Calcific Shoulder Tendinitis: Causes and Treatment

By the myphysiohelp.it team

Calcific Tendinitis of the Shoulder: Calcific tendinitis of the shoulder is a condition characterized by the deposition of calcium crystals (hydroxyapatite) within the rotator cuff tendons, particularly the supraspinatus. It affects approximately 2-7% of the adult population, with a peak incidence between 30 and 60 years of age and a slightly higher prevalence in women.
It is a peculiar condition because it has a natural course with well-defined phases and, in most cases, tends to resolve spontaneously — although the timelines can be long and the pain in the acute phase can be truly intense.

What is Calcific Tendinitis?

Tendon calcification typically goes through three phases:

• Phase 1 — Pre-calcific (Formative)

The tendon tissue undergoes metaplastic transformation: tendon cells transform into cartilage cells (chondrocytes) that produce calcium deposits. In this phase, the patient is generally asymptomatic or experiences mild pain.

• Phase 2 — Calcific

It is divided into:

• Formation phase: the deposit consolidates. Moderate, intermittent pain.

• Resorption phase: the body begins to resorb the calcification. This is the most painful phase because resorption generates an intense inflammatory reaction in the subacromial bursa. The pain can be extremely acute, with inability to move the arm.
• Phase 3 — Post-calcific (Reparative)

The calcification has been resorbed, and the tendon repairs itself with scar tissue and then with normal collagen fibers. Pain progressively reduces.

Causes and Risk Factors

The exact cause is not known, but predisposing factors have been identified:

• Age 30-60 years (rare before 30 and after 70)
• Female sex (slightly more frequent)
• Metabolic conditions: diabetes, thyroid disorders
• Genetic predisposition
• Repeated microtrauma to the tendon
• Can coexist with adhesive capsulitis

Symptoms

• Variable pain: from absent (incidentally discovered calcifications) to excruciating (resorption phase)
• Acute crises: sudden, very intense pain, with inability to move the arm. Can wake one up at night.
• Limited movement: especially in abduction and flexion
• Night pain: common, similar to supraspinatus tendinitis
• In intercritical periods: mild or absent pain

Diagnosis

• X-ray: first-choice examination. Calcification is clearly visible as a radiopaque deposit in the tendon. Allows measurement of size and density.
• Ultrasound: evaluates the tendon, bursa, and characteristics of the calcification (solid, fragmented, in resorption phase).
• MRI: rarely necessary, useful for excluding associated tendon lesions.

Treatment

Acute Phase (Painful Crisis)

The acute resorption crisis requires aggressive pain treatment:

• High-dose NSAIDs (by medical prescription)
• Ice: 15-20 minutes, several times a day
• Subacromial corticosteroid injection: very effective for acute crisis. Unlike non-calcific tendinitis, cortisone is particularly indicated here.
• Relative arm rest: avoid painful movements

Chronic/Intercritical Phase

• Physiotherapy: rotator cuff and scapular muscle strengthening program (similar to supraspinatus tendinitis).
• Focused shockwave therapy (ESWT): the treatment with the best evidence for calcific tendinitis. 3-5 sessions, once a week. Shockwaves fragment the calcification and promote its resorption. Success rate: 60-80%.
• PEMF magnetotherapy: can contribute to the resorption process.
• Ultrasound-guided lavage (barbotage/needling): under ultrasound guidance, needles are inserted into the calcification, and the deposit is aspirated/lavaged. Effective in 60-70% of cases.

Surgical Treatment

Reserved for resistant cases after 6-12 months:

• Arthroscopic removal: arthroscopic excision of the calcification.
• Success rate: >90%
• Recovery: 2-4 months post-operative

Exercises

Exercises follow the same phases as supraspinatus tendinitis, adapted to the calcification phase.

In Acute Phase

During the painful resorption crisis, perform only gentle and passive exercises to maintain a minimum of mobility without further irritating the inflamed bursa and tendon.

Exercise 1: Codman’s Pendulum (acute phase)
Difficulty: Easy | Equipment: Stable table or chair | Duration: 2-3 minutes

Starting position:
Stand next to a stable table. Lean forward at approximately 45-60 degrees, resting the hand of the unaffected arm on the surface. The affected arm hangs freely downwards, completely relaxed and without any additional weight.
Step-by-step execution:

• Step 1: Shift your body weight slightly to swing the arm in small clockwise circles (8-10 very small circles). The arm should move solely due to gravity and the body’s inertia.
• Step 2: Reverse direction and perform 8-10 small counter-clockwise circles.
• Step 3: Continue with gentle forward-backward and side-to-side swings (8-10 per direction). Keep the amplitudes small to avoid causing pain.

