Pain guide · Shoulder pain
Calcific tendinitis (often spelt tendonitis) is a build-up of calcium in a rotator cuff tendon. It can cause sudden, severe pain that stops you sleeping or lifting your arm, usually while the body is breaking the calcium down, and it's most common between about 30 and 60.
It usually settles on its own, and the treatments that remove the calcium are less certain than they sound: in a blinded trial, washing it out did no better than a sham procedure. This guide covers the painful phase, injections, barbotage and shockwave, the warning signs, and a plan from gentle movement to full strength.
Exercise is for pain that has been checked or is clearly mild and settling.
Calcium crystals are laid down in a living rotator cuff tendon, most often the supraspinatus on top of the shoulder, then the tendons at the back and front of the shoulder. NHS Scotland guidance prefers the name calcifying tendinitis, because the condition changes over time, and says it isn't a degenerative, wear-and-tear process: once the calcium is resorbed or removed, the tendon rebuilds itself. The cause isn't known.
In 1,219 Dutch adults, deposits were found in 7.8% of shoulders without pain and 42.5% of shoulders with pain under the bony shelf at the top of the shoulder (subacromial pain). Being 30 to 60, having that pain and being a woman raised the odds. Reviews give 2% to 20% of people overall, and NHS Scotland guidance adds a possible link with diabetes and thyroid disease.
The deposit goes through phases: it forms (with variable pain), rests, and is then broken down and cleared by the body (resorbed), after which the tendon repairs. The resorptive phase hurts most: sudden, severe, constant pain, a shoulder you can barely move, and sometimes a mild fever or red skin if crystals leak into nearby tissue. It's usually worst for a few days and eases over 2 to 3 weeks.
When the cycle stalls, a longer, grumbling course looks like rotator cuff pain, with a painful arc as you lift the arm.
An X-ray is the main test, and ultrasound also shows the deposit and how soft it is. A soft, resorbing deposit can be faint on X-ray, and a repeat X-ray months later may show it gone. X-ray findings often don't match symptoms, and deposits are common in shoulders that don't hurt.
Because an acute flare can look like a joint infection, sudden severe pain, or a hot, red shoulder with a fever, needs a same-day check.
The National Institute for Health and Care Excellence (NICE) says most cases resolve in time without treatment. Persistent cases are slower: in a trial of people with symptoms for 3 months or more, every group improved, and at 2 years 73% of deposits had gone on X-ray, 52 of them without lavage or surgery. In another trial, 62% to 73% had fully resorbed at 5 years, whichever treatment people had.
Pain and the deposit don't move in step: outcomes were no better when the deposit had gone than when it was unchanged.
NICE describes painkillers and anti-inflammatory medicines early on, physiotherapy if symptoms persist, and then a steroid injection, lavage (barbotage) or surgery. NHS Scotland guidance adds ice and advice, and notes there's no clear evidence on which non-surgical care works best. An NHS trust leaflet advises keeping the shoulder moving without aggravating it, and using a sling for comfort only, coming off it as soon as possible.
In a blinded trial of 220 adults, both groups given a steroid injection had less pain than the sham group at 2 and 6 weeks, but not at 4 or 24 months. An injection doesn't remove the deposit, and in a Dutch trial more people given an injection alone needed further treatment over 5 years (16 of 25) than those who also had barbotage (4 of 23).
A 2026 Dutch guideline still starts treatment with one injection under the bony shelf of the shoulder (a subacromial injection), as a way to ease the pain.
Barbotage (needling and lavage) means rinsing and breaking up the deposit with a needle under ultrasound, usually with a steroid injection. In a Dutch trial of 48 people, it beat a steroid injection alone at 1 year (86 against 74 on a 100-point shoulder score), but not at 5 years (90 against 87). In the larger, blinded KALK trial (220 adults in Norway and Sweden), lavage with a steroid did no better than a sham procedure at 4 or 24 months, though it cleared more deposits; everyone did four home exercises, taught by a physiotherapist.
An NHS trust leaflet quotes a 60% to 70% chance of a significant or complete improvement, with about a third not responding. Weighing both trials, a 2026 Dutch guideline suggests considering barbotage for painful, especially large, deposits after an injection hasn't helped, repeated once if needed; it says to tell people the extra benefit is modest and that recovery typically takes 6 to 12 months. It keeps keyhole surgery for persistent, disabling pain with a large deposit after other treatments, including barbotage, have failed.
In a 2003 trial of 144 people, high-energy shockwave improved a 100-point shoulder score by 31 points at 6 months, against 15 for low-energy and 7 for sham shockwave. But a 2020 Cochrane review of 32 trials found benefits over placebo too small to matter: about 0.8 points less pain on a 10-point scale, where 1.5 is the change people notice, with more side effects.
NICE says the evidence on whether it works is inadequate, so it should only be used in research. The Dutch guideline notes that high-energy shockwave can be very painful, and that evidence for low-energy shockwave is lacking.
