Calcific Tendinitis: Symptoms, Causes and Treatment Options

Calcific tendinitis is a musculoskeletal disorder characterized by the deposition of calcium hydroxyapatite crystals within tendons, most commonly in the rotator cuff of the shoulder, leading to inflammation, pain, and restricted joint mobility during both rest and movement phases.

Calcific tendinitis symptoms and clinical presentation include acute or chronic shoulder pain, limited range of motion, localized tenderness, and episodic exacerbations caused by inflammatory resorption phases, often impairing daily functional activities and sleep quality in affected individuals.

Diagnosis of calcific tendinitis involves imaging modalities such as X-ray and ultrasound, which identify calcific deposits and assess their size and location, while clinical evaluation focuses on pain patterns, joint stiffness, and exclusion of other degenerative or inflammatory tendon disorders.

Treatment of calcific tendinitis includes conservative approaches such as nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections, while advanced interventions like extracorporeal shock wave therapy or ultrasound-guided needling are considered in persistent or severe cases.

What is Calcific Tendinitis, and Is It the Same as Shoulder Calcification?

Let’s begin by correcting the most common mistake. Our patients often arrive with an X-ray saying, “Doctor, I have calcification in my shoulder.” However, in the medical world, “calcification” (osteoarthritis) and “calcific tendinitis” are two completely different conditions. Calcification is an age-related process that develops as joint cartilage wears out over the years, causing the bones to rub against each other. In a way, it’s like the joint rusting.

Calcific tendinitis is a much different and more dramatic condition. Here, there is no problem with your bones or cartilage. The issue lies within the tendons of the muscle group called the “Rotator Cuff” that allows you to lift your arm. For reasons unknown, your body starts to deposit calcium crystals inside these tendons. Imagine this like a sharp stone piece that has gotten into your shoe lining. Or, more accurately, picture a pimple filled with toothpaste-like substance forming inside the tendon. This deposit creates mechanical pressure and triggers severe chemical inflammation. That’s the source of the unbearable pain you feel. While calcification develops slowly over the years, calcific tendinitis can suddenly wake you one morning as if a knife has been stabbed into your shoulder.

What Causes Calcific Tendinitis and Who Is at Risk?

The most honest moment in medicine is when it says, “we don’t know the cause.” The exact reason for calcific tendinitis remains a mystery. There isn’t a single answer to the question “Why me?”—but we do have strong clues. This condition doesn’t result from trauma; it is not directly related to falling or hitting. The process starts with a deterioration in the tendon’s biological structure.

Some parts of our tendons are relatively “poor” in blood supply. We call this the “critical zone.” As we age or due to genetic predisposition, the oxygen supply to this area decreases. Tendon cells deprived of oxygen go under stress and develop a strange defense mechanism by starting to produce calcium.

When we examine the risk factors, we see that certain groups are more prominent. Surprisingly, this condition is not a disease of the very elderly but rather of the middle-aged individuals who lead an active life.

Those at risk include:

• Individuals aged between 40 and 60
• Women
• Desk workers
• People with sedentary lifestyles
• Diabetic patients
• Those with thyroid problems

Especially diabetes and thyroid gland disorders (hypothyroidism) change the body’s metabolic balance and pave the way for calcium buildup. Also, genetic factors play a significant role; if your family members have had similar complaints, your tendons may be predisposed as well.

What Are the Stages of the Disease and How Does Calcific Tendinitis Progress?

This disease is not static, meaning the calcium in the shoulder doesn’t just sit there. Calcific tendinitis is a dynamic process with a beginning and an end, progressing in a cycle. The nature of the pain experienced by patients changes according to these stages. Sometimes, you may feel mild soreness, while other times you may feel pain severe enough to rush to the emergency room.

The disease generally progresses through the following stages:

• Pre-Calcific Stage:

Cellular-level changes begin in the tendon tissue. There is no visible calcification yet, only a preparatory stage. This period is generally silent and painless.

• Formative Stage:

Calcium crystals begin to deposit into the tendon. The accumulated calcium at this stage is hard and has a chalky consistency. The patient may feel a dull pain in the shoulder that increases with movement. There may also be a “catching” or “clicking” sensation when raising the arm. However, this pain is generally tolerable.

