A note on this column: This article is general medical information, not a description of a service offered at this practice. Dr. Ishiguro's surgical practice is focused on hip and knee conditions — he does not treat calcific tendinitis or other shoulder disorders. This column is written to help readers understand a common cause of shoulder pain and know when and how to seek the right specialist, typically a shoulder-focused orthopaedic surgeon, a musculoskeletal radiologist, a sports medicine physician, or a physiotherapist.
What calcific tendinitis is
Calcific tendinitis (also called calcific tendinopathy or calcifying tendinitis; in Japan, sekkai chinchakusei kenban-en) is a condition in which deposits of calcium — mostly a form of calcium phosphate similar in texture to toothpaste or chalk — form inside the tendons of the rotator cuff, the group of four tendons that wrap around the ball of the shoulder joint. The supraspinatus tendon, on top of the shoulder, is the most commonly affected.
Unlike the "wear and tear" calcification seen in ageing or badly damaged tendons, calcific tendinitis is generally understood as an active, cell-driven process in otherwise living tendon tissue. The exact trigger is still not known. A widely cited model describes the condition as a cycle: in a formative phase, the deposit is laid down and may cause relatively little pain; in a later resorptive phase, the body starts breaking the deposit down and clearing it away. Paradoxically, it is often this resorptive phase — when the deposit softens and the surrounding tissue becomes inflamed — that produces the most intense pain. After the deposit has been resorbed, the tendon usually remodels and heals (Uhthoff & Loehr, J Am Acad Orthop Surg, 1997).
Who gets it
Calcium deposits in the rotator cuff are more common than many people expect, and they don't always cause symptoms. In a Dutch study of 1,219 adults who had shoulder X-rays, calcific deposits were found in 7.8% of people with no shoulder pain, and in 42.5% of people with subacromial (outer shoulder) pain. Being between 30 and 60 years old, having subacromial pain, and being female were each associated with higher odds of having a deposit; the authors noted that deposits longer than about 1.5 cm were more often associated with symptoms (Louwerens et al., J Shoulder Elbow Surg, 2015).
Key points at a glance
- Calcium deposits form inside a rotator cuff tendon — most often the supraspinatus, on top of the shoulder
- Most common in people aged roughly 30–60, somewhat more often in women
- Many deposits cause no symptoms and are found by chance on X-ray
- The condition often resolves on its own as the body resorbs the deposit, though this can take months
- The most painful stage is often the resorptive phase, when the deposit is being broken down
- Most people are treated without surgery; surgery is usually reserved for persistent, disabling cases
Symptoms
Symptoms vary a great deal from person to person and over the course of the condition. Two broad patterns are commonly described:
A chronic, grumbling pattern — aching in the outer shoulder or upper arm, pain when raising the arm to the side or overhead, and discomfort lying on the affected side. This can look very similar to shoulder impingement (subacromial pain syndrome) or rotator cuff tendinopathy.
An acute, severe pattern — sudden, intense pain, often without a clear injury, that can make it hard to move the arm at all and can keep people awake at night. This acute flare is typically associated with the resorptive phase, and in some cases calcium material leaks into the neighbouring subacromial bursa, causing marked inflammation. Although distressing, an acute flare does not by itself mean that the tendon is badly damaged.
How it is diagnosed
A clinician will usually start with a history and examination of the shoulder, including range of motion and rotator cuff strength. Because the symptoms overlap with several other shoulder conditions, imaging is particularly helpful here:
Plain X-rays are usually the key test — calcium deposits show up clearly as white densities above the head of the humerus, and X-rays can show the size, location, and appearance of the deposit (a dense, sharply outlined deposit versus a fainter, cloudy one that may be in the process of resorbing). Ultrasound can locate the deposit precisely, assess its consistency, check the rest of the rotator cuff, and is also used to guide needle-based treatments. MRI is not usually necessary to make the diagnosis, but may be used if a rotator cuff tear or another problem is suspected.
| Condition | Key distinguishing feature |
|---|---|
| Calcific tendinitis | Calcium deposit visible on X-ray or ultrasound; may present with sudden, severe pain during the resorptive phase |
| Subacromial pain syndrome | Pain with overhead reaching and provocative tests, without a significant calcium deposit |
| Rotator cuff tear | Often more noticeable weakness when actively lifting the arm; a tear is seen on ultrasound or MRI |
| Frozen shoulder | Loss of both active AND passive movement in several directions, especially rotation |
Treatment options
Because many deposits eventually resorb on their own, treatment is generally aimed at controlling pain and keeping the shoulder moving while that process happens, with more active interventions considered when symptoms persist and significantly affect daily life. Commonly used options include:
Commonly used treatment options
- Relative rest and activity modification — reducing painful overhead activity during a flare, while avoiding complete immobilisation
- Pain relief medication — such as anti-inflammatory medication where appropriate, as advised by a physician or pharmacist
- Physiotherapy and home exercises — to maintain range of motion and gradually restore rotator cuff and shoulder-blade strength
- Subacromial corticosteroid injection — used for short-term pain relief, particularly in acute or severe pain
- Extracorporeal shock wave therapy (ESWT) — focused sound-wave pulses delivered through the skin over the deposit, usually in several sessions
- Ultrasound-guided needling and lavage ("barbotage") — the deposit is punctured and rinsed with saline under ultrasound guidance to break up and remove calcium, often combined with a steroid injection
- Arthroscopic (keyhole) surgery — removal of the deposit, generally reserved for persistent symptoms that have not responded to non-surgical treatment
What the evidence shows
Calcific tendinitis has been studied in a number of randomised trials, and the picture is more nuanced than it might first appear. Several treatments can reduce deposit size, but reducing the deposit does not always translate into a bigger difference in symptoms over the long term — partly because many people improve over time regardless of which treatment they receive.
