resonance imaging (MRI)
The MRI does not have any significance for the diagnosis of Tendinitis calcarea. The calcium deposit is poorly demonstrated, whereby confusion with a lesion of the rotator cuff (rotator cuff rupture) can readily occur.
Therapy
One cannot express a general opinion about the individual course of the illness. While some patients “sit out” the malady during the course of the body’s own self-healing process, a surgical treatment is required for other patients, especially those who suffer under severe pain and whose calcium deposits are larger than 1 cm and which have a hard consistency. Since one attributes a high tendency of spontaneous healing to this malady, surgery is usually quite rare.
Within the scope of surgery, the calcium deposits will be removed and the region of the shoulder tip (subacromial area) is extended for the shoulder tendons.
Conservative therapy
Within the scope of an acute inflammation of the bursa and thus with severe pain, the arm can be relieved temporarily with a shoulder orthesis (a type of bandage). The administration of analgesics (=painkilling medicines) and NSAR (=Non Steroid Anti Rheumatics), which act as strong anti-inflammatory agents, reduce the pains. Cooling of the shoulder (cryotherapy) relieves pain and also reduces the inflammatory processes. A rapid pain reduction can be achieved by injecting a mild narcotic, as needed, with an additional cortisone supplement. The mixture should be injected from the side or from the back beneath the shoulder tip (subacromial infiltration). The local narcotic provides an immediate pain-reliving effect, while the cortisone, which represents the most potent anti-inflammatory medicine, provides pain relief even after the narcotic effect has worn off. Since cortisone permits the blood sugar level to increase greatly, diabetes patients (Diabetes mellitus) must adjust their insulin demand accordingly and control the blood sugar level more frequently.
As soon as the pain has subsided, physical therapy (physiotherapy) should be begun. The goals of the physical therapy are a relief of the shoulder tendons beneath the shoulder tip as well as retention of the mobility of the shoulder joint. The shoulder joint is the body joint, which tends towards a lasting stiffness when confronted with a limitation of mobility that is caused by pain or by other, persistent immobility due to a capsular attrition.
Through a shock wave therapy (ESWT – Extracorporeal Shock Wave Therapy), a pain reduction can be achieved. It is based on the physical principle of a high pressure impulse in the form of an acoustic wave. The calcium deposit is “shot” with this acoustic wave. In addition, it is possible to partially activate biological processes, which lead to a resolution of the calcium deposits. The effect of the shock wave therapy is difficult to predict. In order to achieve an effect on the calcium deposit, a focused shock wave should be performed. Several studies have demonstrated the successful application of the ESWT for treatment of Tendonitis calcarea. Up to 30-70% of cases yielded good to excellent results (patient satisfaction).
Surgical therapy
For patients, who suffer under persistent, severe pains, and whose calcium deposits are larger than 1 cm and which indicate a hard consistency, surgical treatment can be required. However, since one has attributed a high tendency of spontaneous healing to Tendonitis calcarea, the indication for an operation should be taken rather conservatively.
Within the scope of an operation, the calcium deposits will be removed and the subacromial area will be extended.
Normally, the surgical procedure is minimally invasive, i.e. endoscopically. An arthroscopy describes the observation (endoscopy) of a joint by introducing an endoscope via a very small incision (0.5-1 cm). By means of special instruments, a treatment of damaged joint structures can also occur during the endoscopical examination.
According to the endoscopy of the shoulder joint, especially by which additional damage can eventually be diagnosed (shoulder arthrosis, rotator cuff rupture), an extension of the shoulder tip region usually is made by conservative bone ablation from the under surface of the Acromion (subacromial decompression). Hereby the bursa of the shoulder tip will also be removed. As soon as the calcium deposit site has been located, it can be removed.
The removal of the calcium deposit can also be made via a normal, open surgery (that is not less invasive). Then the operation occurs via a small skin incision of approximately 3 cm.
After a surgical procedure, the shoulder should be treated gently for an interval of approximately 3 weeks. Usually, the postoperative care occurs in connection with anti-inflammatory and pain-killing medicine. Physical therapeutic exercises should retain the mobility of the shoulder. .
| 