Sets and repetitions: 2-3 minutes of gentle swings — Repeat 4-5 times a day
Common errors to avoid:

• Making circles too wide, which stimulates the inflammatory reaction of the bursa.
• Contracting the shoulder muscles during swings.
• Adding weight to the hand in the acute phase.

How to know you are doing it correctly:
The exercise does not cause increased pain. You feel a slight sensation of decompression in the joint. Movements are minimal and relaxed. After performing, the pain does not worsen compared to before.

Exercise 2: Gentle Passive Mobilization from Supine
Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Lie supine on a mat, with knees bent for lumbar comfort. Grasp the wrist of the affected arm with the hand of the unaffected arm. The affected arm is completely relaxed along the side.
Step-by-step execution:

• Step 1: With the unaffected hand, very slowly raise the affected arm upwards. Proceed with extreme gradualness, stopping at the first signs of pain.
• Step 2: Once the tolerable point of tension is reached (which in the acute phase might be very limited), hold the position for 10-15 seconds, breathing deeply.
• Step 3: Very slowly return the arm to the starting position. Never force the range: in the acute phase, maintaining even minimal mobility is sufficient.

Sets and repetitions: 5-8 repetitions — Repeat 2-3 times a day
Common errors to avoid:

• Forcing the movement beyond the pain threshold (in the acute phase, the limit can be very low).
• Performing the movement too quickly.
• Forgetting to apply ice for 15-20 minutes after exercises.

How to know you are doing it correctly:
Pain does not increase during or after execution. You can maintain the reached position for the entire duration without defensive contraction. The tolerable range gradually increases in subsequent days.

In Intercritical/Chronic Phase

When acute pain has reduced, you can proceed with a progressive strengthening and mobility program, similar to that for supraspinatus tendinitis but with care not to irritate the calcification area.

Exercise 3: Codman’s Pendulum (chronic phase)
Difficulty: Easy | Equipment: Table, light dumbbell (0.5-1 kg) optional | Duration: 2-3 minutes

Starting position:
Stand next to a stable table, leaning forward at 45-60 degrees. The affected arm hangs freely. In the chronic phase, it is possible to add a light weight (0.5-1 kg) to the hand, if tolerated.
Step-by-step execution:

• Step 1: Shift your body weight to generate circular swings in a clockwise direction, with progressively increasing amplitude compared to the acute phase. 15-20 circles.
• Step 2: Reverse direction and perform 15-20 counter-clockwise circles.
• Step 3: Continue with forward-backward and side-to-side swings (15-20 per direction), using any added weight to increase the decompressive effect.

Sets and repetitions: 2-3 minutes of swings — Repeat 4-5 times a day
Common errors to avoid:

• Transitioning too quickly from small to large circles after an acute crisis.
• Using too heavy a weight that causes defensive muscle contraction.
• Forgetting to warm up first with small circles.

How to know you are doing it correctly:
The arm swings freely with greater amplitude compared to the acute phase. No pain is felt, only a slight decompressive traction in the shoulder. The additional weight, if used, does not cause discomfort.

Exercise 4: External Rotation with Resistance Band
Difficulty: Intermediate | Equipment: Light-medium resistance band, door handle | Duration: 5 minutes

Starting position:
Attach a resistance band to a closed door handle. Stand with the side of the affected arm opposite the door. Elbow bent at 90 degrees, tucked against the side. Hold the resistance band with the hand of the affected arm.
Step-by-step execution:

• Step 1: Slowly rotate the forearm outwards against the resistance of the band, keeping the elbow firmly tucked against the side. Concentric phase duration: 2-3 seconds.
• Step 2: Once maximum tolerable external rotation is reached, hold for 1-2 seconds.
• Step 3: Slowly return to the starting position, controlling the eccentric phase (4 seconds). Do not let the band pull the arm back abruptly.

Sets and repetitions: 3 sets x 12-15 repetitions — 30-second rest between sets
Common errors to avoid:

• Detaching the elbow from the side during rotation.
• Using a band that is too resistant, causing postural compensations.
• Performing the eccentric phase too quickly.

How to know you are doing it correctly:
You feel the external rotator muscles (infraspinatus and teres minor) working without pain in the calcification area. The movement is fluid and controlled in both phases.

