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Calcific Tendinitis PDF Evidence

Illustration of a physiotherapist supporting a person's arm out to the side during a gentle lift.
Calcific tendinitis of the shoulder: a chalky calcium deposit builds up inside one of the rotator cuff tendons, often the supraspinatus, and can cause sudden severe pain when it inflames the surrounding tissue. Kieran Hirpara 4.0

Calcific tendinitis causes shoulder pain from calcium deposits; treatment ranges from observation to washing out the calcium.

What you're feeling

You may experience acute or chronic pain in your shoulder caused by inflammation around calcium deposits in your rotator cuff tendons. This condition, known as calcific tendinitis, can significantly impact your quality of life and may result in time off work. The pain is often intense and can flare up without warning. You might notice that certain movements trigger sharp discomfort, while others feel dull and persistent.

Daily tasks that require reaching or lifting become difficult. Simple actions like tucking in a shirt or reaching behind your back to fasten a bra can be challenging. You may find it hard to sleep on the affected side, as the pressure can worsen the pain. Nighttime discomfort is common, often disrupting your rest and leaving you feeling fatigued. The pain may also be worse upon waking, making it hard to start your day.

In some cases, you might experience atypical symptoms. For instance, pain could be isolated to the back of your shoulder or affect overhead movements if the teres minor muscle is involved. Rarely, you might have calcifying lesions in other areas, such as the medial collateral ligament, or in both shoulders simultaneously. However, most people experience localized shoulder pain that interferes with routine activities.

The good news is that symptomatic calcific tendinitis has a good likelihood of completely resolving in the long term. Conservative treatment is often the primary choice, especially for acute cases, and shows clinically significant improvement. About 72% of patients achieve excellent or good results with non-surgical care, regardless of the deposit size or location. If symptoms persist, your surgeon may discuss other options, but many find relief through conservative measures. Understanding these symptoms helps you manage expectations and work with your healthcare team to find the best path forward.

What's actually happening

Calcific tendinitis is a condition where calcium builds up inside the tendons of your shoulder. These tendons are the tough, rope-like bands that connect your muscles to your bones. Think of them as the cables that help you lift and move your arm. When calcium deposits form, they create a hard lump within this soft tissue. This buildup can irritate the surrounding area, causing significant pain and limiting how well you can use your shoulder.

Your shoulder is a complex ball-and-socket joint. It relies on a group of muscles and tendons called the rotator cuff to stay stable and move smoothly. The long head of the biceps also plays a role in keeping this joint steady. In many cases, the calcium deposits affect these structures. You might feel pain in the front of your shoulder. This happens because the deposit interacts with the surrounding soft tissues rather than being a single, isolated issue. The pain is your body’s signal that something is wrong in that delicate balance.

As you age, changes in your tendons become more common. Swimmers and active individuals often see these structural changes earlier. The calcium deposit itself can vary in size. If the lesion is larger than 1 cm, you are nearly three times more likely to need surgery to remove it. However, many people find relief without an operation. Conservative treatments, such as shock wave therapy, are often very successful at relieving pain and restoring function with very few side effects.

If surgery is needed, your surgeon will likely remove the calcium deposit. This is often done using a small camera and instruments (arthroscopy). In many cases, the surgeon will also repair the rotator cuff at the same time. This combination leads to significant improvements in pain and shoulder function. It takes time for these benefits to fully show. You should expect to wait at least six months after surgery for your shoulder function to reach its best level. During this time, your surgeon will guide you through recovery to ensure the best possible outcome.

What we can do about it

Most people find relief without surgery. Your journey usually starts with simple self-care and guided movement. You will likely try oral anti-inflammatory medication to calm the pain. Your surgeon may also recommend physical therapy to restore your shoulder’s range of motion and strength. These nonsurgical modalities are the primary choice for acute calcific tendinitis.

You should give conservative treatment time to work. The condition has a good likelihood of completely resolving in the long term. In fact, 72% of patients achieve excellent or good results with nonsurgical care. This success rate holds true regardless of where the calcium is located, its size, or how severe your initial symptoms were. If your pain is protracted, it can lead to time off work and impaired quality of life. Consistent effort with therapy is key to getting back to your daily routine.

If self-care and therapy are not enough, your surgeon may suggest medical interventions. Corticosteroid injections are a common option to reduce inflammation and pain. Another effective noninvasive treatment is extracorporeal shock wave therapy (ESWT). This therapy uses sound waves to break up the calcium deposits. It is safe and produces a high rate of success in pain relief and functional restoration. Patients often see reduced painful symptoms and improved shoulder function after this treatment. Complications from ESWT are negligible.

Surgery is considered only when conservative care reaches its limit. Your surgeon might recommend operative treatment if your calcific lesions are larger than 1 cm, as these have a 2.8 increased likelihood of needing surgery. Arthroscopic removal of the calcification leads to improved clinical outcomes for chronic cases. The majority of patients who undergo this surgical management also require a concomitant rotator cuff repair.

