Calcific Tendinitis

Upper Limb

Overview

Calcific tendinitis is an inflammatory condition characterized by calcium hydroxyapatite deposition within tendons, most commonly affecting the rotator cuff of the shoulder. The condition presents with acute or chronic pain and functional limitation, often self-limiting but capable of causing significant disability during acute phases.

Pathophysiology

Calcific tendinitis involves deposition of calcium hydroxyapatite crystals within tendon tissue, typically progressing through stages: formative (asymptomatic crystal deposition), calcific (mature deposits with possible inflammation and resorption), and post-calcific (resorption and healing). The exact etiology remains unclear but involves intrinsic tendon factors, vascular changes, and cellular responses to crystal formation. Acute inflammation occurs when the body attempts to resorb deposits, triggering an intense local inflammatory response that may cause sudden severe pain.

Patient Education

Calcific tendinitis often resolves spontaneously over weeks to months as your body naturally reabsorbs the calcium deposits; maintaining movement within pain tolerance and avoiding immobilization accelerates recovery.

Typical Presentation

Site

Supraspinatus tendon most common; also infraspinatus, subscapularis, and less commonly biceps tendon. Shoulder anterolateral region typically over the insertion

Quality

Sharp, acute, sometimes burning or throbbing pain; may be described as catching or stabbing

Intensity

Highly variable: ranges from mild asymptomatic findings on imaging to severe incapacitating pain; acute phases can be 7-10/10

Aggravating

Overhead activities, reaching across body, sleeping on affected side, sudden movements, activities requiring shoulder elevation and external rotation

Relieving

Rest, ice application, anti-inflammatory medications, heat after acute phase, pendulum exercises, arm support

Associated

Night pain, significant functional limitation in acute phase, local swelling and warmth, loss of active range of motion (especially abduction and external rotation), referred pain to lateral arm, muscle guarding and protective spasm

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neer Impingement Sign

Procedure

Patient seated or standing. Stabilise the scapula with one hand and, with the arm internally rotated (thumb down), passively raise it forwards to full flexion.

Positive Finding

Reproduction of the familiar anterior or lateral shoulder pain near the end of range.

Sensitivity / Specificity

72%/60%

Reference: Hegedus EJ et al., Br J Sports Med 2012; PMID 22773322

Interpretation

Supports a subacromial pain source. A calcific deposit in the cuff often produces this, but the test cannot show calcification; X-ray or ultrasound is needed. Neer sign pooled figures (72%/60%) are from Hegedus (2012) meta-analysis; original description Neer 1972.

Sources

No accuracy study

Hawkins-Kennedy Test

Procedure

Patient seated or standing. Raise the arm to 90° of forward flexion with the elbow bent to 90°, support the elbow, then turn the forearm down to internally rotate the shoulder.

Positive Finding

Reproduction of the familiar anterolateral shoulder pain.

Interpretation

Supports a subacromial pain source but does not identify calcific tendinitis. In the acute resorptive phase, pain can be severe and many movements are painful. Pooled sensitivity/specificity for the Hawkins–Kennedy test vary widely across studies (Hegedus 2012); no single confirmed pair is shown. Original description: Hawkins & Kennedy 1980 (Am J Sports Med, not JBJS).

Sources

No accuracy study

Painful Arc Test

Procedure

Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where pain appears and disappears.

Positive Finding

Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.

Interpretation

A mid-range painful arc supports a subacromial source, which includes a calcific deposit in supraspinatus. Imaging confirms calcification. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.; 28 studies, all in patients seen by specialists) found the painful arc the most useful pain-provocation test: a positive arc made rotator cuff disease more likely (likelihood ratio 3.7) and a normal arc made it less likely (0.36). The review reports likelihood ratios rather than one sensitivity and specificity pair, so no figure is shown.

Sources

No accuracy study

Infraspinatus Strength Test (External Rotation at 0° Abduction)

Procedure

Patient seated, arm at the side, elbow bent to 90°. Ask the patient to push outwards against your hand; compare sides.

Positive Finding

Weakness or pain on resisted external rotation.

Interpretation

Pain or weakness suggests posterior cuff involvement, or pain inhibition from a deposit. Weakness in calcific tendinitis is often due to pain rather than a tear. Park (2005) reported the infraspinatus strength test as highly specific (~90%) for rotator cuff disease; sensitivity is lower and a single confirmed pair is not shown.

