Calcification in the Shoulder: How Ultrasound Guided Us Through Every Phase of Treatment
Pain when raising the arm, especially when bringing it towards horizontal. Uncomfortable nights. Everyday movements, like brushing your hair or reaching for something on a shelf, turned into a challenge. That's how a patient came to KINEO Benidorm with a calcification in the supraspinatus tendon, a common cause of shoulder pain that many people know as calcific tendinitis of the rotator cuff. With this case we're opening a series on how real-time ultrasound changes the way we treat musculoskeletal injuries. Not because of the technique itself, but because it lets us decide by seeing.
What the ultrasound told us
Rotator cuff calcifications aren't static: they go through different phases as they evolve, and ultrasound lets us tell them apart. In the resting phase, the deposit appears as a bright focus with an acoustic shadow behind it and no blood flow signal (Doppler). In the resorptive phase, by contrast, it looks fragmented and irregular, with flow around it (Cesarec et al., 2020).
The initial ultrasound, on 30 June, showed a deposit of around 8 mm with a very sharp edge and a complete acoustic shadow: the ultrasound bounces off it like off a stone. It's the typical pattern of a hard calcification, in the resting phase.
The problem was twofold. First, when raising the arm towards 90°, the deposit knocked against the acromial arch — what's known as mechanical conflict or subacromial impingement — which explained the pain. Second, a calcification this hard can take a long time to resorb on its own. The body eventually clears the calcium, but at its own pace, and that pace can mean months of pain.
The decision: setting the clean-up in motion
To understand the strategy, let's go back to the building-site analogy. The body clears calcium through an inflammatory reaction in which macrophages act like the emergency crew that clears the rubble. In a hard calcification, that crew hasn't arrived yet. Our hypothesis was to call them in, in a controlled way.
To do this we applied ultrasound-guided percutaneous electrolysis with the EPTE system, in this case at high intensity: 6 mA, in four pulses of four seconds. This is the dosage that triggers a more intense local inflammatory response. We prioritised intensity for two reasons: the patient tolerated it well, and every week of friction between the acromion and the calcification meant more irritation for the tendon. Ultrasound let us place the needle exactly in the deposit and watch the galvanic effect in real time.
We complemented this with resistive diathermy in thermal mode to increase blood flow in the area, with the idea of encouraging clean-up cells to arrive and aiding drainage.
It's worth being clear: using electrolysis to speed up the resorption of a calcification is our own clinical reasoning. It extrapolates the mechanism by which this technique is used in tendinopathies to restart tissue repair, and there are still no studies that have specifically evaluated it in calcifications.
Three weeks later
After three sessions, on 21 July, the picture was different. The acoustic shadow had practically disappeared and the deposit no longer had a sharp edge: it looked like an amorphous patch. That's the appearance of a softer calcification, in the resorptive phase. The patient also reported a clear reduction in pain.
With the calcium in that state, we referred her to Orthopaedics for a barbotage, an ultrasound-guided lavage in which the deposit is fragmented and aspirated with a needle. Soft calcium is aspirated more easily than hard calcium, which is why the timing mattered. This procedure has scientific backing: in a clinical trial, barbotage combined with injection gave better results at one year than injection alone (de Witte et al., 2013), although at five years the function of both groups had evened out (de Witte et al., 2017).
The barbotage was performed with local anaesthetic and PRGF (plasma rich in growth factors), and afterwards the pain disappeared completely. After a week of active rest and a gradual return to exercise, the patient got back to her normal life: work, sport and daily activity.
What this case teaches us
A single case doesn't prove that a technique works. The calcification might have evolved the same way regardless, and several treatments played a part in the recovery. What it does illustrate is the value of deciding by seeing: ultrasound told us what phase the calcification was in, guided the needle, confirmed the change, and marked the right moment to refer her on.
At KINEO Benidorm, ultrasound is part of every shoulder assessment. If you have pain when raising your arm, find out more about our shoulder specialty or our invasive EPTE physiotherapy, and request your assessment.
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