Korean J Fam Pract.

2014;4:239-245

Original
Article

, *, , , , , ,

Lifestyle Factors That Influence the Diagnosis of Calcifying Tendinitis among

Men with Shoulder Pain
In-Cheon Kim, Sunmi Yoo*, Young-Bok Kim, Seung Guk Park, Young-Jee Jeon, Yong-Hyun Jung, Seung-Hyun Cha, Hui-Ho Yaang

Department of Family Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Background: Smoking is a major cause of tissue hypoxic damage which is one of hypotheses for pathophysiology of calcifying
tendinitis in shoulder. The purpose of this study was to assess the association between smoking and various lifestyle factors
expected to lead to hypoxic damage with calcifying tendinitis.
Methods: We examined patients with shoulder pain who performed ultrasound on shoulders at the outpatient orthopedic
department of a university hospital from May 2011 to March 2013. The subjects were surveyed using a specific questionnaire
for 18 patients who were diagnosed with calcifying tendinitis and 41 control patients who were diagnosed with non-calcifying
tendinitis. Logistic regression analysis was used to calculate the odds ratio of smoking and lifestyle factors for calcifying tendinitis.
Results: Mean smoking amount was 13.9 pack-year in the calcifying tendinitis group and 21.2 pack-year in the non-calcifying
tendinitis group. Current smokers were prevalent in 38.9% among the calcifying tendinitis group and 17.5% among the non-
calcifying tendinitis group, but the difference was not statistically significant. Current smoking was associated with increased risk
of calcifying tendinitis (odds ratio [OR], 5.53; 95% confidence interval [CI], 1.33 to 22.94). Being overweight (body mass index23
kg/m2) (OR, 3.79; 95%CI, 1.08 to 13.25) and frequent exercise (OR, 4.49; 95%CI, 1.13 to 18.1) were related to an increase of
calcifying tendinitis. Coincidence of dominant hand and painful shoulders, exercise using shoulders, and current alcohol intake
had no relationship with calcifying tendinitis.
Conclusion: Current smoking and obesity may be risk factors for calcifying tendinitis causing acute shoulder pain.

Keywords: Calcifying Tendinitis; Shoulder Pain; Cellular Hypoxia; Smoking; Overweight

tendinitis) 3%
3050 .1,2)
(calcifying (rotator cuff
tendon) .1,2)
Received: August 26, 2013, Accepted: June 29, 2014
*Corresponding Author: Sunmi Yoo
Tel: 051-797-3220, Fax: 051-797-0589 .
E-mail: syoo@paik.ac.kr ,1-3)
.3)
Korean Journal of Family Practice
Copyright 2014 by The Korean Academy of Family Medicine (hypoxic areas)

Vol. 4, No. 3 Sep 2014 | 239

In-Cheon Kim, et al: Lifestyle Factors for Diagnosing Calcifying Tendinitis

(metabolic factor) (local .

hypoxia) (fibrocartilaginous metaplasia)
1,3-5)
. Neers test
(non-calcifying tendinitis) Hawkins test (tendinitis)
6,7)
. (tendinosis) .
18 41
8)
. .
9)
, (IRB number 2013-029),
10)
. .
.
, , 2.
18
3)
41
. . 1
, ,
.
33 . 7
. , 4, 4, 4,
7, 7 .
. (body mass index, BMI)
(kg) (m) .

. World
Health Organization Asia-Pacific Region BMI
1. 23 kg/m2
2011 5 2013 3 .12)
10
. , , ,
iU 22 (Philips, Bothell, WA, USA) . , ,
380 , ,
2 . , ,
. , , ,
, Ellman , .
, 1, 23, 4
11)
, .
, , , .
30% , ,
. , .
3
, , , 100
(supraspinatus), ,
(infraspinatus) 3 mm 3
.13) 5

240 | Vol. 4, No. 3 Sep 2014 Korean J Fam Pract

 :

