Calcific Tendinopathy of the Shoulder: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Dense calcification of the supraspinatus.jpeg|thumb|Calcification of the supraspinatus]]
[[File:Dense calcification of the supraspinatus.jpeg|thumb|Calcification of the supraspinatus]]
Calcific tendonitis refers to the calcification and tendon degeneration around the shoulders rotator cuff insertions. It usually results in shoulder pain with decreased range of motion. Diagnosis is made by shoulder x-rays, with visible signs of calcium deposits overlying the rotator cuff insertion.Treatment consists of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Those who fail conservative treatment may choose to have arthroscopic decompression of the calcium deposits.<ref>Orthobullets [https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis Calcific Tendonitis]Available:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)</ref><br><br>
Calcific tendonitis refers to the calcification and tendon degeneration around the shoulders rotator cuff insertions. It usually results in shoulder pain with decreased range of motion. Diagnosis is made by shoulder x-rays, with visible signs of calcium deposits overlying the rotator cuff insertion.Treatment consists of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Those who fail conservative treatment may choose to have arthroscopic decompression of the calcium deposits.<ref>Orthobullets [https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis Calcific Tendonitis]Available:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)</ref>


== Epidemiology ==
== Epidemiology ==
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== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Clinical presentation varies.<ref name="Cacchio">Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.( LOE 1b )</ref>  Symptoms may last several days or become chronic; there is no clear prediction of disease course.&nbsp;Time required for symptoms to disappear is typically too long for patient’s QoL.<ref name="Cacchio" /> The typical clinical manifestation is a sub-acute, low-grade shoulder pain that increases at night (50% of patients), with restricted range-of-motion.<ref name="Serafini" /><br>The condition goes through 4 stage, see table below.  
The chief patient complaints to expect in calcific tendinopathy are:
 
* Night pain, causing loss of sleep.<sup><ref name="Ebenbichler">Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.</ref>,&nbsp;<ref name="Gimblett">Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.</ref>,&nbsp;<ref name="Alexander">Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.</ref>,&nbsp;<ref name="Wainner" />.</sup>
* Constant dull ache<sup><ref name="Wainner" /></sup>.  
* Pain increases considerably with AROM<sup><ref name="Wainner" /></sup>.
* Decrease in ROM, or complaint of stiffness&nbsp;<sup><ref name="Fusaro">Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.</ref>,&nbsp;<ref name="Alexander" />,&nbsp;<ref name="Wainner" /></sup>.  
* Radiating pain up into the suboccipital region, or down into the fingers<ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Wainner" />.<br>The condition goes through 4 stage, see table below.  


{| width="400" cellspacing="1" cellpadding="1" border="1"
{| width="400" cellspacing="1" cellpadding="1" border="1"
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! colspan="2" scope="col" bgcolor="#33cc00" | Stages<ref name="Wainner">Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic &amp; Sports Physical Therapy [serial online]. March 1998;27(3):231-237. ( LOE 4 )</ref>
! colspan="2" scope="col" bgcolor="#33cc00" | Stages<ref name="Wainner">Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic &amp; Sports Physical Therapy [serial online]. March 1998;27(3):231-237. ( LOE 4 )</ref>
|-
|-
| bgcolor="#66ff66" align="center" | Stage Name  
| bgcolor="#66ff66" align="center" | Stage Name
| bgcolor="#66ff66" align="center" | Presentation
| bgcolor="#66ff66" align="center" | Presentation
|-
|-
| &nbsp;Chronic (Silent)<br>&nbsp;Phase  
|&nbsp;Chronic (Silent)<br>&nbsp;Phase
|  
|  
*Presence of the calcific deposit&nbsp;<br>is asymptomatic and may be so for years.
*Presence of the calcific deposit&nbsp;<br>is asymptomatic and may be so for years.
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|-
|-
|  
|  
Mechanical Phase&nbsp;  
Mechanical Phase&nbsp;


|  
|  
*Tendon impingement being a prominent finding  
*Tendon impingement being a prominent finding
*Pain of less severe nature than the acute phase
*Pain of less severe nature than the acute phase


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== Outcome Measures  ==
== Outcome Measures  ==
*[https://www.physio-pedia.com/Visual_Analogue_Scale VAS Pain scale]<ref name="Cacchio" /><br>
*[https://www.physio-pedia.com/Visual_Analogue_Scale VAS Pain scale]<ref name="Cacchio">Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.( LOE 1b )</ref><br>
*[[DASH Outcome Measure]]<br>
*[[DASH Outcome Measure]]
 
