Arthroscopic Decompression of Calcific Tendinitis of the Shoulder and Repair of Residual Rotator Cuff Defect

Abstract

Background:

Calcific tendinitis is a common source of shoulder pain and represents pathologic deposition of calcium hydroxyapatite within rotator cuff tendon tissue, most commonly the supraspinatus tendon.

Indications:

Arthroscopic decompression of calcific tendinitis with possible rotator cuff repair is indicated in patients with persistent, debilitating symptoms of pain and/or dysfunction who are recalcitrant to nonoperative treatments, including corticosteroid administration, ultrasound-guided needle barbotage, and/or extracorporeal shockwave therapy.

Technique Description:

With the patient in a beach chair position, a standard diagnostic shoulder arthroscopy is performed to evaluate for concomitant pathologies. Within the subacromial space, a thorough bursectomy is performed and the area of calcium deposition is localized with a spinal needle. A scalpel may be used to create a small incision through the rotator cuff tendon in line with its fibers to promote egress of calcific debris. Surrounding tissue and loose debris are removed with an arthroscopic shaver. Following decompression, the rotator cuff repair is inspected, and if a bursal-sided or full-thickness tear is identified, an arthroscopic repair is performed with a construct individualized to the specific tear pattern.

Results:

Surgical treatment conferred greater functional improvement and comparable pain reduction to nonoperative treatments in a systematic review comprised of 27 randomized trials. While the addition of a rotator cuff repair remains controversial, combined excision of calcific tendinitis with concomitant rotator cuff repair led to greater functional outcomes and pain reduction at 2-year minimum follow-up compared with isolated decompression.

Conclusion:

Calcific tendinitis within the shoulder may be treated successfully with arthroscopic decompression and subsequent repair of a residual rotator cuff defect, followed by a graduated physical rehabilitation program.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

The following is a video presentation describing our surgical technique for arthroscopic decompression of calcific tendinitis within the shoulder and subsequent repair of a residual rotator cuff defect.

The authors’ disclosures are listed here and are available online.

In this video, we will provide a brief overview of calcific tendinitis of the shoulder, review nonoperative and surgical treatment options, discuss a case presentation along with surgical pearls, describe our postoperative management, and review patient-reported outcomes.

Calcific tendinitis of the shoulder is a condition characterized by the presence of calcium hydroxyapatite within the rotator cuff tendon. It is estimated to account for 7% of all clinical presentations of shoulder pain. The presence of calcific densities does not always cause symptoms and has been reported to occur in 5% to 10% of asymptomatic individuals. ¹ Calcium deposition most commonly arises within a hypovascular region of the supraspinatus tendon. The most commonly espoused etiology of calcific tendinitis was described by Uhthoff and Loehr. ⁵ In their theory of reactive calcification, cells within the rotator cuff tendon, or tenocytes, undergo cellular metaplasia and transform into fibrocartilage with accompanying formation of calcium deposits. Calcific tendinitis typically occurs in 3 stages: precalcific, calcific, and resorptive stages. During the resorptive stage, cell-mediated phagocytosis of calcium deposits can generate acute and often severe shoulder pain.

Initial treatment of calcific tendinitis consists of pain control with oral anti-inflammatories and, if presenting with exquisite pain, a corticosteroid injection into the subacromial space. Nonoperative treatment modalities, including extracorporeal shock wave therapy and ultrasound-guided needle barbotage, have shown efficacy in 70% to 80% of cases. ³ Given the effectiveness of nonoperative treatment, surgical treatment is reserved for patients whose symptoms are recalcitrant to at least 3 months of nonoperative treatment. A recent study reported that patients with calcium deposits >1 cm were 2.8 times more likely to undergo surgical treatment, and therefore, inspection of the size of calcific densities on preoperative imaging may provide information for patient counseling. ² Surgery may be performed via open or arthroscopic approaches. Arthroscopy offers a less invasive technique that allows for treatment of concomitant intra-articular pathologies, such as frozen shoulder.

In this case presentation, a 52-year-old right-hand-dominant female presented with 4 months of atraumatic right shoulder pain. She localized her pain to the anterolateral aspect of her shoulder and endorsed increased symptoms with overhead activities. Her physical examination was notable for full active shoulder range of motion in all planes, and full, but painful strength testing against manual resistance of the supraspinatus. She had no tenderness over her bicipital groove or acromioclavicular joint and she was neurovascularly intact throughout her right upper extremity.

On standard shoulder radiographs, a calcific density measuring approximately 12 mm in the coronal plane was visualized adjacent to the greater tuberosity at the presumed site of the distal supraspinatus tendinous insertion.

Magnetic resonance imaging of the right shoulder revealed the presence of intratendinous hypointense signal within the supraspinatus tendon, consistent with calcium hydroxyapatite deposition. No discrete rotator cuff tear was appreciated.