. Table 1. Characteristics of study participants

, , , Non-calcifying Calcifying
. 2007 National Institute on Characteristic tendinitis tendinitis P-value*
Alcohol Abuse and Alcoholism (NIAAA) Alcohol Use (n=41) (n=18)

Disorders Identication Test . NIAAA Age (y) 52.910.0 57.611.9 0.13

1 14 g . BMI (kg/m2) 22.93.2 24.02.9 0.23

19.5% 1 55.4 g 4 Dominant hand

. 1 14 g 20% Right 35 (87.9) 17 (100.0) 0.30

88 mL, 4.5% 340 mL, 7% 230 mL Left 0 0
14)
1/4, 1, 1 . Both 4 (10.3) 0
2 Painful shoulder
, .13) Right 27 (65.9) 13 (78.2) 0.99

Left 12 (29.3) 5 (27.8)

3. Both 2 (4.9) 0

Occupation
t-, Fisher exact test
Office workers 27 (67.5) 12 (70.6) 1.00
.
Laborers 12 (30.0) 5 (29.4)
.
Others 1 (2.5) 0
,
Occupation using shoulders 13 (34.2) 6 (35.3) 0.82
, ,
Hypertension 7 (17.9) 6 (35.3) 0.28
.
Diabetes mellitus 5 (12.8) 2 (11.8) 0.64
MedCalc (ver. 12.5; MedCalc Soware, Mariakerke, Belgium)
Dyslipidemia 1 (2.6) 1 (5.9) 0.52
P 0.05 .
Exercise frequency 0.09

None (time/wk) 13 (33.3) 5 (29.4)

1 7 (17.9) 1 (5.9)

Table 1 23 9 (23.1) 1 (5.9)

. 52.9 4 10 (25.6) 10 (58.8)

2
, 57.6 BMI 22.9 kg/m , Exercise using shoulders 6 (15) 3 (17.6) 0.54
2
24 kg/m . Smoking status
(35 87.9%; 17 Never 12 (30) 2 (11.1) 0.12
100%), 27(65.9%), Current 7 (17.5) 7 (38.9)
13(78.2%). Former 21 (52.5) 9 (50)
13(34.2%), 6
Alcohol intake
(35.3%) .
None 10 (25) 3 (17.6) 0.84
(13.9) (21.2)
Current 24 (60) 11 (64.7)
, (38.9%)
Former 6 (15) 3 (17.6)
(17.5%)
Values are presented as meanSD or number (%).
.
BMI: body mass index.
Table 2 *Obtained by chi-square test or Fisher exact test for categorical
. outcomes and t-test for continuous outcomes. Calculated as weight in
kilograms divided by height in meters squared.
BMI 23 kg/m2

Vol. 4, No. 3 Sep 2014 | 241

In-Cheon Kim, et al: Lifestyle Factors for Diagnosing Calcifying Tendinitis

Table 2. Comparison of life style factors between calcifying tendinitis Table 3. Factor associated with calcifying tendinitis among men with
group and non-calcifying tendinitis group acute shoulder pain

Non-calcifying Calcifying Odds ratio*

Variable tendinitis tendinitis P-value* Variable (95% confidence
(n=41) (n=18) interval)

BMI (kg/m2) 0.042 Overweight

<23 24 (64.9) 6 (35.3) BMI<23 kg/m2 1.00

2
23 13 (35.1) 11 (64.7) BMI 23 kg/m 3.79 (1.08-13.25)

