10/10/2025
💠 Calcific Tendinopathy of the Shoulder: A Physiotherapist’s Guide to Assessment and Evidence-Based Management
Calcific Tendinopathy of the Shoulder (also known as Rotator Cuff Calcific Tendinopathy or RCCT) is a common and often severely painful condition involving the deposition of calcium crystals, primarily in the rotator cuff tendon insertions and the subacromial-subdeltoid bursa.
As physiotherapists, understanding the pathology and optimizing nonoperative management is crucial, as this is typically the first line of treatment.
🩻 Clinical and Pathophysiological Essentials
▪️ RCCT most commonly affects the supraspinatus tendon (involved in about 80% of cases).
▪️ Clinically, patients usually present with atraumatic shoulder pain, which may be acute or chronic, alongside pain during movement that restricts range of motion (ROM).
👥 Key Patient Profile and Risk Factors
▪️ Peak incidence occurs between ages 30 and 60 years.
▪️ Women are reported to be affected twice as often as men.
▪️ Risk factors include occupations requiring prolonged use of the arms in internal rotation and slight abduction (e.g., desk workers, cashiers) or excessive overhead movements.
▪️ It is reported to be associated with metabolic and endocrine conditions, including diabetes mellitus, hypertension, and hypothyroidism.
🔬 Stages of Pathology (Reactive Calcification Hypothesis)
▪️ Precalcific Stage: Fibrocartilaginous tissue forms.
▪️ Calcific Stage (Formative/Resting/Resorptive): Macrophage phagocytosis of deposits begins in the resorptive phase. This phase often brings swelling and acute pain, sometimes presenting with systemic symptoms like fever or malaise.
▪️ Postcalcific Stage: Fibroblasts reconstruct tendon tissue, normally leading to complete tendon healing.
🧠 Assessment Pearls for the Clinician
During the physical examination, patients may localize tenderness over the subacromial space or laterally over the proximal arm, and may hold the shoulder in internal rotation to relieve pain.
🧾 Assessment Strategies
▪️ ROM Assessment: Assess active and passive ROM. Nonoperative management has been shown to improve active ROM in forward flexion and internal rotation.
▪️ Impingement Maneuvers: Pain reported during provocative maneuvers may indicate subacromial impingement, which can be caused by calcific tendinopathy.
▫️ Hawkins test
▫️ Neer test
▫️ Yocum test
▪️ Imaging: While diagnosis is typically confirmed by X-ray, ultrasound is valuable as it can detect more radiolucent calcifications missed by X-ray, and allows for dynamic evaluation of conditions like subacromial impingement.
💪 Physical Therapy: The Cornerstone of Nonoperative Care
Nonoperative management, including physical therapy, is the typical starting point for treatment.
The focus of physical therapy programs should be on regaining range of motion and correcting scapular mechanics.
🏋️ Therapeutic Exercise Regimens
Programs are often similar to those used for subacromial impingement.
Key muscles targeted for therapeutic exercise include:
▪️ Upper, Middle, and Lower Trapezius
▪️ Serratus Anterior
Studies evaluating nonoperative management (including passive stretching and passive ROM exercises) show significant improvements in mean VAS pain scores and Constant/UCLA scores.
However, approximately 36.7% of patients managed with physical therapy may fail treatment and require surgery.
Prognostic indicators suggest that factors such as bilateral occurrence, medial extension, and a high volume of calcific deposits are associated with an increased risk of persistent symptoms.
⚡ Adjunctive Modalities
Physical therapy commonly includes potential adjunctive modalities:
▪️ Iontophoresis
▪️ Deep transverse friction massage
▪️ Laser therapy
▪️ Cryotherapy
While therapeutic ultrasound may help resolve calcifications and offer short-term clinical improvement, studies have shown that resolution of the calcium deposits does not necessarily correlate with long-term symptom status.
🩺 Interventional Considerations and Collaboration
When patients do not respond adequately to NSAIDs and physical therapy, other interventions may be considered.
As physiotherapists, we should be aware of the evidence supporting these modalities:
▪️ Ultrasound-Guided Percutaneous Irrigation of Calcific Tendinopathy (US-PICT):
Also known as barbotage or lavage; involves the aspiration and irrigation of calcific deposits.
Appears to improve pain and function and may reduce the need for surgery compared to other minimally invasive procedures.
▪️ Extracorporeal Shock Wave Therapy (ESWT):
Uses repetitive pulses to break up calcium deposits.
May be associated with reduced pain and improved function at 3–6 months compared to sham treatments.
🧩 Referral for Operative Management
Operative management (most commonly arthroscopy) is typically reserved for patients experiencing severe calcific tendinopathy or persistent symptoms refractory to nonoperative management lasting longer than 6 months (reported in about 10% of patients).
Postoperative rehabilitation, which PTs will manage, involves initiating active and passive shoulder and elbow ROM immediately, with strengthening exercises beginning around 6–12 weeks postoperative.