In 82 people whose symptoms had lasted despite treatment, barbotage and high-energy shockwave gave similar results at 1 year and after about 7 years. Barbotage removed more calcium, and fewer people needed further treatment after it (about 1 in 4, against about 4 in 10 after shockwave), though by 7 years that difference could have been chance. Network meta-analyses, which compare many treatments at once, rank needling, shockwave and comprehensive physiotherapy highly, but they rest on low-quality trials.
No trial has tested exercise on its own against no exercise for calcific tendinitis. But exercise was part of every group in the key trials, comprehensive physiotherapy ranked first for function in a 2025 network meta-analysis, and NHS leaflets give staged movement exercises. The long-lasting, rotator-cuff-like picture is managed like rotator cuff pain, so the strengthening stages here borrow their doses from a rotator cuff pain trial (Holmgren's).
In an acute flare, move within comfort only. An NHS trust leaflet says keep the shoulder moving but don't aggravate it, don't push into pain, and repeat the exercises only if there's no increase in symptoms.
Once the acute pain settles, or for the long-lasting, rotator-cuff-like picture, use a rule borrowed from rotator cuff pain (Holmgren's trial): pain up to about 5 out of 10 during the exercises is acceptable, and by your next session it should be back to where it was before. If it isn't, use a lighter band or weight or a smaller range next time, not nothing.
After barbotage, one NHS trust gives gentle stretches, to a felt stretch and held for 20 to 30 seconds, until you see the physiotherapist about 2 weeks later.
Start at the first stage. Each move opens a full guide with a 3D demo.
Painkillers as advised, a sling for comfort only and off as soon as you can manage, and keep the shoulder moving without aggravating it. Doses come from an NHS trust leaflet unless marked.
3D demoPendulum exercise (Codman's pendulum)Beginner · A bench or box1 to 2 minutes in all, small and relaxed, 4 to 5 times a day
3D demoSeated upper-back lift (sit tall, shoulders back)Beginner · A bench or boxDraw the shoulder blades back and hold 20 to 30 s; 5 times
Easier: Elbows back · Harder: Prone Y-T-W raises
3D demoElbow bend and straighten (elbow range of motion)Beginner · No equipment10 to 15 times · If the arm has been in a sling
Harder: Dumbbell biceps curl
3D demoWrist & forearm flowBeginner · No equipment10 to 15 of each movement
Harder: Wrist flexor stretch
3D demoTable slide (seated forward reach)Beginner · A bench or box5 to 10 slow reps, within comfort · Editorial; the leaflet starts assisted lifting once the worst has passed
Easier: Pendulum exercise (Codman's pendulum) · Harder: Overhead lat stretch at a bench
Move on when: The pain changes from constant to mostly on movement, and nights are easier. An acute flare is usually worst for a few days and eases over 2 to 3 weeks.
Four to five short sessions a day at first. Doses are from NHS trust leaflets unless marked.
3D demoTable slide (seated forward reach)Beginner · A bench or box10 reps · The leaflet's assisted forward lift
Easier: Pendulum exercise (Codman's pendulum) · Harder: Overhead lat stretch at a bench
3D demoStick-assisted external rotation (lying)Beginner · Other / check instructions10 reps holding 5 s, or 2 to 3 holds of 20 to 30 s · The two NHS leaflets' doses
Harder: Standing band external rotation
3D demoCross-body shoulder stretchBeginner · No equipment3 holds of 30 s, if the back of the shoulder is tight · Editorial; skip it if it pinches
Harder: Sleeper stretch
3D demoStanding band external rotationBeginner · A band + An anchor point2 sets of 10 to 15, light · Editorial
Harder: Side-lying external rotation
3D demoBand internal rotationBeginner · A band + An anchor point2 sets of 10 to 15, light · Editorial
Harder: Side-lying external rotation
3D demoBand rowBeginner · A band + An anchor point2 sets of 12 to 15 · Editorial
Move on when: Range is nearly back, and pain comes only with effort.
Start here straight away if there has been no acute flare. About 5 days a week. Doses follow the Holmgren trial in rotator cuff pain, as in the site's impingement guide, unless marked.
3D demoSide-lying external rotationBeginner · A dumbbell3 sets of 15, lowering over 3 s · The Holmgren trial's dose
Easier: Standing band external rotation · Harder: Cuban rotation
3D demoScaption raiseBeginner · A dumbbell3 sets of 15, thumbs up, to shoulder height, lowering over 3 s · Modelled on the Holmgren trial
Easier: Band lateral raise · Harder: Smith machine upright row
3D demoProne Y-T-W raisesBeginner · No equipment2 to 3 rounds of 8 · Editorial
Easier: Wall angel · Harder: Bent-over reverse fly
3D demoScapular push-up (push-up plus)Beginner · No equipment3 sets of 10 to 15, on a wall or bench first · Editorial
Easier: Dumbbell shoulder-blade punch · Harder: Pike push-up
3D demoDumbbell shoulder-blade punchBeginner · A dumbbell + A bench or box2 to 3 sets of 15 · Editorial
Harder: Scapular push-up (push-up plus)
3D demoCross-body shoulder stretchBeginner · No equipment3 holds of 30 to 60 s, twice a day, if it doesn't pinch · The Holmgren trial's dose
Harder: Sleeper stretch
Move on when: Every set passes the pain rule, and lifting to shoulder height is comfortable.
