The severe shoulder pain often comes on suddenly: a calcified shoulder affects more people than know about it. However, the calcified tendons only become noticeable in the advanced stage. FOCUS Online asked doctor Robert Drechsel which therapy makes sense.
Shoulder pain is often cruel. They often come from calcifications in and on the tendons of the shoulder joint. This joint is an exception compared to the other joints in the human organism: it is the most flexible, because the joint head of the humerus is not attached to the joint socket, but is only supported flexibly by a solid muscle ring, the rotator cuff.
In this way, movements in almost all directions are possible. Changes in this tendon network, such as calcification, can lead to the so-called calcified shoulder, medical tendinosis calcarea. The disease develops in different phases, initially usually unnoticed by those affected.
Only when a certain stage has been reached do acute problems arise – above all, excruciating pain. Immediate help from the doctor is then essential, after that: further treatment. FOCUS Online talked about symptoms and therapy with Robert Drechsel, specialist in orthopedics and trauma surgery at the ONZ in Weiden.
FOCUS Online: How do I notice that my shoulder pain is caused by an acute calcified shoulder?
Robert Drechsel: The acute pain can be so severe that those affected come into the practice in tears. However, shoulder pain can have a variety of causes, only one of which is calcification with an acute inflammatory reaction of the tendon. The supraspinatus tendon, i.e. one of the tendons of the rotator cuff, is usually affected here.
The most common symptom of a painful shoulder is impingement symptoms. A summary of several possible causes of shoulder pain – for example problems in the bones, muscles or tendons if they are accompanied by a narrowing of the space under the acromion and straining of tendons.
The cause of the calcified shoulder is therefore calcified tendon tissue. Isn’t this also possible in other joints apart from the shoulder?
Drechsel: Yes, for example on the hip, knee or elbow – but most often on the shoulder.
How do these calcifications form on the tendons?
Drechsel: Risk factors are incorrect strain on the shoulder, so-called micro-traumas, but also frequent overhead work. Diabetes mellitus is also a risk factor. Poor posture when working on a computer, for example, but also lack of exercise and, last but not least, previous tendon injuries can trigger shoulder pain.
It is not yet known exactly why the calcifications then develop. The trigger, it is suspected, could be a lack of oxygen. In any case, it is known that the following stages are passed through: the pre-calcification, the calcification and the post-calcification stage.
So there is also a calcified shoulder without symptoms?
Drechsel: The lime as such is not decisive. It mainly depends on the size of the lime deposits. Smaller ones hardly restrict shoulder mobility, there is no inflammation and those affected do not notice anything about their calcified shoulder. This is comparable to the heel spur. Many have this bony outgrowth but never experience any discomfort.
How does it come to the other to the severe pain?
Drechsel: If the lime deposits change, the lime deposit can burst, it empties itself. The escaping calcium crystals irritate the bursa and it can become inflamed. So it is only when the lime breaks through and inflammation develops that most people experience very sudden and severe symptoms such as pain, often combined with massive restriction of shoulder mobility. After the calcium deposit has burst, the body begins to absorb the calcium.
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So the calcified shoulder can heal on its own?
Drechsel: Yes, a dismantling phase begins. This is also the reason why the calcified shoulder can usually be treated conservatively.
Let’s stay with the acute case – what do you do when someone with extreme shoulder pain comes to the practice?
Drechsel: I examine the patient manually, there are various shoulder tests. The calcified shoulder can then usually be visualized relatively well using ultrasound. In addition to this diagnosis, an X-ray can determine the extent of the calcification and thus determine the degree and stage.
Which therapy do you start with?
Drechsel: That mainly depends on the intensity of the pain. In the event of severe pain, we treat it immediately with injections – for example under the acromion with cortisone and a local anesthetic. The patient usually feels better immediately.
Otherwise, we recommend common medication such as NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen or diclofenac during the pain phase, provided there are no contraindications. Alternatively, shock therapy with oral steroids can also be considered.
Some patients tend to refuse cortisone injections. What is your opinion on this?
Drechsel: Cortisone is actually somewhat controversial in the treatment of tendon disorders. It is known that cortisone should not be injected directly into the tendon because this can lead to tendon necrosis and tears in the tendon. You can inject cortisone around the tendons with relatively little risk, but if this is done too close under the skin, the subcutaneous fatty tissue can break down and unsightly dents form. Therefore, the indication for cortisone infiltration is always made individually for the individual patient and their clinical picture.