Exercise 5: Eccentric Full Can
Difficulty: Intermediate | Equipment: Light dumbbell (0.5-1 kg) | Duration: 5 minutes

Starting position:
Stand upright. Hold a light dumbbell (0.5-1 kg) with the hand of the affected arm. Arm along the side, thumb pointing upwards (“full can” position).
Step-by-step execution:

• Step 1: Raise the arm laterally and slightly forward (scapular plane, approximately 30 degrees anterior to the frontal plane) up to 70-80 degrees. Thumb always pointing upwards. Ascent: approximately 2 seconds.
• Step 2: Once the height is reached, begin a very slow and controlled descent. The eccentric phase should last at least 5 seconds.
• Step 3: At the starting position, rest for 2-3 seconds and repeat. If pain occurs, reduce the weight or height.

Sets and repetitions: 3 sets x 10 repetitions — 45-second rest between sets
Common errors to avoid:

• Rotating the thumb downwards (“empty can” position), which compresses the calcification area.
• Exceeding 80 degrees of elevation, risking impingement on the calcification.
• Descending too quickly, losing the eccentric benefit.

How to know you are doing it correctly:
You feel controlled muscle fatigue in the lateral part of the shoulder during the slow descent. No acute pain in the calcification area. The thumb remains pointed towards the ceiling throughout the execution.

Exercise 6: Scapular Retraction with Resistance Band
Difficulty: Intermediate | Equipment: Medium resistance band | Duration: 5 minutes

Starting position:
Stand upright. Hold a resistance band with both hands, arms extended forward at shoulder height, hands shoulder-width apart. Band slightly taut.
Step-by-step execution:

• Step 1: Pull the band by opening your arms laterally, guiding the movement with your shoulder blades retracting (moving closer together) and depressing (moving downwards).
• Step 2: Once maximum retraction is reached (band near the chest), hold the position for 2-3 seconds, feeling the contraction between the shoulder blades.
• Step 3: Slowly return to the starting position in 3-4 seconds, controlling the band’s return.

Sets and repetitions: 3 sets x 12-15 repetitions — 30-second rest between sets
Common errors to avoid:

• Raising the shoulders towards the ears during the movement.
• Bending the elbows to make the exercise easier.
• Arching the lumbar area to compensate.

How to know you are doing it correctly:
You feel a strong contraction in the area between the shoulder blades (rhomboids and middle trapezius). Shoulders remain low throughout the movement. The exercise is painless in the calcification area.

Exercise 7: Wall Push-up Plus
Difficulty: Intermediate | Equipment: Wall | Duration: 5 minutes

Starting position:
Stand facing a wall, at arm’s length. Hands placed on the wall at shoulder height, slightly wider than shoulders. Body aligned from head to feet.
Step-by-step execution:

• Step 1: Bend your elbows and move closer to the wall in a controlled manner, keeping your body aligned. Descend until your chest lightly touches the wall.
• Step 2: Push with your hands to return to the starting position with arms fully extended.
• Step 3: Add the “plus” phase: once arms are extended, push your hands further against the wall, protracting your shoulder blades forward (shoulder blades move away from each other). Hold the protraction for 2-3 seconds, then release.

Sets and repetitions: 3 sets x 10-15 repetitions — 30-second rest between sets
Common errors to avoid:

• Omitting the “plus” phase (scapular protraction), which is the key element of the exercise.
• Lowering the pelvis or arching the back.
• Performing the movement too quickly.

How to know you are doing it correctly:
You feel specific muscle work in the lateral part of the chest (serratus anterior) during scapular protraction. The shoulder blades visibly move forward in the “plus” phase. No pain in the calcification area.

Exercise 8: Posterior Capsule Stretch (Cross-Body Stretch)
Difficulty: Easy | Equipment: None | Duration: 3 minutes

Starting position:
Stand upright with a straight back. Raise the affected arm in front of your body at shoulder height, with the elbow extended.
Step-by-step execution:

• Step 1: Bring the affected arm horizontally across your chest towards the opposite shoulder.
• Step 2: With the hand of the unaffected arm, grasp the elbow or the back of the affected arm and gently pull it towards the opposite shoulder, increasing the stretch of the posterior capsule.
• Step 3: Hold the position for 30 seconds, breathing deeply and relaxing the muscles. Slowly release and repeat.

Sets and repetitions: 3 repetitions — 2 times a day
Common errors to avoid:

• Raising the affected shoulder towards the ear during stretching.
• Rotating the torso in the direction of the arm, nullifying the stretch.
• Pulling abruptly or excessively hard.

How to know you are doing it correctly:
You feel a clear and tolerable stretch in the posterior part of the affected shoulder. The tension remains constant and bearable during the 30 seconds. Over time, the flexibility of the posterior capsule progressively improves.

Recovery Times

Learn More: This article is part of our Shoulder Pain: Complete Guide, where you will find an overview of all related conditions, with links to specific guides and exercise programs.

