What is Rotator Cuff Calcification?
It is a poorly understood condition which is often referred to as Rotator Cuff Calcinosis. It is characterised by the development of calcium deposit or deposits within the substance of the rotator cuff tendons. The calcium causes a localised swelling within the tendon. The swollen part of the tendon may then have difficulty passing under the acromion with movement of the shoulder. This will then result in Shoulder Impingement. It may result in low grade through to extremely severe pain.
Natural History of Rotator Cuff Calcification
The cause of this condition is uncertain. It usually arises gradually over weeks and months. However in some cases it begins suddenly, sometimes almost overnight. Some patients recall a preceding incident, often quite trivial in nature.
When the calcium appears slowly the associated pain can gradually increase as the size of the calcium deposit increases. These slow on-set cases may reach a plateau in pain severity. The calcium may then very slowly dissolve away into the tissues, the tendon swelling decreases and the shoulder impingement pain resolves. However in some patients the calcium does not dissolve and the thickening of the tendon persists. The calcium in the slow on-set cases tends to be chalky or putty-like in consistency. It is not possible to predict which group a patient belongs to. That may only become apparent with observation and serial X-rays over a period of time.
Sudden onset cases of calcification are typically severely painful. A patient might go to bed with some vague shoulder soreness and wake next morning with excruciating pain. The calcium in these cases is typically semi-liquid or toothpaste-like in consistency. It can be under extreme pressure. This might explain why the calcium sometimes bursts out of the tendon and a gradual recovery follows. But in a minority of patients severe pain persists and intervention is required.
Diagnosis of Rotator Cuff Calcification
The description of the pain symptoms and clinical examination may help.
Gradual On-set Type:
- Symptoms may be no different to other causes of Shoulder Impingement
- There is often a very localised area of tenderness at the top of the shoulder
- If the area of calcium is large enough it may be felt with gentle finger pressure
Sudden On-set Type:
- The rapid onset of excruciating pain with no obvious cause is typical
- The calcified area can be exquisitely tender to touch
- X-rays, Ultrasound or an MRI Scan will confirm the diagnosis.
Treatment of Rotator Cuff Calcification
Some cases recover with non-surgical treatment. If the pain is not disabling the patient may require some activity modification, analgesics or anti-inflammatories while the behaviour of the condition is observed over time. Many patients recover spontaneously.
If symptoms are not settling, serial X-rays may help to understand whether the calcium is dissolving away. If no trend towards improvement is observed the balance may swing towards a surgery. This would involve a decompression of the rotator cuff tendons, removal of the calcium and patching the resultant defect in the rotator cuff. Mr Lyons does not find attempting to draw the calcium off with a needle helpful. The calcium in these slow onset cases is usually too firm or hard for the syringe and needle to remove.
When the calcium has built up very suddenly and associated with severe pain the material tend to be more liquid in nature. It may build up to such pressure that the calcium bursts out of the tendon and the pain gradually resolves. If this does not occur a surgery to remove the calcium and relieve the severe pain may be require as a matter of urgency.