Coincidence of dominant hand 0.72 Coincidence of dominant hand and painful shoulder 1.36 (0.33-5.57)
and painful shoulder
Exercise using shoulder 1.51 (0.30-7.71)
No 11 (28.2) 4 (23.5)
Smoking
Yes 28 (71.8) 13 (76.5)
No or former smoking 1.00
Smoking status 0.07
Current smoking 5.53 (1.33-22.94)
None and former 33 (82.5) 10 (55.6)
Smoking amount (pack-years)
Current 7 (17.5) 8 (44.1)
5 1.00
Smoking amount (pack-years) 0.43
>5 1.88 (0.44-8.14)
5 13 (32.5) 4 (22.2)
Alcohol intake
>5 27 (67.5) 14 (77.8)
No or former drinker 1.00
Alcohol intake 0.70
Current drinker 1.85 (0.50-6.78)
None and former 18 (45.0) 6 (35.3)
Exercise frequency
Current 22 (55.0) 11 (64.7)
No or 23 times/wk 1.00
Alcohol consumption (bottle/wk) 0.49
4 times/wk 4.49 (1.13-18.1)
0.5 6 (20.7) 5 (37.5)
BMI: body mass index.
>0.5 23 (79.3) 9 (64.3) *Logistic regression analysis was done for each lifestyle factor separately
Exercise frequency (times/wk) 0.02 adjusting for age, occupation group, and occupation using shoulders.

Calculated as weight in kilograms divided by height in meters squared.
<4 29 (74.4) 7 (41.2)

4 10 (25.6) 10 (58.5)

Values are presented as number (%). 4

BMI: body mass index.
(P=0.02).
*Calculated as weight in kilograms divided by height in meters squared.

Obtained by chi-square test or Fisher exact test for categorical Table 3

outcomes. . , ,

(odds ratio [OR], 5.53;
(P=0.042). 95% confidence interval [CI], 1.33 to 22.94). BMI 23 kg/m2
23 kg/m2
(P=0.07). 5 , (OR, 3.79; 95% CI, 1.08 to 13.25). 4

. (OR, 4.49; 95% CI, 1.13 to 18.10).
, , ,
.
(P=0.7, P=0.49).

242 | Vol. 4, No. 3 Sep 2014 Korean J Fam Pract

 :

.19)
. .

2
5.53 . BMI 23 kg/m .9)
3.79 (tendinopathy)
. hypoxia inducible factor 1 alpha (HIF-1)
, . HIF-1 Bcl-2 adenovirus E1B 19 kDa-interacting
protein 3 (apoptosis)
.
. .20,21)
interleukin-1 (IL-1), interleukin-6 (IL-6)
1.74 tumor necrosis factor-alpha (TNF-)
10 4.24 . IL-1, IL-6,
10)
. . TNF- .9) IL-1, IL-6 TNF-
( (hypersensitivity)
) .
6.11 , ,
.
5.53 . . ,
. .

. . ,
40% 5.4%
.15) .
16)
.

. 94 cm
1.8 , 80 cm . BMI
1.5 .
94 cm . BMI
2 , 80 cm
9)
1.6 . BMI .
2
BMI 30 kg/m
17)
2.5 . .

. .
.
1.59 .18)

.16) :

Vol. 4, No. 3 Sep 2014 | 243

In-Cheon Kim, et al: Lifestyle Factors for Diagnosing Calcifying Tendinitis

JJ, Kransdorf MJ. Osseous involvement in calcific tendinitis: a

. retrospective review of 50 cases. AJR Am J Roentgenol 2003;
181:965-72.
. 6. Churgay CA. Diagnosis and treatment of biceps tendinitis and
: 2011 5 2013 3 tendinosis. Am Fam Physician 2009;80:470-6.
7. Meloni F, Milia F, Cavazzuti M, Doria C, Lisai P, Profili S, et al.
18 Clinical evaluation of sodium hyaluronate in the treatment of
41 patients with sopraspinatus tendinosis under echographic guide:
. , experimental study of periarticular injections. Eur J Radiol 2008;
(body mass index, BMI), , 68:170-3.
, , , 8. Sagone AL Jr, Lawrence T, Balcerzak SP. Effect of smoking on
. tissue oxygen supply. Blood 1973;41:845-51.
: 13.9, 9. Rechardt M, Shiri R, Karppinen J, Jula A, Heliovaara M, Viikari-
21.2, Juntura E. Lifestyle and metabolic factors in relation to shoulder
17.5%, 38.9% pain and rotator cuff tendinitis: a population-based study. BMC
. Musculoskelet Disord 2010;11:165.
(odds 10. Baumgarten KM, Gerlach D, Galatz LM, Teefey SA, Middleton
ratio [OR], 5.53; 95% confidence interval [CI], 1.33 to 22.94). BMI WD, Ditsios K, et al. Cigarette smoking increases the risk for
2
23 kg/m (OR, 3.79; 95% CI, 1.08 to 13.25) rotator cuff tears. Clin Orthop Relat Res 2010;468:1534-41.
4 (OR, 4.49; 95% CI, 1.13 to 18.1) 11. Ellman H. Diagnosis and treatment of incomplete rotator cuff
. tears. Clin Orthop Relat Res 1990;(254):64-74.
, , 12. World Health Organization Regional Office for the Western
. Pacific, International Obesity Task Force, International
: Association for the Study of Obesity. The Asia-Pacific
. perspective: redefining obesity and its treatment. Sydney: Health
Communications Australia; 2000.
: ; ; ; ; 13. US Centers for Disease Control and Prevention. Health
behaviors of adults: United States, 2005-2007. Vital and Health

