A Novel Classification in Calcific Tendinitis of the Shoulder: Evaluating MRI Localization and Related Treatment Strategies

Calcific tendinitis of the shoulder is among the frequently encountered shoulder problems. Conservative treatment is often preferred for its management. Persistent pain, impingement symptoms due to large calcific deposits, and extension into the bone are indications for surgical intervention.

Although many classification methods for calcific tendinitis have been defined in the literature, none of them is directly related to prognosis, treatment options, or surgical management.

The aim of this study is to create a new, easy-to-apply, practical, and treatment-related classification system for calcific tendinitis based on the localization of the deposits on MRI.

Furthermore, the aim is to compile the current patient cohort according to this new classification and examine the relationship between the treatment applied and the deposit localization in the proposed classification.

Study Overview

• Status: Recruiting
• Conditions: Calcific Tendinitis of Shoulder
• Intervention / Treatment: Procedure: Debridement; Procedure: Side to side repair; Procedure: Anchor Fixation; Other: Conservative non-surgical treatment

Detailed Description

Introduction

Calcific tendinopathy (calcific tendinitis) associated with calcific deposits in the shoulder is a common disorder of the rotator cuff tendons. It accounts for up to 7% of all painful shoulders, with the highest prevalence recorded in the fourth and sixth decades. Although the chemical composition of the deposits has been extensively studied across different stages of the disease, the pathogenesis and the factors inducing deposit resorption remain largely unclear. Despite the self-limiting nature of calcific tendinitis, surgical intervention may be required in persistent cases. Surgical treatment primarily involves debridement of the calcific deposit and tendon repair if cuff integrity is compromised. Based on current understanding, calcific tendinitis can be regarded as a form of tendinopathy within the spectrum of rotator cuff tendon disorders.

To date, numerous classification systems have been defined in the literature to characterize calcific deposits in the shoulder. These classifications are based on pathogenesis (Uhthoff-Loehr Classification), plain radiographic imaging(Gärtner-Hayer Classification), and ultrasound imaging (Chiou and Scofienza Classifications). However, none of these systems are directly related to clinical practice or correlate with treatment modalities.

The study aims to establish a novel classification system, based on MRI findings, that is easy to understand and apply, and directly consistent with management options (surgical/conservative). In this study, the aim is to organize the calcific tendinitis patients the investigators have followed according to the system that is recently defined and to evaluate the concordance between the applied treatment modalities and the localization determined by the novel classification.

Materials and Methods

MRI scans, treatment protocols, and operative notes (for those who underwent surgery) of all calcific tendinitis patients followed at the American Hospital and Koç University Hospital since 2004 will be reviewed. Patients will be divided into five groups in the new classification based on the localization of the calcific deposit on MRI. These groups, determined by the location of the calcific deposit, are defined as:

Extratendinous group (E): Calcific deposit located outside the tendon. Intratendinous Articular group (Ta): Calcific deposit located within the tendon, closer to the articular (joint) side.

Intratendinous Bursal group (Tb): Calcific deposit located within the tendon, closer to the bursal side.

Complete Intratendinous group (Tc): Calcific deposit completely encompassing the inside of the tendon.

Intraosseous group (I): Calcific deposit extending into the bone.

To select patients, the MRI scans of all calcific tendinitis cases who presented to and were followed at VKV American Hospital and Koç University Hospital between 2004 and 2025 will be reviewed and grouped according to the aforementioned classification. The operative reports of the patients who were operated on will be examined to determine the surgical procedure performed, and the hospital records of the non-operative patients will be reviewed to determine the conservative treatment methods applied. Patients whose MRI imaging and clinical records are inaccessible or who have conditions precluding clinical evaluation will be excluded from the study. All included patients will be compiled according to the specified classification system. The treatment modalities applied to the patients will be included in the data set, and the relationship between the classification groups and the applied treatment method will be evaluated.

• Study Type: Observational
• Enrollment (Estimated): 400

Contacts and Locations

• Study Contact: Name: Ata Cem Akbaba, Medical Doctor; Phone Number: +905377397395; Email: atacemakbaba1996@hotmail.com
• Study Contact Backup: Name: İlker Eren, Medical Doctor; Phone Number: +905333174047; Email: ilker.eren@gmail.com

Study Locations

• Turkey (Türkiye)
  • Zeytinburnu
    • Istanbul, Zeytinburnu, Turkey (Türkiye), 34010
      • Recruiting
      • Koç University Hospital
      • Contact: Ata Cem Akbaba, Medical Doctor; Phone Number: +905377397395; Email: atacemakbaba1996@hotmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

The study popuation consists of individuals who were followed for calcific tendinitis and received conservative or surgical treatment by the physicians of our clinic at American Hospital and Koç University Hospital since 2004.

Description

Inclusion Criteria

• Patients who underwent surgical treatment for calcific tendinitis
• Presence of single or multiple calcific deposits within the rotator cuff tendons

Exclusion Criteria

• History of prior ipsilateral shoulder surgery for indications other than calcific tendinitis
• Revision surgery for calcific tendinitis
• Incomplete clinical documentation or unavailable MRI data

Study Plan

How is the study designed?