If you do proceed to surgery, expect a gradual recovery. Functional scores improve slowly after the procedure. They typically reach more than 75 percent at six months after surgery. At least 6 months of follow-up is needed for these improvements to become statistically significant. Most patients report significant improvements in shoulder pain and function after the operation. Your surgeon will discuss whether arthroscopic, endoscopic, or open surgery is best for your specific case.

What to expect

Your shoulder pain from calcific tendinitis may last for a long time. These symptoms can be protracted. This often means time off work and a lower quality of life. The good news is that this condition has a good likelihood to completely resolve in the long-term. Many people find their symptoms settle on their own.

If your pain does not go away, your surgeon may suggest treatment. Non-surgical options like shock wave therapy or needle aspiration are effective. Shock wave therapy offers a high rate of success in pain relief and functional restoration with negligible associated complications. Needle aspiration is only slightly invasive and painful. These treatments work well for many patients.

If surgery is needed, your surgeon will remove the calcium deposit. You will likely need a rotator cuff repair at the same time. This is a common part of the procedure. Your shoulder pain and function will improve significantly after surgery. However, recovery is not instant. Functional scores for patients undergoing arthroscopic treatment improved slowly. You will see more than 75 percent improvement at six months after surgery.

It takes time to feel the full benefit of arthroscopic removal. At least 6 months of follow-up is needed for these improvements to become statistically significant. Do not rush your healing. Your surgeon will guide you through this process. Most patients are satisfied with the final results.

When to see someone

See your GP if you have persistent shoulder pain that does not improve with rest. Calcific tendinitis is an acute or chronically painful condition caused by inflammation around calcium deposits in the rotator cuff tendons. You should seek help if symptoms interfere with your sleep or work, or if you experience weakness, instability, or locking. Conservative treatment is the primary choice, especially for acute cases, and shows clinically significant improvement with 72% of patients achieving excellent or good results. However, if your pain remains severe despite conservative care, ask for a specialist review. Your surgeon can determine if further steps are needed to restore function and relieve pain.

Reviewed by Kieran Hirpara · 2026-04-27 00:00:00+00:00.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