At her initial office visit, the patient was administered a subacromial space corticosteroid injection and prescribed a 6-week course of physical therapy rehabilitation. On follow-up visit 6 weeks later, the patient reported mildly improved symptoms, but persistent pain that interfered with her quality of life. She subsequently underwent an ultrasound-guided needle barbotage procedure, which did not confer meaningful resolution of her symptoms. After a comprehensive discussion of nonoperative and operative treatment options, the patient elected to proceed with an arthroscopic decompression of calcific tendinitis, subacromial decompression, and possible rotator cuff repair.

In the operating room, the patient was placed in the beach chair position. After standard sterile preparation and draping, a diagnostic shoulder arthroscopy was performed with a posterior viewing portal and anterior working portal. Intra-articular assessment did not demonstrate any evidence of adhesive capsulitis, consistent with the patient's full passive range of motion during examination under anesthesia. In patients with concomitant frozen shoulder, an arthroscopic capsular release may be performed at this stage. The articular side of the rotator cuff tendons appeared intact.

The arthroscope was then moved to the subacromial space, which revealed extensive subacromial bursitis. A thorough subacromial bursectomy was performed with a 4.0-mm arthroscopic shaver and radiofrequency ablator passed through a lateral portal. Next, the site of calcium deposition was localized with an 18-gauge spinal needle. Identifying the precise areas of calcification can be a clinical challenge, particularly for smaller and/or multiple lesions. Hyperemic areas along the bursal surface of the rotator cuff may denote the presence of underlying calcium. An arthroscopic probe can provide additional tactile feedback to aid in localization. Extravasation of calcium with a toothpaste-like appearance, as in this case, is consistent with calcific tendinitis in its acute or resorptive phase. In contrast, chronic calcific tendinitis will demonstrate a chalk-like appearance arthroscopically, as depicted in this photo obtained from a different patient. An 11-blade scalpel was inserted through the lateral portal to make a small incision in line with the rotator cuff overlying the site of calcium deposition to facilitate egress of calcium. A probe or the arthroscopic shaver itself may be used to manually express additional calcium. Note that it is unnecessary to excise 100% of visualized calcific densities. Residual loose calcific debris was lavaged thoroughly with arthroscopic fluid suctioned through an arthroscopic shaver. Following this step, the residual bursal-sided defect in the supraspinatus tendon was inspected. In a recent analysis of 239 patients who underwent arthroscopic treatment for recalcitrant calcific tendinitis, Drummond et al ² reported that 83% of patients required a concomitant rotator cuff repair. Given the remaining defect, we proceeded with rotator cuff repair. For this delaminated, bursal-sided tear of the supraspinatus, 2 high tensile-strength nonabsorbable sutures were passed in an inverted horizontal mattress fashion through the edge of the torn tendon. Sutures were fixed into a single lateral row knotless suture anchor placed on the lateral aspect of the greater tuberosity. The repair was visualized with appropriate suture tensioning and balanced apposition of tendon to the greater tuberosity footprint.

The authors highlight the following pearls and pitfalls pertaining to this procedure:

1. An 18-gauge spinal needle can aid localization of calcific tendinitis with minimal trauma to surrounding tissue by puncturing the rotator cuff and evaluating for egress of calcific debris.

2. An 11-blade scalpel may be used to make a small incision in line with rotator cuff fibers to facilitate decompression of calcium deposits.

3. Care must be taken to avoid overaggressive debridement of native rotator cuff tissue. The surgical goal is to decompress the area of calcium deposition, rather than achieve complete evacuation of all calcific debris.

Postoperatively, the patient was immobilized in a shoulder abduction brace for 4 weeks. Passive range of motion was initiated 10 to 14 days postoperatively, followed by active-assisted range of motion exercises at 3 to 4 weeks postoperatively. Active range of motion commences at 6 weeks with a goal of full active range of motion at 12 weeks postoperatively. Strengthening exercises are introduced gradually at approximately 3 months postoperatively. Patients are typically permitted to resume all recreational activities by 6 months postoperatively.

Recent literature has highlighted the benefits of surgical intervention for calcific tendinitis. A 2023 systematic review of 27 randomized trials comparing nonoperative and operative treatment for calcific tendinitis of the shoulder demonstrated that surgical treatment conferred greater functional improvement and comparable pain reduction to nonoperative treatments. ¹

The additional benefit of concomitant rotator cuff repair with decompression of calcific tendinitis remains controversial. In a 2022 cohort study of 47 patients, Pang et al ⁴ demonstrated that a combined excision of calcific tendinitis with concomitant rotator cuff repair resulted in greater functional outcomes and pain reduction at 2-year minimum follow-up compared with isolated decompression.

At 3 months postoperatively, the patient reported her shoulder pain had now resolved without requiring pain medications. She had returned to activities of daily living without discomfort. Her physical examination demonstrated 160° of active forward flexion, 120° of abduction, and 45° of external rotation without pain. Rotator cuff strength was intact to manual resistance testing.

Radiographs performed in this patient at 3 months postoperatively show interval resolution of previously demonstrated calcium deposits overlying the greater tuberosity.

In conclusion, calcific tendinitis within the shoulder may be treated successfully with arthroscopic decompression and subsequent repair of a residual rotator cuff defect, followed by a graduated physical rehabilitation program. Here are our references. Thank you for your attention.