Calcific Tendinitis — বাংলা Clinical Note
প্রধান site: Shoulder-এর rotator cuff tendon, বিশেষ করে supraspinatus tendon। AAOS অনুযায়ী calcific tendinitis হলো rotator cuff tendon-এর ভিতরে calcium deposit জমা হওয়া, যা inflammation এবং mechanical impingement তৈরি করে shoulder pain সৃষ্টি করে।
Clinical focus: নিচের management adult shoulder calcific tendinitis ধরে লেখা। Renal disease, peptic ulcer, anticoagulant use, pregnancy, uncontrolled HTN/DM থাকলে dose individualize করতে হবে।
1. Definition / সংজ্ঞা
Calcific tendinitis হলো tendon-এর ভিতরে calcium hydroxyapatite crystal deposition হওয়া, যার ফলে tendon inflammation, severe pain, tenderness, stiffness এবং shoulder movement limitation হয়।
বাংলায় সহজভাবে:
কাঁধের tendon-এর ভিতরে চুন/ক্যালসিয়াম জাতীয় পদার্থ জমে tendon ফুলে যায় ও ব্যথা করে—এটাই calcific tendinitis।
2. Cause / Etiology / Pathophysiology — কারণগুলো
মূল কারণ
- Exact cause unknown / Idiopathic: অধিকাংশ ক্ষেত্রে নির্দিষ্ট কারণ পাওয়া যায় না। AAOS বলছে 30–60 বছর বয়সী adult এবং female sex-এ risk বেশি; tendon overuse-এর সাথে association থাকতে পারে।
- Tendon overuse / repeated microtrauma: বারবার overhead কাজ, heavy lifting, repetitive shoulder movement tendon cell injury ও local inflammation বাড়াতে পারে।
- Degenerative tendon change: বয়স বা chronic mechanical stress-এর কারণে tendon-এর normal collagen structure দুর্বল হয়।
- Fibrocartilaginous metaplasia: tendon cell fibrocartilage-like tissue-এ পরিবর্তিত হয়ে calcium deposition-এর পরিবেশ তৈরি করে। Review literature-এ stages হিসেবে precalcific → calcific → postcalcific phase বর্ণনা করা হয়; calcific phase আবার formative, resting, resorptive phase-এ ভাগ করা হয়।
- Resorptive phase pain: calcium deposit যখন body reabsorb করতে শুরু করে, তখন inflammatory reaction বেশি হয়—এই সময় acute severe pain বেশি হয়।
- Metabolic association: Diabetes mellitus ও thyroid disorder-এর সাথে calcific tendinopathy বেশি দেখা যেতে পারে—তাই recurrent/bilateral case-এ metabolic screening clinically useful।
3. Symptoms / Clinical Features — লক্ষণগুলো
- Shoulder pain: সাধারণত shoulder-এর front বা lateral side-এ pain/tenderness থাকে।
- Acute severe pain: অনেক সময় trauma ছাড়াই হঠাৎ তীব্র pain শুরু হয়; রোগী arm তুলতে পারে না।
- Night pain: রাতে ব্যথা বাড়ে, affected side-এ শুতে পারে না।
- Painful arc: হাত 60–120° abduction করলে pain বাড়ে—subacromial impingement pattern।
- ROM limitation: active movement কমে যায়; severe pain থাকলে passive movement-ও painful হতে পারে।
- Stiffness: দীর্ঘদিন থাকলে adhesive capsulitis-like stiffness হতে পারে।
- Weakness: true weakness না হয়ে pain inhibition-এর কারণে arm weak মনে হয়; rotator cuff tear থাকলে true weakness থাকে।
- Local tenderness: greater tuberosity/subacromial area-এ tenderness পাওয়া যায়।
- Functional limitation: কাপড় পরা, চুল আঁচড়ানো, overhead reach, back pocket reach করতে কষ্ট হয়।
4. Clinically Diagnosis — Clinical Diagnosis কীভাবে করবেন
History
- Pain onset: acute না chronic
- Trauma history আছে কি না
- Night pain আছে কি না
- Overhead activity/occupation
- Diabetes, thyroid disease, CKD, rheumatologic disease
- Previous injection/physiotherapy/surgery
- Red flag: fever, severe swelling, systemic illness, chest pain, cervical radicular pain
Examination
- Inspection: shoulder posture, swelling, muscle wasting
- Palpation: greater tuberosity, subacromial bursa, AC joint
- ROM: active + passive abduction, flexion, external/internal rotation
- Painful arc test: 60–120° pain
- Impingement tests: Neer, Hawkins-Kennedy
- Rotator cuff strength: Jobe/empty-can, external rotation lag, lift-off/belly-press
- Cervical screen: Spurling test, neck ROM, neurological exam
- Neurovascular exam: sensory, motor, pulse
AAOS clinical exam-এ tenderness, arm movement, passive stiffness, strength, এবং associated shoulder problem evaluate করার কথা উল্লেখ করেছে।
5. Investigations — Specific Investigation
1) X-ray shoulder — first-line
Views: AP internal rotation, AP external rotation, scapular Y view, axillary view.
