Few shoulder conditions are as painful or as confusing as calcific tendonitis. You might wake up one morning with searing pain in your shoulder that came from nowhere. You cannot lift your arm, sleep on that side or reach behind your back. An X-ray or ultrasound shows a calcium deposit sitting inside one of your rotator cuff tendons, most commonly the supraspinatus.

The natural question is: why is there calcium in my tendon, and what do I do about it?

What is calcific tendonitis?

Calcific tendonitis (also called calcific tendinopathy) is a condition where calcium crystals form within a rotator cuff tendon. The supraspinatus tendon is affected in roughly 80% of cases, though any rotator cuff tendon can be involved (Chianca et al., 2018).

It is surprisingly common. Studies estimate that calcium deposits are present in 2.5% to 20% of asymptomatic shoulders, meaning many people have them without knowing it (ElShewy, 2016). The condition tends to affect people between the ages of 30 and 60 and is more common in women.

The stages: why pain comes and goes

This is where calcific tendonitis gets interesting, and where understanding the process changes how you think about your pain.

The condition progresses through distinct stages (ElShewy, 2016; Chianca et al., 2018):

1. Pre-calcific stage. The tendon undergoes cellular changes. There is usually no pain at this point and nothing visible on imaging.

2. Formative (calcific) stage. Calcium crystals are actively deposited within the tendon. The deposit is chalk-like and well-defined on imaging. Pain during this phase is typically mild or moderate, often described as a dull ache with overhead activities.

3. Resorptive stage. This is the stage that brings most people to the clinic. Your body recognises the calcium deposit as something that should not be there and launches an inflammatory response to reabsorb it. The deposit becomes soft and paste-like. Blood vessels grow into the area. Pressure builds inside the tendon.

This is when the pain can be extreme: sudden onset, severe, often waking you at night. It can feel like the worst shoulder pain you have ever experienced. But here is the important part: this intense pain is actually a sign that your body is actively breaking down and clearing the deposit. The resorptive phase is your body healing itself.

4. Post-calcific stage. The calcium is reabsorbed and the tendon remodels. Pain resolves. In many cases, the tendon returns to normal.

Does it go away on its own?

In many cases, yes. The natural history of calcific tendonitis is generally favourable. A significant proportion of calcium deposits will resorb spontaneously over time (Saran et al., 2024; Greis et al., 2015). The challenge is that the timeline is unpredictable. Some deposits clear within months. Others persist for years.

The resorptive phase, when the body is actively breaking down the deposit, is the most painful but also the most encouraging. If you are in severe pain, it may actually mean the condition is resolving.

How to treat it

Treatment depends on which stage you are in and how much the pain is affecting your life.

Conservative management

Most cases of calcific tendonitis respond to non-surgical treatment. A systematic review and meta-analysis by Angileri and colleagues (2023) comparing operative and nonoperative approaches found that both produced significant improvements, with no clear superiority of surgery over conservative care for most patients.

Conservative treatment typically includes:

Manual therapy and joint mobilisation. Restoring normal shoulder mechanics and addressing compensatory stiffness in the thoracic spine and neck reduces the mechanical load on the affected tendon. When the shoulder is not moving well, the supraspinatus works harder than it should.
Targeted rehabilitation. Progressive strengthening of the rotator cuff and scapular stabilisers is essential. The goal is to improve the tendon’s capacity to handle load, reduce impingement and support the shoulder through recovery. This is not optional: it is the foundation of long-term improvement.
Activity modification. Avoiding aggravating overhead movements during the acute phase, while maintaining as much normal function as possible. Complete rest is rarely helpful and can lead to stiffness and deconditioning.
Pain management. During the resorptive phase, the inflammation is actually your body’s mechanism for clearing the deposit. Suppressing it aggressively with anti-inflammatory medication may slow that process. Paracetamol can help take the edge off. If the pain is severe, speak to your GP about appropriate short-term options that balance pain relief with allowing the healing process to continue.

What if conservative care does not resolve it?

Most patients respond well to the approach above. But if a deposit is large, persistent and not improving after a sustained course of conservative treatment, there are further options we can refer you for:

Shockwave therapy (ESWT). Focused acoustic waves break up the deposit and stimulate resorption. The evidence supports its effectiveness for calcific tendonitis (Xue et al., 2024; Mouzopoulos et al., 2007).
Ultrasound-guided barbotage. A needle is used under ultrasound guidance to break up and aspirate the deposit. Effective for large or stubborn deposits (Gatt and Charalambous, 2014).
Surgery. Arthroscopic removal is a last resort. The evidence does not suggest it produces better outcomes than non-surgical approaches for most patients (Angileri et al., 2023).

What to expect during recovery

Recovery from calcific tendonitis is rarely linear. There are a few things worth knowing:

The resorptive phase can be intensely painful but temporary. If your pain suddenly gets much worse, it may be a sign the deposit is breaking down. This is a good thing, even though it does not feel like it.
Deposits can migrate. As calcium is resorbed, it can move into the surrounding bursa (the fluid-filled sac above the tendon), causing bursitis. This can create a temporary flare of pain but usually settles as the calcium clears (Saran et al., 2024).
Rehabilitation continues after the pain settles. Once the acute phase passes, building strength and restoring full range of motion prevents recurrence and addresses any compensatory patterns that developed while you were in pain.
Recurrence is possible but not common. Most people who go through a full course of treatment and rehabilitation do well long-term.

When to get help

If you have shoulder pain that is not settling, particularly if it is severe, waking you at night or limiting your ability to use your arm, it is worth getting it assessed. An ultrasound or X-ray can confirm whether a calcium deposit is present and which stage it is in. From there, the right treatment plan depends on your specific situation.

At our Sandton practice, we regularly treat shoulder pain from a range of causes including calcific tendonitis. We can assess your shoulder, identify what is driving your symptoms and build a rehabilitation programme around your needs. If imaging, shockwave therapy or a referral for barbotage is appropriate, we can arrange that too.

Get in touch or book an appointment.

References

CALCIFIC TENDONITIS: WHAT IT IS, WHAT TO EXPECT AND HOW TO TREAT IT