Sources

No accuracy study

Palpation of the Rotator Cuff

Procedure

Patient seated with the hand behind the back to bring the supraspinatus insertion forward. Palpate just below the anterolateral acromion and along the greater tuberosity.

Positive Finding

Marked focal tenderness over the tendon insertion.

Interpretation

Focal tenderness supports cuff involvement. Palpation cannot identify a calcific deposit; X-ray or ultrasound is needed to confirm it and to plan treatment.

Sources

No accuracy study

Resisted Horizontal Adduction

Procedure

Patient seated, arm at 90° of flexion and internally rotated. Ask the patient to push the arm across the body against resistance.

Positive Finding

Reproduction of the familiar shoulder pain.

Interpretation

Not a recognised test for calcific tendinitis; no test can detect calcium clinically. Pain simply shows this loading position is provocative.

Sources

⚠ Red Flags

  • •Sudden severe pain with inability to move arm (possible rupture)
  • •Signs of infection: fever, spreading erythema, warmth, increased swelling
  • •Neurological signs: numbness, tingling, weakness suggesting nerve compromise
  • •Systemic symptoms: unexplained weight loss, fatigue, fever (possible autoimmune or malignancy)
  • •Severe unrelenting pain unresponsive to conservative treatment lasting >6 weeks
  • •Symptoms following trauma with immediate functional loss

⚡ Yellow Flags

  • •High pain catastrophization or fear-avoidance behaviors limiting movement
  • •Beliefs that calcium deposits are permanent or require surgery
  • •Poor coping strategies or significant anxiety about condition
  • •Work or activity-related fear with potential for kinesiophobia
  • •Expectations for rapid resolution leading to non-compliance with staged recovery
  • •Secondary gain factors or compensation claims

Osteopathic Techniques

Shockwave therapy (ESWT) has moderate evidence for calcific tendinitis. No trials of osteopathic or manual techniques for calcific tendinitis were found.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)No trials found

Rationale

Gentle mobilisation to keep the shoulder moving. No trials in calcific tendinitis.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Calcific Tendinitis

Searched 24 Oct 2026: no trials of shoulder articulation in calcific tendinitis.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular musclesNo trials found

Rationale

Eases tension in the muscles around the shoulder. No trials in calcific tendinitis.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Calcific Tendinitis

Searched 24 Oct 2026: no trials of shoulder soft tissue technique in calcific tendinitis.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracicNo trials found

Rationale

Low-force, patient-powered upper-back technique. No trials in calcific tendinitis.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Calcific Tendinitis

Searched 24 Oct 2026: no trials of thoracic MET in calcific tendinitis.

Rehabilitation Exercises

Pendulum Circles

Range of MotionBeginner

Active-Assisted Shoulder Flexion (using opposite arm or wall slide)

Range of MotionBeginner

Sleeper Stretch (shoulder internal rotation)

StretchingBeginner

Cross-Body Shoulder Stretch (horizontal adduction)

StretchingBeginner

Isometric Shoulder External Rotation (arm at side, neutral elbow)

StrengtheningBeginner

Side-Lying External Rotation with light resistance band

StrengtheningIntermediate

Prone Horizontal Abduction (T-position)

StrengtheningIntermediate

Scapular Retraction (shoulder blade squeeze, standing or seated)

PosturalBeginner

Wall Slides (shoulder flexion-abduction pattern with scapular control)

PosturalIntermediate

Resistance Band Pull-Apart (external rotation emphasis)

StrengtheningIntermediate

Quadruped Shoulder Reach (gentle dynamic mobilization)

Range of MotionIntermediate

Standing Resistance Band Diagonal Patterns (functional reaching)

StrengtheningAdvanced

Referral Criteria

  • •Acute severe pain with complete loss of function not improving after 48 hours of conservative care
  • •Suspected tendon rupture (sudden weakness, complete loss of ability to initiate motion, positive drop-arm test)
  • •Fever, spreading erythema, or systemic signs suggesting infection
  • •Neurological deficits: weakness, sensory changes, or dermatomal patterns
  • •Failure to improve after 6-8 weeks of appropriate conservative treatment
  • •Chronic calcifications causing persistent limitation affecting quality of life despite compliance with rehabilitation
  • •Imaging evidence of large, symptomatic deposits in patients with functional goals requiring intervention
  • •Suspected autoimmune or systemic disease contributing to calcification
  • •Signs of concurrent impingement or rotator cuff tear
  • •Psychological distress or catastrophic pain beliefs affecting recovery trajectory