Finding: rotator cuff tendon area-এ radio-opaque calcium deposit দেখা যায়। X-ray soft tissue দেখায় না, কিন্তু calcium deposit দেখাতে পারে।
2) Ultrasound shoulder
- Calcium deposit-এর size, consistency, exact location দেখা যায়
- Subacromial bursitis, rotator cuff tear, dynamic impingement assess করা যায়
- Injection/lavage/barbotage guidance-এর জন্য useful
3) MRI shoulder
- Routine case-এ সবসময় দরকার নেই
- Indication: suspected rotator cuff tear, atypical pain, failed conservative treatment, pre-operative planning
- MRI fluid, inflammation, rotator cuff tear এবং calcium build-up confirm করতে পারে।
4) Blood tests — routine নয়, selected case
- CBC, ESR, CRP: fever/infection/inflammatory arthritis suspicion
- FBS/HbA1c: diabetes association/recurrent case
- TSH: thyroid disorder suspicion/recurrent-bilateral case
- Serum calcium/phosphate/PTH: unusual diffuse calcification/metabolic suspicion
- Uric acid: gout differential হলে
6. Differential Diagnosis
- Rotator cuff tendinopathy / tear
- Subacromial bursitis
- Shoulder impingement syndrome
- Adhesive capsulitis
- AC joint arthritis
- Glenohumeral osteoarthritis
- Biceps tendinitis
- Cervical radiculopathy
- Septic arthritis — fever, severe toxic patient
- Gout/pseudogout
- Referred cardiac pain — left shoulder pain with chest symptoms
7. Complication of Disease — রোগের জটিলতা
- Chronic shoulder pain: untreated হলে pain months ধরে থাকতে পারে।
- Restricted ROM: pain-এর কারণে shoulder নাড়ানো কমে যায়, পরে stiffness তৈরি হয়।
- Adhesive capsulitis: দীর্ঘদিন immobilization করলে frozen shoulder হতে পারে।
- Subacromial impingement: calcium deposit acromion-এর নিচে rubbing করে movement pain বাড়ায়।
- Rotator cuff tear: chronic inflammation বা procedure-related tendon weakening থাকলে tear হতে পারে।
- Sleep disturbance: night pain-এর জন্য sleep quality কমে যায়।
- Functional disability: dressing, bathing, overhead activity, work productivity কমে যায়।
- Recurrence: calcium deposit resolve হওয়ার পরও কিছু patient-এ পুনরায় pain/deposit হতে পারে।
8. Treatment / Management — Guideline-based Practical Approach
AAOS অনুযায়ী treatment goal হলো pain কমানো ও function restore করা; initial management বেশিরভাগ ক্ষেত্রে nonsurgical—rest, NSAID, physiotherapy, steroid injection, shockwave therapy, saline lavage; failed case-এ arthroscopic removal করা হয়।
A. Non-pharmacological Management
Acute severe pain phase — first 1–2 weeks
- Relative rest; complete immobilization দীর্ঘদিন নয়
- Overhead work, heavy lifting, painful arc activity avoid
- Ice pack 15–20 min, দিনে 3–4 বার
- Sling only short period, severe pain হলে 2–3 দিন
- Gentle pendulum exercise as tolerated
Subacute phase
- Physiotherapy:
- Pendulum exercise
- Passive → active-assisted ROM
- Posterior capsule stretch
- Scapular stabilization
- Rotator cuff strengthening pain কমলে
- Posture correction
- Gradual return to activity