Two or three sessions a week, adding load one change at a time. Doses are editorial.
3D demoFace pullIntermediate · A band3 sets of 12 to 15
Easier: Prone Y-T-W raises · Harder: Barbell rear-delt row
3D demoCable external rotationBeginner · A cable machine3 sets of 10 to 12
Harder: Side-lying external rotation
3D demoFarmer's carryBeginner · A dumbbell + A kettlebell3 walks of 30 to 40 m
Harder: Suitcase carry
Move on when: Overhead work and lifting feel normal. Keep some rotator cuff work in your week.
One NHS trust gives gentle stretches (a lying overhead reach, turning the arm out with a stick, and a hand behind the back), each held for 20 to 30 seconds, 2 to 3 times, until a physiotherapy review about 2 weeks later. Occasionally a second treatment is needed about 6 weeks after the first. After that, go back to the stage that fits. The two stretches the 3D figure can't show are below.
Source 14
From the same NHS trust leaflet.
Source 14
From the same NHS trust leaflet.
Source 14
| Habit or position | Why it matters | Instead |
|---|---|---|
| Keeping the arm still in a sling | An NHS trust advises using the sling for comfort only and coming off it as soon as possible, and the NHS says not to stop using the shoulder completely. | Pendulums and table slides within comfort.Try: Pendulum exercise (Codman's pendulum) |
| Forcing stretches in the acute flare | The leaflet says don't push into pain. | Range work within comfort.Try: Table slide (seated forward reach) |
| Lying on the sore side, or heavy overhead lifting, during a flare | Both usually make it hurt more (editorial). | Lie on your back or the other side with a pillow, and work below shoulder height. |
| Repeated steroid injections | The benefit lasts weeks, and an injection doesn't remove the calcium. | One injection to help you get moving, if advised. |
| Courses of low-energy shockwave | Evidence for low-energy shockwave is lacking, and NICE recommends shockwave only in research. | Ask what the evidence is, and keep up the exercises.Try: Side-lying external rotation |
| Chasing a calcium-free X-ray | In a blinded trial, pain and function didn't depend on the deposit going. | Judge progress by pain and function. |
A 25-minute band routine for healthy shoulders: move the shoulder and upper back through their range, then strengthen the rotator cuff and shoulder blades.
25 minBeginner12 movesA wall, A bandA 12-minute routine for a stiff upper back and rounded shoulders: chin tucks, wall angels, Y-T-W raises and open books.
12 minBeginner8 movesA foam roller, A wallEight gentle neck and shoulder stretches for desk stiffness, done standing or seated in ten minutes.
10 minBeginner8 movesA wallCalcium crystals deposited in a rotator cuff tendon, usually the supraspinatus on top of the shoulder. It's commonest between about 30 and 60, and in women.
The worst pain usually comes as the body breaks the calcium down, which can cause sudden, severe, constant pain and a shoulder you can barely move, sometimes with a mild fever. It's usually worst for a few days and eases over 2 to 3 weeks.
An acute flare usually eases within weeks, and NICE says most cases resolve in time without treatment. Persistent cases can take many months: in trials, people kept improving over 2 to 5 years. No one can promise you a date.
Often. In one trial, most deposits had gone within 2 years, many without lavage or surgery, and in another, 62% to 73% had fully resorbed at 5 years whatever the treatment. Pain can settle even if the deposit stays.
The evidence is mixed. It beat a steroid injection alone at 1 year in one trial but not at 5 years, and it was no better than a sham procedure in a larger, blinded trial. A 2026 guideline still suggests it for large deposits when an injection hasn't helped.
High-energy shockwave beat a sham treatment in a 2003 trial, but a Cochrane review found only small benefits, too small to matter to most people. NICE says it should only be used in research.
It can ease pain over the first few weeks, and a guideline starts treatment with one, but it doesn't remove the calcium or give a lasting advantage. Use the relief to keep moving.
In a flare, gentle pendulums and assisted movement within comfort; then range; then the rotator cuff strengthening that helps rotator cuff pain. Avoid forcing stretches or heavy overhead lifting while it's acute.
Rarely. It's kept for persistent, disabling pain with a large deposit after other treatments, including barbotage, have failed.
The cause is unknown. NHS Scotland guidance says it isn't degenerative, and that the tendon rebuilds itself after the calcium goes.
In one trial followed for about 7 years, deposits didn't come back in the treated tendons, though 15% of people who had needling developed a new deposit in another tendon. If pain returns, the same plan applies.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