Frequently Asked Questions (FAQ)

Does calcification go away on its own?
Yes, in most cases, calcification tends to resorb spontaneously. The process can take 6-24 months. Shockwave therapy can significantly accelerate it.

Is shockwave therapy painful?
Focused shockwave therapy causes moderate discomfort during treatment (3-5 minutes). The pain is tolerable, and the benefit largely outweighs the temporary discomfort.

Should I avoid calcium in my diet?
No. Tendon calcification is not related to dietary calcium intake. It is not necessary to change your diet.

Can calcification return?
Recurrence in the same shoulder is rare (less than 10%). However, calcifications can appear in the contralateral shoulder in 10-20% of cases.

Is it the same as supraspinatus tendinitis?
No. Supraspinatus tendinitis is an overuse/degenerative tendinopathy. Calcific tendinitis is characterized by calcium deposits in the tendon with a specific cyclical course. The two treatments are different.

When is surgery urgent?
Surgical intervention is never urgent for calcific tendinitis. It is indicated only after failure of conservative treatment for at least 6-12 months. The vast majority of cases resolve without surgery.

Scientific References

• Uhthoff HK, et al. Calcifying tendinitis: a new concept of its pathogenesis. Clin Orthop Relat Res. 1976;(118):164-168.
• Louwerens JK, et al. Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy. Br J Sports Med. 2014;48(19):1443-1449.
• Ioppolo F, et al. Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis. Phys Ther. 2012;92(11):1376-1385.
• Arirachakaran A, et al. Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for calcific tendinopathy. Eur J Orthop Surg Traumatol. 2017;27(3):381-390.
• Sansone V, et al. Calcific tendinopathy of the rotator cuff. Medicine. 2018;97(46):e13278.
• De Witte PB, et al. Subacromial impingement syndrome and rotator cuff tear. Maturitas. 2014;78(4):293-297.
• Merolla G, et al. Arthroscopic treatment of calcific tendinitis of the shoulder. Int J Shoulder Surg. 2013;7(3):97-102.
• Albert JD, et al. High-energy extracorporeal shock-wave therapy for calcifying tendinitis. J Bone Joint Surg Am. 2007;89(2):335-341.
• Del Castillo-Gonzalez F, et al. Treatment of calcifying tendinitis of the shoulder. Rev Esp Cir Ortop Traumatol. 2016;60(1):53-63.
• Chiou HJ, et al. Calcific tendinopathy: mechanisms and US-guided treatment. Radiographics. 2020;40(3):750-769.

Dr. Cosimo Pilotto — physical therapist | MyPhysioHelp.it

Related articles:

• Supraspinatus Tendinitis
• Adhesive Capsulitis
• Rotator Cuff Syndrome
• PEMF Magnetotherapy
• Shoulder Dislocation

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• Laser Therapy: Indications and Benefits
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Frequently Asked Questions

What is calcific tendinitis of the shoulder?

Calcific tendinitis of the shoulder is a condition characterized by the deposition of hydroxyapatite calcium crystals within the rotator cuff tendons, particularly the supraspinatus. It affects a notable percentage of the adult population and typically follows a natural course with distinct phases, often resolving spontaneously.

How is calcific tendinitis diagnosed?

The primary diagnostic method for confirming calcific tendinitis is an X-ray, which effectively visualizes the calcium deposits within the affected tendons. This imaging allows for clear identification of the calcification and helps guide subsequent management strategies.

Which phase of calcific tendinitis is typically the most painful?

The resorption phase is generally considered the most painful stage of calcific tendinitis. During this period, the body actively works to reabsorb the calcium deposits, which can trigger an intense inflammatory reaction and lead to severe pain, often limiting arm movement.

What are the initial treatment approaches for acute pain associated with calcific tendinitis?

For acute pain episodes, aggressive treatment is often recommended to manage symptoms effectively. This typically involves the use of non-steroidal anti-inflammatory drugs (NSAIDs), application of ice, and in some cases, steroid injections to reduce inflammation and discomfort.

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Sources and Scientific References

1. Chianca V et al. (2018). Rotator cuff calcific tendinopathy: from diagnosis to treatment. Acta Biomed. 89:186-196. DOI | PubMed
2. Bechay J et al. (2020). Calcific tendinopathy of the rotator cuff: a review of operative versus nonoperative management. Phys Sportsmed. 48:241-246. DOI | PubMed
3. Desmeules F et al. (2025). Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 55:235-274. DOI | PubMed
4. Xue X et al. (2024). Effect of extracorporeal shockwave therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. BMC Musculoskelet Disord. 25:357. DOI | PubMed
5. Page MJ et al. (2016). Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev. 2016:CD012225. DOI | PubMed