Persistent/chronic case
- ESWT: chronic calcific tendinitis-এ pain/function improvement এবং calcium resorption-এ evidence আছে; high-energy ESWT-এর systematic review positive ফল দেখিয়েছে।
- US-guided barbotage/lavage: calcium deposit needle দিয়ে break/aspirate করা হয়; তবে 2023 BMJ RCT lavage + steroid বনাম sham treatment-এ clear benefit পায়নি, তাই patient selection গুরুত্বপূর্ণ।
- Surgery: 3–6 মাস conservative treatment fail, severe disability, large deposit, associated rotator cuff tear হলে arthroscopic calcium removal ± cuff repair।
9. Pharmacological Treatment — Bangladesh Prescription-style Drug List
Important prescribing rule
একসাথে ২টি oral NSAID দেবেন না — যেমন aceclofenac + naproxen + etoricoxib একসাথে নয়। GI bleed, renal injury, BP rise, CV risk বাড়ে।
1) Paracetamol
Generic name: Paracetamol / Acetaminophen
Therapeutic category: Analgesic, antipyretic
Pharmacological class: Para-aminophenol derivative; central analgesic
Why used: Mild–moderate pain control; NSAID contraindicated হলে safer option
Adult dose: 500 mg–1 g PO every 6–8 hours PRN
Max dose: সাধারণত 3–4 g/day; liver disease/alcohol use/low body weight হলে কম
Duration: 3–7 days PRN
Bangladesh available brand examples: Napa Rapid 500 mg, G-Paracetamol 500 mg, Neopara 500 mg — MedEx paracetamol brand list-এ এসব strength দেখা যায়।
Side effects: Usually safe; overdose হলে hepatotoxicity, nausea, rash
Interactions: Alcohol, enzyme inducer, warfarin long-term high dose
Specific purpose: Calcific tendinitis-এ baseline analgesia; gastritis/CKD patient-এ NSAID alternative হিসেবে useful।
2) Aceclofenac
Generic name: Aceclofenac
Therapeutic category: NSAID; drugs for osteoarthritis/rheumatoid arthritis
Pharmacological class: Non-selective COX inhibitor NSAID
Why used: Pain + inflammation কমাতে; acute painful shoulder tendinitis-এ commonly prescribed
Adult dose: 100 mg PO twice daily after meal
SR option: 200 mg once daily after meal
Duration: 5–10 days; chronic use avoid unless reviewed
Bangladesh available brand examples: Flexi 100 mg / Flexi SR 200 mg, Reservix 100 mg / Reservix SR 200 mg, Movex 100 mg / Movex SR 200 mg, Avenac 100 mg, Ceclofen 100 mg, Ufenac 100 mg / Ufenac SR 200 mg — MedEx list-এ available strengths হিসেবে আছে।
Side effects: Dyspepsia, epigastric pain, nausea, diarrhea, dizziness, edema; serious—GI bleeding, renal impairment, BP rise
Interactions: Lithium/digoxin level বাড়াতে পারে; diuretic effect কমাতে পারে; anticoagulant effect বাড়াতে পারে; methotrexate toxicity বাড়াতে পারে।
Avoid/caution: Peptic ulcer, CKD, uncontrolled HTN, heart failure, anticoagulant, aspirin-sensitive asthma, pregnancy late trimester
Specific purpose: Inflammatory tendon pain কমানো; painful ROM improve করা।
3) Naproxen Sodium
Generic name: Naproxen sodium
Therapeutic category: NSAID; drugs for osteoarthritis/rheumatoid arthritis