<br>
 
[[Image:Outcome.jpg]]<br>
 
Images:&nbsp;<ref name="Lam" />
 
== Examination  ==
 
As Calcific tendinopathy is a soft tissue injury that can only be conclusively diagnosed via imaging, it is important to rule out other shoulder pathologies. It is recommended that the initial images include the anteroposterior view in neutral, internal, and external rotation<sup><ref name="Gimblett">Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.</ref></sup>. Imaging will provide definitive proof of calcific build-up through what appear to be “bone spurs”.&nbsp; An ultrasound image of the area is also advised, as this will rule out or rule in any differential diagnosis of soft tissue injuries such as a [[Rotator Cuff Tears|rotator cuff tear]]&nbsp;<sup><ref name="Rapp">Rapp S M. With few advances in calcific tendinitis treatment, diagnosing it becomes critical.  Orthopedics Today. 2008; 70.</ref></sup>.&nbsp; 20-46.4&nbsp;% of all cases are bilateral in nature, so all images and examinations should be conducted in a bilateral fashion <sup><ref name="Fusaro">Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.</ref>,&nbsp;<ref name="Gimblett" /></sup>. Only 35% of cases are symptomatic, so bilateral imaging and examination can detect calcified deposits in an asymptomatic shoulder, if one side is already experiencing calcific tendinitis. This can help to guide treatment and decrease possible patient expenses and future visits.<br>
 
Since imaging is the only way to diagnose calcific tendinopathy, physical examinations will seek to rule out a condition rathar than to rule in a condition.&nbsp; Several systemic diseases are associated with an increased risk of calcification, such as [[Gout|gout]], hypercalcemia of any cause, and various rheumatic diseases<ref name="Ebenbichler">Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.</ref>,&nbsp;<ref name="Gimblett" />.
 
<u>The chief patient complaints to expect in calcific tendinopathy are:<br></u>1.) Night pain, causing loss of sleep.<sup><ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Alexander">Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.</ref>,&nbsp;<ref name="Wainner" />.</sup><br>2.) Constant dull ache<sup><ref name="Wainner" /></sup>.<br>3.) Pain increases considerably with AROM<sup><ref name="Wainner" /></sup>.<br>4.) Decrease in ROM, or complaint of stiffness&nbsp;<sup><ref name="Fusaro" />,&nbsp;<ref name="Alexander" />,&nbsp;<ref name="Wainner" /></sup>.<br>5.) Radiating pain up into the suboccipital region, or down into the fingers<ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Wainner" />.
 
• Observation-check bilaterally for swelling, atrophy or scapular movement that will indicate compensation for decreased humeral movement.
 
• Palpation-attention to any swelling, temperature difference, point tenderness. Most specifically, the supraspinatus tendon, as it is the most commonly affected<sup><ref name="Gimblett" /></sup>. The infraspinatus, teres minor, subscapularis, and biceps tendons are also involved and follow in incidence in the afore-mentioned order<sup><ref name="Wainner" /></sup>.
 
• Neuro and cervical screen may be indicated as N&amp;T, or radiating pain may be present.
 
• AROM and PROM-pain and decreased ranges may be present in any, or all planes (depending on tendon(s) involved).&nbsp; Observe end feel, may be empty 2˚ to pain.
 
• MMT’s-may demonstrate decrease from contralateral side or be limited by pain.