title: "Calcific Tendinitis" slug: calcific-tendinitis region: shoulder audience: patient mesh_terms: ["Calcinosis", "Tendinopathy", "High-Energy Shock Waves", "Shoulder Pain", "Rotator Cuff", "Extracorporeal Shockwave Therapy", "Shoulder", "Chronic Disease"] article_count: 180 model_used: Qwen3.6-35B-A3B-Q8_0.gguf generated_at: '2026-06-13T10:43:43+00:00' key_articles: - title: "Editorial Commentary: Is Magnetic Resonance Imaging of the Shoulder Ever Appropriate in Evaluating Patients With Calcific Tendinopathy of the Rotator Cuff?" ref_num: 1 evidence_tier: commentary evidence_level: 5 doi: 10.1016/j.arthro.2020.01.014 year: 2020 - title: "Predictive factors for failure of conservative management in the treatment of calcific tendinitis of the shoulder" ref_num: 2 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jseint.2021.01.013 year: 2021 - title: "Predictive factor for failure of conservative management in the treatment of calcific tendinitis of the shoulder" ref_num: 3 evidence_tier: paper evidence_level: 3 doi: 10.1177/2325967121s00208 year: 2021 - title: "Long-Term Course of Shoulders After Ultrasound Therapy for Calcific Tendinitis" ref_num: 4 evidence_tier: paper evidence_level: 1 doi: 10.1097/phm.0000000000000939 year: 2018 - title: "Calcific tendinitis: Natural history and association with endocrine disorders" ref_num: 5 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2006.06.007 year: 2007 - title: "Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder" ref_num: 6 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2007.03.023 year: 2008 - title: "Calcific tendinitis of the shoulder in the Korean population: demographics and its relation with coexisting rotator cuff tear" ref_num: 7 evidence_tier: paper evidence_level: 4 doi: 10.5397/cise.2020.00010 year: 2021 - title: "Recovery pattern after arthroscopic treatment for calcific tendinitis of the shoulder" ref_num: 8 evidence_tier: paper doi: 10.1016/j.otsr.2020.03.005 year: 2020 - title: "Calcific tendinitis of the rotator cuff" ref_num: 9 evidence_tier: paper evidence_level: 5 doi: 10.5312/wjo.v7.i1.55 year: 2016 - title: "Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: Does the initial radiologic aspect affect the final results?" ref_num: 10 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2009.07.008 year: 2010 - title: "Functional Recovery of the Shoulder after Arthroscopic Treatment for Chronic Calcific Tendinitis" ref_num: 11 evidence_tier: paper evidence_level: 4 doi: 10.5397/cise.2018.21.2.75 year: 2018 - title: "Diagnosis and treatment of calcific tendinitis of the shoulder" ref_num: 12 evidence_tier: paper evidence_level: 5 doi: 10.5397/cise.2020.00318 year: 2020 - title: "Case report - calcification of the medial collateral ligament of the knee with simultaneous calcifying tendinitis of the rotator cuff" ref_num: 13 evidence_tier: case_report evidence_level: 5 doi: 10.1186/s12891-016-1147-z year: 2016 - title: "Calcific tendinitis of the rotator cuff associated with intraosseous loculation: Two case reports" ref_num: 14 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2009.02.009 year: 2009 - title: "Calcific tendinitis of the shoulder" ref_num: 15 evidence_tier: paper evidence_level: 5 doi: 10.1016/s0030-5898(03)00089-0 year: 2003 - title: "Clinical and Structural Results of Rotator Cuff Repair Compared With Rotator Cuff Debridement in Arthroscopic Treatment of Calcifying Tendinitis of the Shoulder" ref_num: 16 evidence_tier: paper evidence_level: 3 doi: 10.1177/03635465211037690 year: 2021 - title: "Osteolytic lesion of greater tuberosity in calcific tendinitis of the shoulder" ref_num: 17 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2008.09.016 year: 2009 - title: "Restriction of Passive Glenohumeral Abduction Combined With Normal Passive External Rotation Is a Diagnostic Feature of Calcific Tendinitis" ref_num: 18 evidence_tier: paper evidence_level: 3 doi: 10.1177/2325967117752907 year: 2018 - title: "Examination of concomitant glenohumeral pathologies in patients treated arthroscopically for calcific tendinitis of the shoulder and implications for routine diagnostic joint exploration" ref_num: 19 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-017-1839-z year: 2017 - title: "Atypical calcific tendinitis involving teres minor which affects overhead movement: A case report" ref_num: 20 evidence_tier: case_report evidence_level: 5 doi: 10.1016/j.jisako.2025.101055 year: 2026 - title: "Shock Wave Therapy for Calcific Tendinitis of the Shoulder" ref_num: 21 evidence_tier: paper evidence_level: 3 doi: 10.1177/03635465030310031701 year: 2003 - title: "Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy" ref_num: 22 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2014.06.036 year: 2014 - title: "Prospective Randomized Surgical Treatments for Calcifying Tendinopathy" ref_num: 23 evidence_tier: paper evidence_level: 1 doi: 10.1097/01.blo.0000063786.32430.22 year: 2003 - title: "Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study" ref_num: 24 evidence_tier: paper evidence_level: 2 doi: 10.1136/ard.62.3.248 year: 2003 - title: "Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy" ref_num: 25 evidence_tier: paper evidence_level: 1 doi: 10.1302/0301-620x.99b6.bjj-2016-0569.r1 year: 2017 - title: "Short‐Term Outcome After Arthroscopic Bursectomy Debridement of Rotator Cuff Calcific Tendonopathy With and Without Subacromial Decompression: A Prospective Randomized Controlled Trial" ref_num: 26 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.arthro.2015.05.015 year: 2015 - title: "Is common the rotator cuff tear in the calcific tendinitis?" ref_num: 27 evidence_tier: paper evidence_level: 3 doi: 10.5397/cise.2021.00094 year: 2021 - title: "Do therapeutic exercises impact supraspinatus tendon thickness? Secondary analyses of the combined dataset from two randomized controlled trials in patients with rotator cuff-related shoulder pain" ref_num: 28 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2024.03.055 year: 2024 - title: "Sonographically Guided Percutaneous Needle Lavage in Calcific Tendinitis of the Shoulder: Short- and Long-Term Results" ref_num: 29 evidence_tier: paper evidence_level: 4 doi: 10.2214/ajr.07.2254 year: 2007 - title: "A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management" ref_num: 30 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2019.04.003 year: 2019 - title: "Calcific Tendinitis of the Rotator Cuff" ref_num: 31 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-22-11-707 year: 2014 - title: "Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon" ref_num: 32 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.arthro.2010.10.014 year: 2011 - title: "Understanding the Importance of the Teres Minor for Shoulder Function: Functional Anatomy and Pathology" ref_num: 34 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-15-00258 year: 2018 - title: "Intraarticular lesions in calcifying tendinitis: incidence and association with the acromion index" ref_num: 35 evidence_tier: paper evidence_level: 3 doi: 10.1007/s00402-011-1263-z year: 2011 - title: "Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META-analysis" ref_num: 37 evidence_tier: paper evidence_level: 1 doi: 10.1186/s12891-020-03872-4 year: 2021 - title: "How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging" ref_num: 38 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2015.06.005 year: 2015 - title: "In Vivo Shoulder Function After Surgical Repair of a Torn Rotator Cuff" ref_num: 39 evidence_tier: paper evidence_level: 4 doi: 10.1177/0363546511412164 year: 2011 - title: "Sonographic evaluation of the shoulder in asymptomatic elderly subjects with diabetes" ref_num: 40 evidence_tier: paper evidence_level: 3 doi: 10.1186/1471-2474-11-278 year: 2010 - title: "Biceps tendinitis in chronic rotator cuff tears: A histologic perspective" ref_num: 41 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2008.05.044 year: 2008 - title: "The efficacy of repeated needling for calcific tendinitis of the rotator cuff" ref_num: 43 evidence_tier: paper evidence_level: 5 doi: 10.5397/cise.2021.00269 year: 2021 - title: "Value of Preoperative Ultrasound Marking of Calcium Deposits in Patients Who Require Surgical Treatment of Calcific Tendinitis of the Shoulder" ref_num: 44 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.arthro.2006.08.005 year: 2007 - title: "Do anatomic variants of the acromion shape in the frontal plane influence pain and function in calcifying tendinitis of the shoulder?" ref_num: 49 evidence_tier: paper evidence_level: 2 doi: 10.1007/s00167-011-1563-4 year: 2011 - title: "Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain" ref_num: 51 evidence_tier: paper evidence_level: 3 doi: 10.1097/corr.0000000000003342 year: 2024 - title: "Deltoid muscle shape analysis with magnetic resonance imaging in patients with chronic rotator cuff tears" ref_num: 53 evidence_tier: paper evidence_level: 3 doi: 10.1186/1471-2474-14-247 year: 2013 - title: "Ultrasonographic Evaluation of the Shoulders and Its Associations with Shoulder Pain, Age, and Swim Training in Masters Swimmers" ref_num: 54 evidence_tier: paper evidence_level: 4 doi: 10.3390/medicina57010029 year: 2020 - title: "Treatment Algorithm for the Resorption of Calcific Tendinitis Using Extracorporeal Shockwave Therapy: A Data Mining Study" ref_num: 56 evidence_tier: paper evidence_level: 3 doi: 10.1177/23259671241231609 year: 2024 synthesis_version: "v2" verifier_status: skipped