Pharmacological class: Non-selective COX-1/COX-2 inhibitor
Why used: Tendinitis/bursitis pain + inflammation; longer duration pain control
Adult dose: 500 mg initially, then 250 mg every 6–8 hours PRN; common practical regimen 500 mg twice daily after meal
Max: 1000 mg/day generally
Duration: 5–10 days
Bangladesh available brand examples: Naprosyn 250/500 mg, Naprox 250/500 mg, Naxin 250/500 mg, Sonap 250/500 mg, Napro-A 250/500 mg, Ecless 250/500 mg, Diproxen 250/500 mg — MedEx naproxen list-এ tendonitis/bursitis indication ও available strengths উল্লেখ আছে।
Side effects: Heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, vertigo, drowsiness, edema, palpitation।
Interactions: ACE inhibitor effect কমাতে পারে, diuretic effect কমাতে পারে, warfarin/SSRI-এর সাথে GI bleeding risk বাড়ায়, methotrexate toxicity বাড়ায়।
Specific purpose: Moderate inflammatory pain; night pain থাকলে longer acting NSAID হিসেবে useful।
4) Etoricoxib
Generic name: Etoricoxib
Therapeutic category: NSAID / COX-2 inhibitor
Pharmacological class: Selective COX-2 inhibitor
Why used: Pain + inflammation কমাতে, especially gastritis-prone patient-এ non-selective NSAID-এর তুলনায় GI tolerability কিছুটা ভালো হতে পারে; তবে CV/BP risk মনে রাখতে হবে
Adult dose: 60 mg once daily mild–moderate pain; 90 mg once daily severe inflammatory pain; acute severe pain short course 90–120 mg once daily clinician judgment
Duration: 3–7 days; lowest effective dose, shortest duration
Bangladesh available brand examples: Oricox 30/60/90/120 mg, Recox 60/90 mg, G-Cox 90/120 mg, Neocox 60/90 mg, Powercox 90 mg, Medricox 90/120 mg — MedEx brand list-এ এসব strength আছে।
Side effects: Dyspepsia, abdominal pain, nausea, diarrhea, dizziness, edema, BP rise; serious—MI/stroke risk in high-risk patient
Interactions: Warfarin/anticoagulant, ACEI/ARB/diuretic, lithium, methotrexate; other NSAID avoid
Avoid/caution: Ischemic heart disease, stroke history, uncontrolled HTN, CKD, heart failure
Specific purpose: Short-course anti-inflammatory analgesic when strong pain control needed.
5) Diclofenac gel / topical NSAID
Generic name: Diclofenac sodium / diclofenac diethylamine topical
Therapeutic category: Topical NSAID analgesic
Pharmacological class: COX inhibitor NSAID
Why used: Local pain relief; systemic NSAID risk কমাতে topical option
Dose: Affected shoulder area-এ thin layer দিনে 3–4 বার; intact skin only
Duration: 7–14 days
Bangladesh available brand examples: DicloGel 1% w/w, Voligel 1% w/w, Voligel Max 2% w/w, Voltagel 1% w/w, Voltagel DS 2% w/w, Diclomol 1% w/w — MedEx diclofenac sodium list-এ topical gel strengths দেখা যায়।
Side effects: Local burning, rash, itching, photosensitivity; systemic absorption কম হলেও NSAID caution থাকে
Interactions: Oral NSAID/anticoagulant-এর সাথে caution, কিন্তু systemic interaction কম
Specific purpose: Mild localized pain, adjunct to physiotherapy.