• Resorptive Stage:

This is where the real trouble begins. The body eventually detects the calcium deposit and decides to get rid of it, thinking “this doesn’t belong here.” It increases blood flow to the area and sends enzymes to dissolve the calcium. During this phase, the hard calcium softens to a toothpaste consistency. Sounds like healing, doesn’t it? Yes, the body is trying to heal, but this process is incredibly painful. The chemical substances released as the calcium dissolves and the high pressure formed inside the tendon create a volcanic eruption-like effect in the shoulder. The period where patients say, “I woke up crying from the pain,” is actually when the body is trying to clean the calcium.

• Post-Calcific Healing Stage:

After the calcium is cleared, the tendon begins to repair itself, and the pain gradually disappears.

What Symptoms Do Patients with Calcific Tendinitis Experience?

Although symptoms may vary between individuals, the stories of patients who come to us are almost always the same. The most prominent complaint, as you might guess, is pain. But this is not an ordinary fatigue-related pain.

Common symptoms include:

• Sudden onset of severe shoulder pain
• Pain that wakes you at night
• Inability to sleep on the painful side
• Difficulty raising the arm sideways
• Difficulty combing hair
• Inability to fasten bra hooks
• Difficulty wearing a jacket
• Pain radiating from shoulder to arm

Night pain is particularly characteristic. When the patient lies down, the pressure inside the shoulder changes, leading to throbbing pain throughout the night. This can cause chronic fatigue and a depressive mood. Also, avoiding use of the arm due to pain may eventually lead to shrinkage of the shoulder capsule, causing a secondary condition called “frozen shoulder,” which complicates things further.

How Is Calcific Tendinitis Diagnosed and What Methods Are Used?

Diagnosing the condition is quite easy with today’s technology. A good physical examination and the patient’s description usually lead us to a strong suspicion. However, to confirm the diagnosis and plan treatment, we need to visualize the inside of the tendon.

Diagnostic methods include:

• X-ray
• Ultrasonography
• MRI (Magnetic Resonance Imaging)

X-ray: The first step. It shows bone structures and calcium deposits. Calcium appears on the X-ray as a white spot like bone. It tells us where the calcium is but not its consistency.

MRI: Shows the overall quality of the tendon, any tears, and the presence of edema. However, it may sometimes be insufficient in detailing the calcium structure.

Ultrasound: As an Interventional Radiologist, this is my most valued and helpful diagnostic tool. When I examine the shoulder with ultrasound, I not only see the calcium but also assess whether it’s hard or soft, its exact location within the tendon, and if there is surrounding fluid—as if watching a live video. Moreover, during treatment, it is the only guide that shows me exactly where to insert the needle. If an X-ray is a photo, ultrasound is a live broadcast.

Is Medication and Physical Therapy Sufficient for Treatment?

Due to the nature of the disease, even if we do nothing, the body will eventually clear the calcium over months or years. However, the problem is that living with such severe pain for months is not feasible. Therefore, we start with simpler methods initially.

Conservative treatment options include:

• Pain-relief medications
• Anti-inflammatory medications
• Shoulder rest
• Cold compress application
• Physical therapy exercises

The purpose of these methods is to “manage” the pain. They do not remove the calcium but try to suppress the inflammation caused by the body. Some patients feel relief during this period. However, if the calcification is large and there is intense pressure from the “resorptive” phase, medications are often insufficient. If the patient still cannot sleep at night despite taking boxes of painkillers, then waiting any longer is pointless.

Is ESWT (Shock Wave Therapy) an Effective Method?

When medications are ineffective, one of the non-surgical options is ESWT. This method is an adaptation of the sound wave technology used for breaking kidney stones, applied to the shoulder. Shock waves sent through the skin aim to break down the calcium inside the tendon and stimulate the body’s healing mechanism.

Some features of ESWT:

• Does not require anesthesia
• Does not damage the skin
• Applied in sessions
• May cause pain during the procedure

ESWT does not physically remove the calcium, it only “disperses” it and waits for the body to absorb it. The success rate varies. While it works very well in some patients, its effect may be limited in very hard calcifications. Additionally, the healing process can take weeks.

What Is Interventional Radiology and Barbotage Treatment?