Overview

  • Shoulder MRI may be warranted for preoperative planning in select patients with chronic calcific tendinopathy and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low [1].
  • Patients with calcific lesions >1 cm have a 2.8 increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder [2].
  • The majority of patients who undergo surgical management for removal of the calcific deposit require a concomitant rotator cuff repair and experience significant improvements in shoulder pain and function [3].
  • Treatment of calcific tendinitis of the shoulder with extracorporeal shock waves produces a high rate of success in pain relief and functional restoration with negligible associated complications [6].
  • Patients undergoing arthroscopic treatment of a calcific deposit in the shoulder have satisfactory clinical and radiological outcomes at final follow-up, with functional scores improving slowly and reaching more than 75 percent at six months after surgery [8].
  • Arthroscopic removal of calcification leads to improved clinical outcomes in patients with chronic calcific tendinitis, but at least 6 months of follow-up is needed for these improvements to become statistically significant [11].
  • The primary choice of treatment for calcific tendinitis is conservative, especially in patients with acute calcific tendinitis [12].
  • Arthroscopic treatment of calcifying tendinitis provides good to excellent clinical results [16].
  • Routine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of calcific tendinitis due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment [19].
  • Endoscopic and open surgery are equally effective in the treatment of chronic calcifying tendinopathy, showing similar clinical and sonographic results [23].

Anatomy & Pathophysiology

  • Rotator cuff disease, shoulder instability, and associated lesions are common pathologic conditions of the shoulder involving soft tissues [42].
  • The long head of the biceps contributes to stability of the glenohumeral joint in all directions, although in vivo studies have not yet established this stabilizing effect or the physiologic load required [32].
  • Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of patients with shoulder pathology [34].
  • In the context of rotator cuff disease, anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues rather than a single entity [41].
  • Long head of biceps tendinopathy is associated with age and cuff tendinopathy on MRI obtained for evaluation of shoulder pain [51].
  • Clinicians can guide patients to understand shoulder pain as age-appropriate and safe, potentially reducing unnecessary visits, tests, and treatments [51].
  • A high prevalence of structural changes in the rotator cuff and biceps tendons in masters swimmers reflects the effect of shoulder symptoms, aging, and swim training [54].
  • In chronic rotator cuff tears, the shape of the deltoid muscle seems only to be influenced by natural aging and is independent of reduced shoulder motion [53].
  • There seems to be no disadvantage to exhausting conservative treatment and delaying implantation of reverse total shoulder arthroplasty in patients with chronic rotator cuff tears [53].
  • Surgical repair of an isolated supraspinatus tear may be sufficient to keep the torn rotator cuff intact and achieve satisfactory patient-reported outcomes, but glenohumeral joint mechanics and shoulder strength are not fully restored with current repair techniques [39].
  • At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved with conservative versus surgical management for rotator cuff tears [37].
  • Over time, supraspinatus tendon thickness in individuals with rotator cuff-related shoulder pain tends to normalize compared to the contralateral side, regardless of the exercise intervention [28].
  • The theoretical concept of a high acromion index resulting in an increased upward force against the subacromial space influencing pain and function in calcifying tendinitis of the shoulder was not supported [49].
  • Ultrasound is a useful tool for discovering subjects in pre-symptomatic stages who may undergo shoulder symptomatic pathologies [40].