6) Esomeprazole — gastroprotection, disease treatment নয়
Generic name: Esomeprazole
Therapeutic category: Anti-ulcerant / acid suppression
Pharmacological class: Proton pump inhibitor, PPI
Why used: NSAID-associated dyspepsia/gastritis/ulcer risk কমাতে; calcific tendinitis নিজে treat করে না
Dose: 20 mg once daily 30 min before breakfast; high-risk patient 20–40 mg/day
Duration: NSAID যতদিন, সাধারণত 5–14 days; ulcer history থাকলে longer clinician judgment
Bangladesh available brand examples: Maxpro 20 mg, Sergel 20/40 mg, Pronex 20/40 mg, Erazole 20/40 mg, Esoral MUPS 20/40 mg, Maxpro MUPS 20 mg, Exium MUPS 20/40 mg — MedEx esomeprazole list-এ available strengths আছে।
Side effects: Headache, diarrhea/constipation, abdominal discomfort; long-term—B12/Mg deficiency, infection risk
Interactions: Clopidogrel effect reduce করতে পারে, warfarin/antiepileptic monitoring দরকার, long-term methotrexate high dose caution
Specific purpose: NSAID prescription-এর সাথে gastric protection।
7) Tizanidine — only if painful muscle spasm আছে
Generic name: Tizanidine hydrochloride
Therapeutic category: Skeletal muscle relaxant
Pharmacological class: Centrally acting α2-adrenergic agonist muscle relaxant
Why used: Shoulder/neck protective muscle spasm থাকলে short-term spasm relief; calcific deposit dissolve করে না
Dose: 2 mg PO at night or 2 mg 2–3 times daily; sedation থাকলে night dose preferable
Duration: 3–5 days, rarely 7 days
Bangladesh available brand examples: Relentus 2 mg, Sirdalud 2 mg, Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg — MedEx brand list-এ আছে।
Side effects: Sedation, dizziness, hypotension, dry mouth, weakness, liver enzyme rise
Interactions: Ciprofloxacin/fluvoxamine avoid; alcohol/benzodiazepine/sedative additive sedation; antihypertensive-এর সাথে hypotension
Specific purpose: Pain-induced muscle spasm কমানো, sleep improve করা।
8) Subacromial corticosteroid injection — specialist procedure
Generic name: Triamcinolone acetonide injection
Therapeutic category: Corticosteroid
Pharmacological class: Synthetic glucocorticoid anti-inflammatory
Why used: Severe pain/subacromial bursitis/failed oral NSAID + physio হলে local inflammation কমাতে
Typical dose: Triamcinolone acetonide 20–40 mg subacromial bursa ± local anesthetic; ultrasound guidance preferred
Frequency: Usually single injection; repeat injection cautiously, tendon weakening risk বিবেচনা করে
Administered by: Orthopedics/PM&R/rheumatology trained clinician
Bangladesh available brand examples: Cenolon 40 mg/ml, Alfacort 40 mg/ml, Cynocort 40 mg/ml, Intracort 40 mg/ml, Trialon 40 mg/ml, Triamon 40 mg/ml — MedEx triamcinolone injection list-এ available।
Side effects: Post-injection flare, local pain, skin depigmentation/atrophy, transient hyperglycemia, infection, tendon rupture risk; systemic steroid effects rare but possible। MedEx corticosteroid adverse effects হিসেবে glucose intolerance, skin/subcutaneous atrophy, post-injection flare, tendon rupture ইত্যাদি উল্লেখ করে।
Interactions: NSAID/aspirin-এর সাথে GI side effect risk বাড়তে পারে; ketoconazole steroid effect বাড়াতে পারে; enzyme inducer steroid metabolism বাড়াতে পারে।
Specific purpose: Acute inflammatory pain rapidly reduce করে physiotherapy শুরু করতে সাহায্য করা।
9) Local anesthetic with injection
Generic name: Lidocaine hydrochloride injection
Therapeutic category: Local anesthetic
Pharmacological class: Amide-type local anesthetic; voltage-gated sodium channel blocker
Why used: Diagnostic/therapeutic injection বা lavage procedure-এ immediate pain relief ও procedure anesthesia
Dose: Site-specific; subacromial injection-এ সাধারণত 1–2% lidocaine small volume ব্যবহার হয়; max dose সাধারণত 4.5 mg/kg without adrenaline, তবে procedural guideline follow করতে হবে
Duration: Single procedure only
Bangladesh available brand examples: Chemocain 2%, G-Lidocaine 2%, Jasocaine 1/2/4%, Lidocaine 2%, Locaine 2%, Z-Lidocaine 2% — MedEx lidocaine injection list-এ আছে।
Side effects: Dizziness, tremor, drowsiness, seizure, hypotension, bradycardia, allergic reaction rare; intravascular injection হলে toxicity risk।
Interactions: Cimetidine ও beta-blocker lidocaine level বাড়াতে পারে; suxamethonium duration prolong করতে পারে।
