Synopsis
Recognise the different syndromes produced by basic calcium phosphate deposition, distinguish focal calcific periarthritis from infection and cuff disease, and use imaging, aspiration and staged conservative or procedural treatment safely.
- Basic calcium phosphate includes hydroxyapatite and produces calcific tendinopathy, acute calcific periarthritis, destructive Milwaukee shoulder and crystal-associated osteoarthritis.
- The usual presentation is severe focal shoulder pain from a resorbing rotator-cuff deposit, but deposits can be asymptomatic and may occur around other joints.
- Routine polarised microscopy does not visualise basic calcium phosphate crystals; a negative crystal report therefore does not exclude the disorder.
- Initial imaging for suspected calcific tendinopathy usually includes a plain radiograph; ultrasound localises the deposit, evaluates the cuff and guides aspiration, injection or lavage.
- First-line care is explanation, short relative rest during extreme pain, early range restoration, graded tendon loading and topical or brief oral analgesia matched to risk.
- For one inflamed bursa or joint, ultrasound-guided aspiration and corticosteroid injection is considered only after infection has been excluded and the tendon itself is avoided.
- Persistent symptomatic focal deposits may be considered for ultrasound-guided needling and lavage; extracorporeal shockwave therapy should be used only in research under current NICE guidance.
Key red flags
Fever, rigors, hypotension, an acutely hot effusion or severe pain on passive movement requires urgent septic-arthritis assessment even when calcification is visible.
Recent trauma with inability to abduct, contour change, bony tenderness or neurovascular deficit raises fracture, dislocation or acute rotator-cuff tear rather than uncomplicated calcific tendinopathy.
Rapid joint destruction, a large recurrent haemorrhagic effusion and profound cuff weakness in an older adult suggests Milwaukee shoulder and warrants specialist imaging and aspiration.
A calcified periarticular mass that is enlarging, unusually located or associated with hypercalcaemia, renal failure or skin breakdown needs investigation for tumour, tumoral calcinosis or metastatic calcification.
Night pain, weight loss, previous cancer or a destructive bone lesion is not explained by an incidental tendon deposit and needs an urgent malignancy pathway.
Progressive objective weakness, cervical neurological signs or a persistently pseudoparalytic shoulder requires assessment for full-thickness cuff failure or neurological disease.
An older person, often a woman, develops major painless or painful swelling, recurrent large haemorrhagic effusions, crepitus, instability and profound active-movement loss from cuff failure and rapid destruction.
Investigation priorities
Confirm a peri-tendinous calcium deposit and assess bone, alignment and destructive change.
Management branches
Focal atraumatic shoulder or periarticular pain suggests calcific disease without systemic instability.
- Examine active and passive movement, cuff strength, focal tendon and bursal tenderness, neck and neurovascular status and sepsis or trauma features.
- Request plain radiographs first and use ultrasound when the deposit, bursa or tendon must be localised or a tear or guided procedure is being considered.
- Treat the opacity as causal only when its site, inflammatory phase and clinical pattern agree; pursue adhesive capsulitis, cuff tear, referred pain or OA otherwise.
A symptomatic deposit has no red flag or major tear and function can be managed conservatively.
- Explain the often self-limiting resorptive phase, use ice or heat by preference and allow only short relative rest during intolerable pain.
- Start comfortable range-of-motion work early, then progressive cuff and scapular loading with physiotherapy and work or sleep modification.
- Offer topical NSAID first where suitable; use a brief oral NSAID or paracetamol only after individual renal, gut, cardiovascular, bleeding and pregnancy assessment.