Classification

  • Calcific tendinitis is a common shoulder disorder [9].
  • Calcific tendinitis should be differentiated from dystrophic calcification because their pathogenesis and natural history are totally different [9].
  • Calcific tendinitis is an acute or chronically painful condition caused by inflammation around calcium deposits in the rotator cuff tendons [15].
  • Symptoms of calcific tendinitis can be protracted, resulting in time off work and impaired quality of life [5].
  • Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term [4].
  • The demographic, radiographic, and clinical features of calcific tendinitis of the shoulder in the Korean population are not different from those of Western populations [7].
  • Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits [10].
  • The primary choice of treatment for calcific tendinitis is conservative, especially in patients with acute calcific tendinitis [12].
  • Patients with calcific lesions >1 cm had a 2.8 increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder [2].
  • The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function [3].
  • Shoulder MRI may be warranted for preoperative planning in the select population of patients with chronic calcific tendinitis and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low [1].
  • Calcific tendinitis of the rotator cuff with tuberosity osteolysis is a distinctive form of calcific tendinitis that should be considered in clinical and surgical practice [17].
  • Restriction of passive glenohumeral abduction combined with normal passive external rotation is a diagnostic feature of calcific tendinitis that can be used to clinically differentiate it from adhesive capsulitis [18].
  • The incidence and type of intraarticular lesions in calcifying tendinitis are comparable to age-matched shoulders with partial- rather than full-thickness rotator cuff tears [35].

Clinical Presentation

  • Calcific tendinitis of the shoulder is an acute or chronically painful condition caused by inflammation around calcium deposits in the rotator cuff tendons [15].
  • Symptoms of calcific tendinitis can be protracted, resulting in time off work and impaired quality of life [5].
  • Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term [4].
  • Calcific tendinitis is a common shoulder disorder that should be differentiated from dystrophic calcification because the pathogenesis and natural history of both are totally different [9].
  • The demographic, radiographic, and clinical features of calcific tendinitis of the shoulder in the Korean population are not different from those of Western populations [7].
  • Restriction of passive glenohumeral abduction combined with normal passive external rotation is a diagnostic feature of calcific tendinitis that can be used to clinically differentiate it from adhesive capsulitis [18].
  • Arthroscopic treatment of calcifying tendinitis provides good to excellent clinical results [16].
  • The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function [3].
  • Patients with calcific lesions >1 cm had a 2.8 increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder [2].
  • Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits [10].
  • The primary choice of treatment for calcific tendinitis is conservative, especially in patients with acute calcific tendinitis [12].
  • Treatment of calcific tendinitis of the shoulder with extracorporeal shock waves has produced a high rate of success in pain relief and functional restoration with negligible associated complications [6].
  • Both ultrasound-guided needling and extracorporeal shock wave therapy improved clinical outcomes and eliminated calcium deposits in the treatment of calcific tendinitis [22].
  • Shoulder MRI may be warranted for preoperative planning in the select population of patients with chronic calcific tendinopathy and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low [1].
  • Routine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of calcific tendinitis due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment [19].
  • Imaging and functional data indicate that calcific tendinitis of the rotator cuff with tuberosity osteolysis is a distinctive form of calcific tendinitis that should be considered in clinical and surgical practice [17].
  • Recognition of atypical presentations of calcific tendinitis with bone erosion may prevent unnecessary biopsy and overtreatment [14].
  • Atypical presentations of calcific tendinitis, such as involvement of the teres minor affecting overhead movement or isolated posterior shoulder pain, should be considered in clinical practice [20].
  • A patient can suffer from both a calcifying lesion within the medial collateral ligament and calcifying tendinitis of the rotator cuff in both shoulders simultaneously [13].

Investigations

  • Shoulder MRI may be warranted for preoperative planning in select patients with chronic calcific tendinopathy and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low [1].
  • Patients with calcific lesions >1 cm have a 2.8 increased likelihood to undergo operative treatment [2].
  • The majority of patients undergoing surgical management for removal of the calcific deposit require a concomitant rotator cuff repair [3].
  • Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term [4].
  • Calcific tendinitis symptoms can be protracted, resulting in time off work and impaired quality of life [5].
  • Demographic, radiographic, and clinical features of calcific tendinitis of the shoulder in the Korean population are not different from those of Western populations [7].
  • Patients undergoing arthroscopic treatment of a calcific deposit in the shoulder had satisfactory clinical and radiological outcomes at final follow-up, with functional scores improving slowly and reaching more than 75 percent at six months after surgery [8].
  • Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits [10].
  • Calcific tendinitis can present with simultaneous calcifying lesions in other locations, such as the medial collateral ligament of the knee [13].
  • Atypical presentations of calcific tendinitis with bone erosion may occur, and recognition of these presentations can prevent unnecessary biopsy and overtreatment [14].
  • Calcific tendinitis of the rotator cuff with tuberosity osteolysis is a distinctive form that should be considered in clinical and surgical practice [17].
  • Restriction of passive glenohumeral abduction combined with normal passive external rotation is a diagnostic feature that can be used to clinically differentiate adhesive capsulitis from calcific tendinitis [18].
  • Atypical presentations of calcific tendinitis, such as involvement of the teres minor affecting overhead movement, should be considered in the context of isolated posterior shoulder pain [20].
  • Shoulder surgeons should be cautious about rotator cuff tears as a comorbidity in calcific tendinitis and aware of the accuracy limitations of sonographic or MRI evaluation [27].
  • The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in management at both individual and population levels [30].
  • MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions [38].
  • Repeating lavage and corticosteroid injections until calcific deposits resolve completely is not recommended due to lack of evidence regarding efficacy and risks [43].
  • Preoperative ultrasound-guided marking of calcific deposits statistically significantly improves the clinical results of arthroscopic surgery at 6 weeks and 2 years [44].