Number of groups / cohorts

5

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Intratendinous Articular (Ta); Calcific deposit sits inside the tendon, closer to the articular side	Procedure: Debridement; Debridement intervention can be described as a surgical intervention, which includes debridement of the calcification deposit.; Procedure: Side to side repair; After the surgical debridement of the deposit, sometimes there is a rotator cuff defect. Side to side repair group consist of the cases when the defect is repaired side to side primarily.; Procedure: Anchor Fixation; Anchor fixation group consist of the cases when the rotator cuff defect cannot be repaired side to side, and the surgeon managed the defect by fixating it to the bone with an anchor.
Intratendinous Bursal (Tb); Calcific deposit sits inside the tendon, closer to the bursal side	Procedure: Debridement; Debridement intervention can be described as a surgical intervention, which includes debridement of the calcification deposit.; Procedure: Side to side repair; After the surgical debridement of the deposit, sometimes there is a rotator cuff defect. Side to side repair group consist of the cases when the defect is repaired side to side primarily.; Procedure: Anchor Fixation; Anchor fixation group consist of the cases when the rotator cuff defect cannot be repaired side to side, and the surgeon managed the defect by fixating it to the bone with an anchor.
Complete Intratendinous (Tc); The calcific deposit is entirely within the tendon and completely encompasses the tendon substance.	Procedure: Debridement; Debridement intervention can be described as a surgical intervention, which includes debridement of the calcification deposit.; Procedure: Side to side repair; After the surgical debridement of the deposit, sometimes there is a rotator cuff defect. Side to side repair group consist of the cases when the defect is repaired side to side primarily.; Procedure: Anchor Fixation; Anchor fixation group consist of the cases when the rotator cuff defect cannot be repaired side to side, and the surgeon managed the defect by fixating it to the bone with an anchor.
Extratendinous (E); Calcific deposit located outside the tendon.	Other: Conservative non-surgical treatment; Non surgical conservative treatment consist of all the treatment modalities e.g. analgesic treatment (NSAIDs, paracetamol...), ice packaging, movement restriction, resting etc.
Intraosseous (I); Calcific deposit extending into the bone.	Procedure: Debridement; Debridement intervention can be described as a surgical intervention, which includes debridement of the calcification deposit.; Procedure: Side to side repair; After the surgical debridement of the deposit, sometimes there is a rotator cuff defect. Side to side repair group consist of the cases when the defect is repaired side to side primarily.; Procedure: Anchor Fixation; Anchor fixation group consist of the cases when the rotator cuff defect cannot be repaired side to side, and the surgeon managed the defect by fixating it to the bone with an anchor.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change from Baseline in American Shoulder and Elbow Surgeons (ASES) Score at 12 Months	The ASES score is a standardized shoulder assessment form. It consists of a patient self-evaluation section (visual analog scale for pain and instability) and a daily function assessment section. The score ranges from 0 to 100, where 0 indicates the worst possible outcome and 100 indicates the best possible outcome.	From preoperative assessment (baseline) to 12 months post-operation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change from Baseline in Subjective Shoulder Value (SSV) at 12 Months	The Subjective Shoulder Value (SSV) is a patient-reported outcome measure where the patient assesses the value of their shoulder expressed as a percentage of an entirely normal shoulder. The scale ranges from 0% to 100%, where higher percentages indicate better shoulder function.	From preoperative assessment (baseline) to 12 months post-operation

Collaborators and Investigators

• Sponsor: Koç University
• Investigators: Principal Investigator: Mehmet S Demirhan, Medical Doctor, Koç University Hospital

Publications and helpful links

General Publications

• Seyahi A, Demirhan M. Arthroscopic removal of intraosseous and intratendinous deposits in calcifying tendinitis of the rotator cuff. Arthroscopy. 2009 Jun;25(6):590-6. doi: 10.1016/j.arthro.2008.12.024.
• Zhao X, Mita K, Shimada T, Okano K, Quan GX, Kanke E, Kawasaki H. Isolation and expression of an ecdysteroid-inducible neutral endopeptidase 24.11-like gene in wing discs of Bombyx mori. Insect Biochem Mol Biol. 2001 Nov 1;31(12):1213-9. doi: 10.1016/s0965-1748(01)00069-8.
• Caliskan E, Eren I, Aslan L, Koyuncu O, Seyahi A, Demirhan M. Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores. Knee Surg Sports Traumatol Arthrosc. 2022 Jul;30(7):2485-2491. doi: 10.1007/s00167-022-06870-2. Epub 2022 Jan 19.

Study record dates

Study Major Dates

• Study Start (Actual): October 2, 2025
• Primary Completion (Estimated): October 1, 2026
• Study Completion (Estimated): October 2, 2026

Study Registration Dates

• First Submitted: January 20, 2026
• First Submitted That Met QC Criteria: February 6, 2026
• First Posted (Actual): February 13, 2026

Study Record Updates

• Last Update Posted (Actual): February 13, 2026
• Last Update Submitted That Met QC Criteria: February 6, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: magnetic resonance imaging; shoulder; calcific deposit; calcific tendinitis; novel classification
• Additional Relevant MeSH Terms: Crystal Arthropathies; Musculoskeletal Diseases; Arthritis; Joint Diseases; Chondrocalcinosis; Rotator Cuff Tear Arthropathy; Surgical Procedures, Operative; Debridement
• Other Study ID Numbers: 2025.407.IRB2.190

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Given the sensitive nature of the patient-specific details, our research group is unwilling to provide this information in order to uphold the principles of patient confidentiality.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No