What the evidence shows — shock wave therapy: In a double-blind trial from Germany and Austria, 144 patients with chronic calcific tendinitis were randomised to high-energy ESWT, low-energy ESWT, or a sham procedure, each followed by physical therapy. At six months, both ESWT groups showed greater improvement in shoulder function than the sham group, with the largest improvement in the high-energy group; self-rated pain and deposit size followed a similar pattern (Gerdesmeyer et al., JAMA, 2003).
What the evidence shows — needling and lavage: A Dutch trial of 48 patients compared ultrasound-guided barbotage plus a subacromial steroid injection with a steroid injection alone. At one year, the barbotage group had better shoulder function scores and greater reduction in deposit size (de Witte et al., Am J Sports Med, 2013). However, at five-year follow-up of the same patients, the difference between the groups was no longer statistically significant — both groups had improved substantially, although more patients in the injection-only group had needed additional treatment along the way (de Witte et al., Am J Sports Med, 2017). A separate trial of 82 patients comparing barbotage with high-energy ESWT found similar improvements in function and pain at one year, with barbotage removing more of the deposit and fewer patients needing further treatment (Louwerens et al., Arthroscopy, 2020).
What the evidence shows — a sham-controlled trial: A larger double-blind trial from Norway and Sweden randomised 220 adults with calcific tendinopathy lasting at least three months to ultrasound-guided lavage plus a steroid injection, sham lavage plus a steroid injection, or sham lavage with local anaesthetic only. All participants also did a home exercise programme. At four months — and again at 24 months — neither active treatment was shown to be superior to the sham procedure, and all three groups improved (Moosmayer et al., BMJ, 2023). This trial has prompted discussion about how much of the improvement seen after procedures reflects the natural course of the condition, exercise, and other non-specific effects.
Reviews that pool the available trials reach broadly cautious conclusions. A 2023 meta-analysis of randomised trials found that ESWT, ultrasound-guided needling, and surgery were each associated with clinically meaningful improvements in pain and function, and suggested it is reasonable to try non-surgical options such as needling or ESWT first; it noted that high-quality trials directly comparing surgery with non-surgical treatment are lacking (Angileri et al., J Shoulder Elbow Surg, 2023). A 2025 network meta-analysis of 33 randomised trials likewise found that physiotherapy-based approaches, shock wave therapy combined with physiotherapy, and needling-based treatments all had supporting evidence, while again highlighting the absence of direct comparisons between operative and non-operative care (Yao et al., EFORT Open Rev, 2025).
In practice, the choice between these options usually depends on how severe and long-lasting the symptoms are, the size and appearance of the deposit, what is available locally, and the patient's own preferences — ideally discussed with a clinician who treats shoulder conditions regularly.
What recovery generally looks like
Many people with calcific tendinitis improve over months, whether or not the deposit disappears completely on X-ray. Acute flares, though very painful, often settle over days to weeks. After needle-based procedures or shock wave therapy, some temporary soreness is common, and follow-up X-rays are sometimes used to check how the deposit is changing. After surgery, recovery typically involves a period of rehabilitation guided by a physiotherapist. Throughout, keeping the shoulder gently moving within comfortable limits is generally encouraged, to reduce the risk of stiffness.
When to see a specialist
It's worth having shoulder pain assessed if it is severe, keeps you awake at night, stops you from lifting your arm, or hasn't improved after several weeks of sensible self-care. Sudden, severe shoulder pain with fever, redness, or feeling generally unwell needs prompt medical attention, as it can indicate infection or another condition that requires urgent care. A simple X-ray is often the first step in identifying a calcium deposit, and a shoulder-focused orthopaedic surgeon, sports medicine physician, or physiotherapist can help you understand the options that fit your situation.
References (PubMed / Journal)
Uhthoff HK, Loehr JW. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997;5(4):183-191. DOI: 10.5435/00124635-199707000-00001
Louwerens JK, Sierevelt IN, van Hove RP, van den Bekerom MP, van Noort A. Prevalence of calcific deposits within the rotator cuff tendons in adults with and without subacromial pain syndrome: clinical and radiologic analysis of 1219 patients. J Shoulder Elbow Surg. 2015;24(10):1588-1593. DOI: 10.1016/j.jse.2015.02.024
Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003;290(19):2573-2580. DOI: 10.1001/jama.290.19.2573
de Witte PB, Selten JW, Navas A, et al. Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids. Am J Sports Med. 2013;41(7):1665-1673. DOI: 10.1177/0363546513487066
de Witte PB, Kolk A, Overes F, Nelissen RGHH, Reijnierse M. Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids: Five-Year Outcomes of a Randomized Controlled Trial. Am J Sports Med. 2017;45(14):3305-3314. DOI: 10.1177/0363546517721686
Louwerens JKG, Sierevelt IN, Kramer ET, et al. Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial. Arthroscopy. 2020;36(7):1823-1833.e1. DOI: 10.1016/j.arthro.2020.02.027
Moosmayer S, Ekeberg OM, Hallgren HB, et al. Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study. BMJ. 2023;383:e076447. DOI: 10.1136/bmj-2023-076447
Angileri HS, Gohal C, Comeau-Gauthier M, et al. Chronic calcific tendonitis of the rotator cuff: a systematic review and meta-analysis of randomized controlled trials comparing operative and nonoperative interventions. J Shoulder Elbow Surg. 2023;32(8):1746-1760. DOI: 10.1016/j.jse.2023.03.017
Yao Y, Yang G, Jiang S, et al. Treatments for rotator cuff calcific tendinitis: a systematic review and network meta-analysis of randomized-controlled trials. EFORT Open Rev. 2025;10(7):520-533. DOI: 10.1530/EOR-2024-0078