Treatment

Non-Operative Management

  • Conservative treatment is the primary choice for calcific tendinitis, especially in patients with acute calcific tendinitis [12].
  • Nonsurgical management remains the mainstay of treatment for calcific tendinitis of the rotator cuff [31].
  • Most patients improve with nonsurgical modalities such as oral anti-inflammatory medication, physical therapy, and corticosteroid injections [31].
  • Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term [4].
  • Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits [10].
  • Extracorporeal shock wave therapy (ESWT) is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder [21].
  • ESWT produces a high rate of success in pain relief and functional restoration with negligible complications [21].
  • ESWT effectively reduced painful symptomatology and increased shoulder function in patients with chronic calcific tendinitis of the shoulder [24].
  • Treatment of calcific tendinitis of the shoulder with shock waves has produced a high rate of success in pain relief and functional restoration with negligible associated complications [6].
  • Both ultrasound-guided needling and extracorporeal shock wave therapy improved clinical outcomes and eliminated calcium deposits in the treatment of calcific tendinitis [22].
  • The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients [30].

Operative Management

  • Patients with calcific lesions >1 cm had a 2.8 increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder [2].
  • Arthroscopic removal of calcification leads to improved clinical outcomes in patients with chronic calcific tendinitis [11].
  • At least 6 months of follow-up is needed for improvements in clinical outcomes after arthroscopic removal of calcification to become statistically significant [11].
  • Patients undergoing arthroscopic treatment of a calcific deposit in the shoulder had satisfactory clinical and radiological outcomes at the final follow-up [8].
  • Functional scores in patients undergoing arthroscopic treatment of a calcific deposit improved slowly, reaching more than 75 percent at six months after surgery [8].
  • Arthroscopic treatment of calcifying tendinitis provides good to excellent clinical results [16].
  • The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair [3].
  • Patients who undergo surgical management for removal of the calcific deposit have significant improvements in shoulder pain and function [3].
  • Endoscopic and open surgery are equally effective in the treatment of chronic calcifying tendinopathy, showing similar clinical and sonographic results [23].
  • Routine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of calcific tendinitis due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment [19].
  • Shoulder MRI may be warranted for preoperative planning in the select population of patients with chronic calcific tendinopathy and prolonged refractory pain [1].
  • The probability of identifying additional cuff pathology requiring surgical intervention via shoulder MRI in patients with chronic calcific tendinopathy and prolonged refractory pain is very low [1].

Complications

  • Calcific tendinitis symptoms can be protracted, resulting in time off work and impaired quality of life [5].
  • Atypical presentations of calcific tendinitis may include bone erosion, which can lead to unnecessary biopsy and overtreatment if not recognized [14].
  • Shoulder surgeons should be cautious about rotator cuff tears as a comorbidity in calcific tendinitis due to accuracy limitations in sonographic or MRI evaluation [27].
  • The probability of identifying additional cuff pathology requiring surgical intervention via preoperative shoulder MRI in patients with chronic calcific tendinopathy is very low [1].
  • Arthroscopic decompression is not recommended in the treatment of rotator cuff tendinopathy [25].

Recovery

  • Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term [4].
  • Symptoms of calcific tendinitis can be protracted, resulting in time off work and impaired quality of life [5].
  • Patients undergoing arthroscopic treatment of a calcific deposit in the shoulder had satisfactory clinical and radiological outcomes at the final follow-up [8].
  • Functional scores for patients undergoing arthroscopic treatment of a calcific deposit improved slowly, reaching more than 75 percent at six months after surgery [8].
  • Arthroscopic removal of calcification leads to improved clinical outcomes in patients with chronic calcific tendinitis, but at least 6 months of follow-up is needed for these improvements to become statistically significant [11].
  • The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair [3].
  • Patients who undergo surgical management for removal of the calcific deposit have significant improvements in shoulder pain and function [3].
  • Percutaneous needle aspiration and lavage is effective in the short term and in the long term in calcific tendinitis of the shoulder [29].
  • Percutaneous needle aspiration and lavage results are similar to or better than those published for other techniques [29].
  • Percutaneous needle aspiration and lavage is only slightly invasive and painful [29].
  • Treatment of calcific tendinitis of the shoulder with shock waves has produced a high rate of success in pain relief and functional restoration with negligible associated complications [6].
  • Shock wave therapy is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder, producing a high rate of success in pain relief and functional restoration with negligible complications [21].
  • A symptom duration of ≤10 months or calcification size of ≤10.82 mm represented the clinical scenarios most likely to show resorption after extracorporeal shockwave therapy (ESWT) [56].
  • The short-term functional outcome of patients with calcific tendonitis after arthroscopic bursectomy and debridement of the calcific deposit is not influenced if performed in combination with or without a subacromial decompression [26].