== Medical Management    ==
== Medical Management    ==
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Needle aspiration of medium to large (&gt;1.5cm) calcium deposits is easily administered in the outpatient setting, and has evidence showing positive outcomes up to 2 years post treatment. The procedure is done under local anesthesia, with ultrasound guidance. Two needles pierce the deposit; one to evacuate the toothpaste-like calcium, and one to flush the shell with saline. Evidence shows that this process is most effective when the disease is in the acute phase, and the calcium within the deposit is viscous enough to be aspirated by a large bore needle. Once progressed to the chronic stage, the calcium in the deposit is too solid in consistency to be aspirated, thereby limiting the effectiveness of the treatment.&nbsp;<ref name="Lam">Lam, F, Bhatia, D, K, J.F. de Beer. Modern management of calcifying tendonitis of the shoulder. Current Orthopaedics; 2006, 20, 446–452.</ref>  
Needle aspiration of medium to large (&gt;1.5cm) calcium deposits is easily administered in the outpatient setting, and has evidence showing positive outcomes up to 2 years post treatment. The procedure is done under local anesthesia, with ultrasound guidance. Two needles pierce the deposit; one to evacuate the toothpaste-like calcium, and one to flush the shell with saline. Evidence shows that this process is most effective when the disease is in the acute phase, and the calcium within the deposit is viscous enough to be aspirated by a large bore needle. Once progressed to the chronic stage, the calcium in the deposit is too solid in consistency to be aspirated, thereby limiting the effectiveness of the treatment.&nbsp;<ref name="Lam">Lam, F, Bhatia, D, K, J.F. de Beer. Modern management of calcifying tendonitis of the shoulder. Current Orthopaedics; 2006, 20, 446–452.</ref>  


Arthroscopic excision of the deposit is argued by some to be the best treatment option for patients in the chronic stage of calcific tendinopathy. This procedure has an advantage over needle aspiration in that it can remove hardened deposits that can’t be drawn through a needle bore. Performing any surgical procedure local to the affected tendon, like any acute injury, will stimulate the body’s calcium resorption system, which will help rid the tendon of any further deposits left behind after surgery. There is currently debate among surgeons concerning acromioplasty during procedures for deposit excision. Some believe that symptoms caused by calcific tendinopathy is independent from [[Rotator Cuff|rotator cuff]] impingement, and therefore the procedure doesn’t need to be performed if a type III acromion is not observed.<ref name="Neer">Neer CS. Anterior acromioplasty for the chronic impingementfckLRsyndrome of the shoulder. J Bone Joint Surg (Am) 1972;54A:fckLR41–50.</ref>&nbsp;<ref name="Uhthoff" />&nbsp;&nbsp;Others have demonstrated that even with small diffuse deposits, pain is not relieved from excision alone, and relief only comes after subsequent acromioplasty.&nbsp;<ref name="Resch">Resch H, Povacz P, Seykora P. Excision of calcium deposit andfckLRacromioplasty? In: Gazielly DF, Gleyze PTT, editors. The cuff.fckLRParis: Elsevier; 1997. p. 169–71.</ref><br><br>  
Arthroscopic excision of the deposit is argued by some to be the best treatment option for patients in the chronic stage of calcific tendinopathy. This procedure has an advantage over needle aspiration in that it can remove hardened deposits that can’t be drawn through a needle bore. Performing any surgical procedure local to the affected tendon, like any acute injury, will stimulate the body’s calcium resorption system, which will help rid the tendon of any further deposits left behind after surgery. There is currently debate among surgeons concerning acromioplasty during procedures for deposit excision. Some believe that symptoms caused by calcific tendinopathy is independent from [[Rotator Cuff|rotator cuff]] impingement, and therefore the procedure doesn’t need to be performed if a type III acromion is not observed.<ref name="Neer">Neer CS. Anterior acromioplasty for the chronic impingementfckLRsyndrome of the shoulder. J Bone Joint Surg (Am) 1972;54A:fckLR41–50.</ref>&nbsp;<ref name="Uhthoff" />&nbsp;&nbsp;Others have demonstrated that even with small diffuse deposits, pain is not relieved from excision alone, and relief only comes after subsequent acromioplasty.&nbsp;<ref name="Resch">Resch H, Povacz P, Seykora P. Excision of calcium deposit andfckLRacromioplasty? In: Gazielly DF, Gleyze PTT, editors. The cuff.fckLRParis: Elsevier; 1997. p. 169–71.</ref>  


== <div id="Shockwave">Physical Therapy Management</div>  ==
== <div id="Shockwave">Physical Therapy Management</div>  ==
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Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis. <ref>Green S<sup>1</sup>, Buchbinder R, Hetrick S.2003 Physiotherapy interventions for shoulder pain. ( LOE 1a )</ref>   
Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis. <ref>Green S<sup>1</sup>, Buchbinder R, Hetrick S.2003 Physiotherapy interventions for shoulder pain. ( LOE 1a )</ref>   