Now we come to the most crucial point. In modern medicine, one of the leading “minimally invasive” methods—meaning creating maximum effect with minimal harm—is Ultrasound-Guided Barbotage (Lavage). This method is the strongest alternative to surgery for treating calcific tendinitis and is also my primary method of choice in the clinic.

Barbotage, in its simplest form, can be described as this: We enter the painful, pressurized, toothpaste-like material inside your shoulder tendon with special needles and extract it by washing. In other words, we physically clean the problem at its source.

The logic of this method is: What the body struggles to dissolve over months, we remove in minutes. Once the calcium is removed, the pressure inside the tendon drops dramatically, and the pain rapidly subsides. And we do all of this without using a scalpel or stitches.

Step-by-Step Barbotage Procedure

My patients usually feel anxious when they hear the word “needle.” However, once they learn about the process, they realize how comfortable it is. This procedure is performed not in an operating room but in a clinic setting, at the ultrasound table. There is no need for hospitalization.

Steps of the procedure:

• The patient lies on their back
• The shoulder area is sterilized
• The needle entry point is numbed
• Calcium is located using ultrasound
• A needle is inserted into the calcium
• Washing is done with saline solution
• Calcium is aspirated
• A therapeutic medication is injected

To elaborate: first, we numb the skin with very fine needles. This ensures that you feel no pain during the procedure—just a touch sensation. Then, by watching the ultrasound screen (just like aiming in a video game), we guide our needle with millimeter precision to the very core of the calcium deposit.

Once the needle is in place, we inject sterile saline and start pulling it back. This “push-pull” motion stirs and breaks up the calcium inside, allowing it to be drawn into the needle. You can see the cloudy, white calcium being collected both on the screen and inside the syringe. We continue this washing process until the fluid comes out clear, indicating the deposit has emptied. Finally, we inject a low-dose medication mixture into the tendon sheath to rapidly reduce the inflammation and ensure comfort after the procedure. That’s it. A highly safe process that takes just 15–20 minutes in total.

What Are the Advantages of the Barbotage Method?

Why do we recommend this method so strongly? Because the comfort and recovery speed it offers to patients are far superior compared to other methods.

Highlights of Barbotage advantages:

• It is a non-surgical solution
• No stitches or incisions
• Performed with local anesthesia
• Very short procedure time
• You can return home immediately
• Pain reduces rapidly
• Minimal side effects
• Lower cost compared to surgery

The greatest advantage is “speed.” While you must wait for improvement with ESWT or medication therapy, Barbotage brings rapid relief because it involves mechanical cleaning. Most of my patients give feedback saying, “For the first time in months, I slept peacefully,” either right after the procedure or that same night. Also, because it is guided by ultrasound, the risk of misplacing the needle is almost zero. We call this “targeted treatment.”

When Is Surgery Necessary for Calcific Tendinitis?

With interventional methods being so advanced, the number of patients requiring surgery has significantly decreased. However, in certain cases, surgery may still be unavoidable.

Surgery is considered in cases such as:

• If Barbotage does not produce results
• If the calcification is very hard
• If there is an accompanying tendon tear
• If pain lasts more than 6 months
• If quality of life is severely affected

If the calcium deposit has hardened like a rock and cannot be broken and aspirated with a needle, then Arthroscopic Surgery (Minimally Invasive Surgery) is considered. In surgery, a camera is inserted into the shoulder, and the calcification is scraped off and cleaned. It is an effective method, but the recovery period is longer; a sling must be worn, and the physical therapy process is more demanding. Therefore, surgery is always kept as the “last resort.” Our goal is to solve the problem without putting you on the operating table.

What Is the Recovery Process Like After Treatment?

After the Barbotage procedure, you can resume your life where you left off—but of course, we have some small rules. Even though the shoulder has been “cleaned,” a healing process still continues in the area.

Post-procedure recommendations:

• Do not strain the arm for the first 2 days
• Avoid heavy lifting
• Apply ice compress
• Use mild painkillers
• Avoid sudden movements

For the first few days, there may be mild soreness after the anesthetic wears off, which is completely normal. Typically, full relief is achieved within one week. It may take a few weeks for the tendon to fully repair itself and regain its original strength. Performing the simple home exercises we provide during this period is crucial for your shoulder health.

Frequently Asked Questions

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.