More modern substances, such as hyaluronic acid specially developed for injection around tendons, are suitable for the treatment of tendinopathy, for example.
Another method, which is now becoming increasingly accepted and is being tested in studies, is plasma therapy ACP (autologous conditioned plasma) with the patient’s own blood. Blood is taken from the patient and processed in a centrifuge. The blood plasma and platelets obtained in this way are injected back into the patient and injected locally around the tendon. The treatment aims to reduce pain and inflammation, promote healing and regeneration. Our experience with it is very good.
Movement as a therapy, as with other orthopedic problems, is probably not good advice for acute calcified shoulders at first?
Drechsel: Reducing stress and, if necessary, immobilising is important during the acute phase, for example with a special arm sling. Movement exercises are therefore not an option for the time being, during the inflammatory phase.
How can the absorption, i.e. the self-healing of the body, be supported? What do you think of extracorporeal shock wave therapy, ESWT for short?
Drechsel: This treatment is increasingly recognized. Studies show that it could have a positive effect on both calcium absorption and tendon changes. Above all, the new, high-energy and focused shock waves have proven themselves in the treatment of calcified shoulders. The treatment provider can use the penetration depth at which the shock wave develops its main effect, as well as the required energy dose, individually adjusted for the respective patient. This is important because every patient has, for example, a differently developed “soft tissue coat”.
The effect is based on the direct stimulus in the tissue and the additional indirect stimulation that stimulates the “self-healing processes” biochemically. The main aim is to regenerate the tendon.
The following happens with ESWT: The focused shock waves act on different levels, the cell membrane becomes more permeable, the mitochondria are activated and overall a bactericidal and anti-inflammatory effect is created, which promotes regeneration.
What natural aids do you recommend for a calcified shoulder?
Drechsel: It can be cold therapy or quark pads, they have proven themselves in many patients.
When the inflammation has subsided, is exercise therapy coming up?
Drechsel: That’s one of the most important parts. The physiotherapist teaches the right exercises and works on the bad posture. For example, sagging shoulders cause a narrowing under the acromion. This risk also exists when muscles are missing and the head slides up as a result. This tightness is irritating and leads to impingement.
Active training, preferably carried out regularly on your own, ensures the long-term success of the treatment. We have the option of providing individual training plans tailored to the disease.
Acute treatment with injections, ESWT, compresses and then exercise therapy are thus the most important factors in the treatment of calcified shoulder. How successful is this and when is an operation still necessary?
Drechsel: Surgery is only an option if these conservative measures do not work properly after three to six months, or if the pain cannot be treated. However, this is very rarely the case; it is probably a little less than ten percent of patients with problems caused by a calcified shoulder.
What happens during the operation? Are the lime deposits sucked off?
Drechsel: The procedure is usually arthroscopic, i.e. using a keyhole technique. In this way, the inflamed bursa can be removed, the tendon can be assessed and, in most cases, the calcification can be removed without any problems.
In some cases, however, an open approach with a small so-called “mini-open” access is necessary. Incidentally, there is no evidence that the minimally invasive procedure achieves a better result than the open operation in connection with the calcified shoulder.
What is the success rate of these operations on the calcified shoulder?
Drechsel: It doesn’t matter whether it’s an operation or only conservative treatment – both are successful, but pain can also remain. But especially if the pain was very severe and other therapies had little success, the operation can bring immediate relief because inflammation and calcium have been eliminated.
After that, it probably depends on the patient whether this success lasts or whether painful calcium deposits occur again, right?
Drechsel: The shoulder operation is only half the way. Good physiotherapy and the patient’s own commitment determine whether the success is permanent. But for anyone who has ever had orthopedic problems, the motto is: keep moving. Not only do you prevent calcified shoulders or prevent the condition from getting worse, but daily exercise is also indispensable for a whole range of other health problems and for prevention.
True to the motto of American scientists, sitting has a similarly devastating effect as inhaling tobacco, they say, referring to studies that certify that people who sit for more than six hours a day reduce their life expectancy by 20 percent. or to put it simply: who rests, he rusts. Which brings us to the subject of arthrosis, osteoporosis and other orthopedic problems.