Specific purpose: Injection/lavage procedure pain-free করা; diagnostic local anesthetic response assess করা।
10. Bangladesh doctors commonly prescribe — Practical prescription pattern
Mild pain
- Paracetamol 500 mg–1 g SOS/TDS
- Diclofenac gel local application
- Physiotherapy + activity modification
Moderate inflammatory pain
- Aceclofenac 100 mg BD after meal or Naproxen 500 mg BD after meal
- Esomeprazole 20 mg OD before breakfast if gastritis/ulcer risk
- Topical diclofenac gel adjunct
Severe acute painful calcific tendinitis
- Etoricoxib 90 mg OD short course or Naproxen/Aceclofenac — one NSAID only
- PPI gastroprotection
- Short sling + ice + early ROM
- If pain uncontrolled: subacromial corticosteroid injection by specialist
Persistent pain >6–12 weeks
- X-ray + ultrasound reassessment
- Structured physiotherapy
- Consider ESWT or US-guided barbotage/lavage
- Surgical referral if failed conservative treatment, large deposit, or rotator cuff tear
11. Prevention — কীভাবে প্রতিরোধ করবেন
- Repetitive overhead work কমানো
- Heavy lifting-এর আগে warm-up
- Shoulder mobility exercise regularly
- Rotator cuff strengthening: external rotation, scapular retraction, wall slide
- Diabetes ও thyroid disorder control
- দীর্ঘদিন shoulder immobilization avoid
- Ergonomic correction: desk height, sleeping posture, carrying load
- Pain শুরু হলে early physiotherapy; pain সহ্য করে heavy overhead activity চালিয়ে যাওয়া যাবে না
- Smoking avoid; tendon healing খারাপ করে
- Steroid injection বারবার avoid unless clear indication
Overview / Summary
Calcific tendinitis হলো rotator cuff tendon-এর ভিতরে calcium hydroxyapatite deposit জমা হওয়া। প্রধান symptom হলো acute বা chronic shoulder pain, night pain, painful arc, ROM limitation। Diagnosis সাধারণত history + examination + shoulder X-ray দিয়ে হয়; ultrasound deposit localization ও guided procedure-এ helpful; MRI দরকার হয় suspected tear/failed treatment/pre-op planning-এ। Initial treatment হলো rest, NSAID/analgesic, physiotherapy; persistent case-এ steroid injection, ESWT, lavage/barbotage; refractory case-এ arthroscopic removal।
Actionable Plan / Steps
- Confirm diagnosis: Shoulder X-ray AP internal/external rotation + ultrasound।
- Rule out red flags: fever, septic arthritis, trauma fracture, cervical radiculopathy, cardiac referred pain।
- Start conservative care: relative rest, ice, paracetamol ± one NSAID, topical NSAID, physiotherapy।
- Gastroprotection: NSAID দিলে high-risk patient-এ esomeprazole/other PPI।
- Review after 1–2 weeks: pain/ROM improve হচ্ছে কি না।
- Persistent severe pain: US-guided subacromial steroid injection consider।
- Chronic >6–12 weeks: ESWT বা US-guided lavage/barbotage consider।
- Failed 3–6 months or cuff tear: arthroscopic removal ± rotator cuff repair referral।
Reference List — Textbook + Guideline + DOI
Textbooks
- Kelley and Firestein’s Textbook of Rheumatology, latest ed. — periarticular disorders/tendinopathy section.
- Apley & Solomon’s System of Orthopaedics and Trauma, latest ed. — shoulder pain/rotator cuff disorders.
- Campbell’s Operative Orthopaedics, latest ed. — arthroscopic management of calcific tendinitis.
- Goodman & Gilman’s The Pharmacological Basis of Therapeutics, latest ed. — NSAIDs, corticosteroids, local anesthetics.
- Katzung Basic & Clinical Pharmacology, latest ed. — analgesics, NSAIDs, glucocorticoids, local anesthetics.
Guideline / clinical source
- AAOS OrthoInfo. Calcific Tendinitis of the Shoulder — diagnosis and treatment overview.
- MedEx Bangladesh — Bangladesh brand names, strengths, pharmacology, dose and drug class for listed medicines.
Peer-reviewed DOI references
- Uhthoff HK, Loehr JW. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997. DOI: 10.5435/00124635-199707000-00001.
- Bannuru RR, et al. High-energy extracorporeal shock-wave therapy for chronic calcific tendinitis of the shoulder. Ann Intern Med. 2014. DOI: 10.7326/M13-1982.
- Gerdesmeyer L, et al. Extracorporeal shock wave therapy for chronic calcifying tendonitis of the rotator cuff. JAMA. 2003. DOI: 10.1001/jama.290.19.2573.
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Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-41-12 Am