Key Evidence

  • [Commentary] Shoulder MRI may be warranted for preoperative planning in the select population of patients with chronic calcific tendinopathy and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low. (10.1016/j.arthro.2020.01.014)
  • [L3] Patients with calcific lesions >1 cm had a 2.8 increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder. (10.1016/j.jseint.2021.01.013)
  • [L3] The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function. (10.1177/2325967121s00208)
  • [L1] Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long-term. (10.1097/phm.0000000000000939)
  • [L3] Calcific tendinitis is a poorly understood condition in which symptoms can be protracted, resulting in time off work and impaired quality of life. (10.1016/j.jse.2006.06.007)
  • [L2] Treatment of calcific tendinitis of the shoulder with shock waves has produced a high rate of success in pain relief and functional restoration with negligible associated complications. (10.1016/j.jse.2007.03.023)
  • [L4] This study reported demographic, radiographic, and clinical features of calcific tendinitis of the shoulder in the Korean population, which were not different from those of Western populations. (10.5397/cise.2020.00010)
  • [Paper] Patients undergoing arthroscopic treatment of a calcific deposit in the shoulder had satisfactory clinical and radiological outcomes at the final follow-up, with functional scores improving slowly and reaching more than 75 percent at six months after surgery. (10.1016/j.otsr.2020.03.005)
  • [L5] Calcific tendinitis is a common shoulder disorder that should be differentiated from dystrophic calcification as the pathogenesis and natural history of both is totally different. (10.5312/wjo.v7.i1.55)
  • [L2] Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits. (10.1016/j.jse.2009.07.008)
  • [L4] Arthroscopic removal of calcification leads to improved clinical outcomes in patients with chronic calcific tendinitis, but at least 6 months of follow-up is needed for these improvements to become statistically significant. (10.5397/cise.2018.21.2.75)
  • [L5] The primary choice of treatment for calcific tendinitis is conservative, especially in patients with acute calcific tendinitis. (10.5397/cise.2020.00318)
  • [Case_report] This is the first case report of a patient suffering from both a calcifying lesion within the medial collateral ligament and calcifying tendinitis of the rotator cuff in both shoulders. (10.1186/s12891-016-1147-z)
  • [L5] Recognition of atypical presentations of calcific tendinitis with bone erosion may prevent unnecessary biopsy and overtreatment. (10.1016/j.jse.2009.02.009)
  • [L5] Calcific tendinitis of the shoulder is an acute or chronically painful condition caused by inflammation around calcium deposits in the rotator cuff tendons. (10.1016/s0030-5898(03)00089-0)
  • [L3] Arthroscopic treatment of calcifying tendinitis provides good to excellent clinical results. (10.1177/03635465211037690)
  • [L2] Imaging and functional data indicate that calcific tendinitis of the rotator cuff with tuberosity osteolysis is a distinctive form of calcific tendinitis that should be considered in clinical and surgical practice. (10.1016/j.jse.2008.09.016)
  • [L3] This finding can be used to clinically differentiate adhesive capsulitis from calcific tendinitis. (10.1177/2325967117752907)
  • [L3] Routine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of calcific tendinitis due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment. (10.1186/s12891-017-1839-z)
  • [Case_report] This case highlights the importance of considering atypical presentations of calcific tendinitis, particularly in the context of isolated posterior shoulder pain. (10.1016/j.jisako.2025.101055)
  • [L3] Shock wave therapy is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder, producing a high rate of success in pain relief and functional restoration with negligible complications. (10.1177/03635465030310031701)
  • [L2] Both treatment modalities for calcific tendinitis improved clinical outcomes and eliminated calcium deposits. (10.1016/j.jse.2014.06.036)
  • [L1] Endoscopic and open surgery are equally effective in the treatment of chronic calcifying tendinopathy, showing similar clinical and sonographic results. (10.1097/01.blo.0000063786.32430.22)
  • [L2] ESWT effectively reduced painful symptomatology and increased shoulder function in patients with chronic calcific tendinitis of the shoulder. (10.1136/ard.62.3.248)
  • [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
  • [L1] This study has demonstrated that the short-term functional outcome of patients with calcific tendonitis after arthroscopic bursectomy and debridement of the calcific deposit is not influenced if performed in combination with or without a subacromial decompression. (10.1016/j.arthro.2015.05.015)
  • [L3] Shoulder surgeons should be cautious about rotator cuff tears as a comorbidity in calcific tendinitis and aware of the accuracy limitations of sonographic or MRI evaluation. (10.5397/cise.2021.00094)
  • [L2] Findings from this study suggest that, over time, supraspinatus tendon thickness in individuals with rotator cuff-related shoulder pain tends to normalize compared to the contralateral side, regardless of the exercise intervention. (10.1016/j.jse.2024.03.055)
  • [L4] Percutaneous needle aspiration and lavage is effective in the short term and in the long term in calcific tendinitis of the shoulder, with results similar to or better than those published for other techniques, and it is only slightly invasive and painful. (10.2214/ajr.07.2254)
  • [L4] The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level. (10.1016/j.jse.2019.04.003)
  • [L5] Nonsurgical management remains the mainstay of treatment for calcific tendinitis of the rotator cuff, with most patients improving with modalities such as oral anti-inflammatory medication, physical therapy, and corticosteroid injections. (10.5435/jaaos-22-11-707)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. (10.1016/j.arthro.2010.10.014)
  • [L5] Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. (10.5435/jaaos-d-15-00258)
  • [L3] The incidence and type of intraarticular lesions in calcifying tendinitis are comparable to age-matched shoulders with partial- rather than full-thickness rotator cuff tears. (10.1007/s00402-011-1263-z)
  • [L1] At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved. (10.1186/s12891-020-03872-4)
  • [L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. (10.1016/j.jse.2015.06.005)
  • [L4] Surgical repair of an isolated supraspinatus tear may be sufficient to keep the torn rotator cuff intact and achieve satisfactory patient-reported outcomes, but glenohumeral joint mechanics and shoulder strength are not fully restored with current repair techniques. (10.1177/0363546511412164)
  • [L3] Ultrasound is an useful tool for discovering in pre-symptomatic stages the subjects that may undergo shoulder symptomatic pathologies. (10.1186/1471-2474-11-278)
  • [L4] In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity. (10.1016/j.jse.2008.05.044)
  • [L5] Repeating lavage and corticosteroid injections until the calcific deposits resolve completely is not recommended due to lack of evidence regarding efficacy and risks. (10.5397/cise.2021.00269)
  • [L3] Preoperative ultrasound-guided marking of calcific deposits is a procedure that statistically significantly improves the clinical results of arthroscopic surgery as seen at 6 weeks and 2 years. (10.1016/j.arthro.2006.08.005)
  • [L2] The theoretical concept of a high acromion index resulting in an increased upward force against the subacromial space, which influences pain and function in calcifying tendinitis of the shoulder, was not supported. (10.1007/s00167-011-1563-4)
  • [L3] Clinicians can guide patients to understand shoulder pain as age-appropriate and safe, potentially reducing unnecessary visits, tests, and treatments. (10.1097/corr.0000000000003342)
  • [L3] Our data support that in chronic rotator cuff tears, there seems to be no disadvantage to exhausting conservative treatment and to delay implantation of reverse total shoulder arthroplasty, as the shape of deltoid muscle seems only to be influenced by natural aging, but to be independent of reduced shoulder motion. (10.1186/1471-2474-14-247)
  • [L4] A high prevalence of structural changes in the rotator cuff and biceps tendons in masters swimmers reflects the effect of shoulder symptoms, aging, and swim training. (10.3390/medicina57010029)
  • [L3] A symptom duration of ≤10 months or calcification size of ≤10.82 mm represented the clinical scenarios most likely to show resorption after ESWT. (10.1177/23259671241231609)