REFERENCES Statistics: Series 10, Number 245. Hyattsville (MD): US

1. Bianchi S, Martinoli C. Ultrasound of the musculoskeletal
system. 2nd ed. Berlin: Springer; 2007.
2. Chan R, Kim DH, Millett PJ, Weissman BN. Calcifying
tendinitis of the rotator cuff with cortical bone erosion. Skeletal
Radiol 2004;33:596-9.
3. Rockwood CA, Matsen FA, Wirth MA, Lippitt SB, Fehringer
EV, Sperling JW. The shoulder. 4th ed. Philadelphia: Saunders;
2009.
4. Seijas R, Ares O, Alvarez P, Cusco X, Garcia-Balletbo M, Cugat R.
Platelet-rich plasma for calcific tendinitis of the shoulder: a case
report. J Orthop Surg (Hong Kong) 2012;20:126-30.
5. Flemming DJ, Murphey MD, Shekitka KM, Temple HT, Jelinek
Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Health Statistics;
2010.
14. Lee JG, Kim JS, Jung JG, Choi TK, Ryou YI. Usefulness of
the alcohol use disorders identification test in screening for
problem drinkers among college students. Korean J Fam Med
2011;32:29-36.
15. Carbone S, Gumina S, Arceri V, Campagna V, Fagnani C,
Postacchini F. The impact of preoperative smoking habit on
rotator cuff tear: cigarette smoking influences rotator cuff tear
sizes. J Shoulder Elbow Surg 2012;21:56-60.
16. Ueno S, Hisanaga N, Jonai H, Shibata E, Kamijima M.
Association between musculoskeletal pain in Japanese

244 | Vol. 4, No. 3 Sep 2014 Korean J Fam Pract

 :
construction workers and job, age, alcohol consumption, and
smoking. Ind Health 1999;37:449-56.
17. Bodin J, Ha C, Serazin C, Descatha A, Leclerc A, Goldberg M,
et al. Effects of individual and work-related factors on incidence
of shoulder pain in a large working population. J Occup Health
2012;54:278-88.
18. Janwantanakul P, Pensri P, Jiamjarasrangsi W, Sinsongsook T.
The relationship between upper extremity musculoskeletal
symptoms attributed to work and risk factors in office workers.
Int Arch Occup Environ Health 2010;83:273-81.
19. Tashjian RZ. Epidemiology, natural history, and indications for
treatment of rotator cuff tears. Clin Sports Med 2012;31:589-
604.
20. Benson RT, McDonnell SM, Knowles HJ, Rees JL, Carr AJ,
Hulley PA. Tendinopathy and tears of the rotator cuff are
associated with hypoxia and apoptosis. J Bone Joint Surg Br
2010;92:448-53.
21. Millar NL, Reilly JH, Kerr SC, Campbell AL, Little KJ,
Leach WJ, et al. Hypoxia: a critical regulator of early human
tendinopathy. Ann Rheum Dis 2012;71:302-10.
Vol. 4, No. 3 Sep 2014 | 245