References

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DOI: 10.1016/j.jse.2006.06.007 [6] Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.03.023 [7] Calcific tendinitis of the shoulder in the Korean population: demographics and its relation with coexisting rotator cuff tear. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2020.00010 [8] Recovery pattern after arthroscopic treatment for calcific tendinitis of the shoulder. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2020.03.005 [9] Calcific tendinitis of the rotator cuff. World Journal of Orthopedics. 2016. DOI: 10.5312/wjo.v7.i1.55 [10] Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: Does the initial radiologic aspect affect the final results?. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.07.008 [11] Functional Recovery of the Shoulder after Arthroscopic Treatment for Chronic Calcific Tendinitis. 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DOI: 10.1177/03635465030310031701 [22] Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.036 [23] Prospective Randomized Surgical Treatments for Calcifying Tendinopathy. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000063786.32430.22 [24] Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study. Annals of the Rheumatic Diseases. 2003. DOI: 10.1136/ard.62.3.248 [25] Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b6.bjj-2016-0569.r1 [26] Short‐Term Outcome After Arthroscopic Bursectomy Debridement of Rotator Cuff Calcific Tendonopathy With and Without Subacromial Decompression: A Prospective Randomized Controlled Trial. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.05.015 [27] Is common the rotator cuff tear in the calcific tendinitis?. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2021.00094 [28] Do therapeutic exercises impact supraspinatus tendon thickness? Secondary analyses of the combined dataset from two randomized controlled trials in patients with rotator cuff-related shoulder pain. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.055 [29] Sonographically Guided Percutaneous Needle Lavage in Calcific Tendinitis of the Shoulder: Short- and Long-Term Results. American Journal of Roentgenology. 2007. DOI: 10.2214/ajr.07.2254 [30] A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.003 [31] Calcific Tendinitis of the Rotator Cuff. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-11-707 [32] Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2010.10.014 [34] Understanding the Importance of the Teres Minor for Shoulder Function: Functional Anatomy and Pathology. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00258 [35] Intraarticular lesions in calcifying tendinitis: incidence and association with the acromion index. Archives of Orthopaedic and Trauma Surgery. 2011. 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DOI: 10.1016/j.jse.2008.05.044 [42] Chapter 24 Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis. 2020. [43] The efficacy of repeated needling for calcific tendinitis of the rotator cuff. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2021.00269 [44] Value of Preoperative Ultrasound Marking of Calcium Deposits in Patients Who Require Surgical Treatment of Calcific Tendinitis of the Shoulder. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.08.005 [49] Do anatomic variants of the acromion shape in the frontal plane influence pain and function in calcifying tendinitis of the shoulder?. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1563-4 [51] Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain. Clinical Orthopaedics & Related Research. 2024. 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c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.