<br>Patients presenting with previously diagnosed calcific tendinopathy may have had medical treatment prior to PT. Limited research exists showing good short and long-term outcomes using an impairment based approach following medical treatment (aspiration or excision). These PT treatments were similar to treatment for adhesive capsulitis or rotator cuff impingment, including PROM/AAROM/AROM, capsule stretching and isometric activation of the affected rotator cuff musculature. Grade II-IV glenohumeral anterior-posterior and caudal glides should also be used when applicable restrictions are found.<ref name="Wainner" />  
<br>Patients presenting with previously diagnosed calcific tendinopathy may have had medical treatment prior to PT. Limited research exists showing good short and long-term outcomes using an impairment based approach following medical treatment (aspiration or excision). These PT treatments were similar to treatment for adhesive capsulitis or rotator cuff impingment, including PROM/AAROM/AROM, capsule stretching and isometric activation of the affected rotator cuff musculature. Grade II-IV glenohumeral anterior-posterior and caudal glides should also be used when applicable restrictions are found.<ref name="Wainner" /><br>
 
== Key Research  ==
 
Lam et al 2006 is a concise evidence summary encompassing most of the research surrounding diagnosis and medical management of calcific tendinopathy. The article outlines indications and contraindications of popular treatment approaches, and gives a thorough explanation of each procedure. There are also helpful radiographs of different types and stages of the pathology.<ref name="Lam" /><br>
 
Wainner &amp; Hasz 1998 is a case study that provides a concise explanation of the pathology as it applies to physical therapy practice. It outlines classification of stages of calcific tendinopathy based on pain and physical exam findings, and also highlights how the combination of orthopaedic and physical therapy management can expedite the healing process.<ref name="Wainner" />
 
== Clinical Bottom Line  ==
 
Calcific tendinopathy is a comparatively common disease with an incidence between 2.7 and 7.5% and minority of cases are symptomatic<sup>3</sup>. Its unknown etiology and impact on quality of life and function are just two reasons it requires further research. A thorough physical examination and patient history review can only help to distinguish it from other pathologies&nbsp; with a similar presentation as imaging is the only definitive diagnosis. Since the condition will often present as a number of other pathologies, treating calcific tendinopathy with traditional therapy, based on a wrongly hypothisized pathology&nbsp;may result on little to no improvement of symptoms. If this situation presents in the clinic, imaging must be ordered to rule out calcific tendinopathy. Current best evidence suggests that shockwave therapy has benefits to reabsorption of the calcific deposit. Impairment based therapy is still believed to be of greatest benefit through increasing blood flow to allow the bodys natural reabsorptive processes to work.<br><div class="researchbox"><br> </div>  
== References  ==
== References  ==


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Introduction[edit | edit source]

Calcification of the supraspinatus

Calcific tendonitis refers to the calcification and tendon degeneration around the shoulders rotator cuff insertions. It usually results in shoulder pain with decreased range of motion. Diagnosis is made by shoulder x-rays, with visible signs of calcium deposits overlying the rotator cuff insertion.Treatment consists of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Those who fail conservative treatment may choose to have arthroscopic decompression of the calcium deposits.[1]

Epidemiology[edit | edit source]

Usually occurs in middle-aged patients between the ages of 30 and 60, with a slight preference for females.[2]

Pathogenesis[edit | edit source]

The exact pathogenesis of calcific tendinitis is unclear. Theories include:

  1. An association with endocrine disorders of thyroid and estrogen metabolism.
  2. Extracellular matrix vesicles are the origin of the pathologic calcification.
  3. Calcification occurs in the setting of tendon degeneration and necrosis, but finding now refute this.[3]

Localisation[edit | edit source]

  • Supraspinatus tendon (80% of cases): critical zone - Most Common
  • Infraspinatus tendon (15% of cases): lower 1/3
  • Subscapularis tendon (5%of cases): pre-insertional fibers[4]

Characteristics/Clinical Presentation[edit | edit source]

The chief patient complaints to expect in calcific tendinopathy are:

  • Night pain, causing loss of sleep.[5], [6], [7], [8].
  • Constant dull ache[8].
  • Pain increases considerably with AROM[8].
  • Decrease in ROM, or complaint of stiffness [9], [7], [8].
  • Radiating pain up into the suboccipital region, or down into the fingers[5], [6], [8].
    The condition goes through 4 stage, see table below.
Stages[8]
Stage Name Presentation
 Chronic (Silent)
 Phase
  • Presence of the calcific deposit 
    is asymptomatic and may be so for years.

Acute Painful Phase

  • Severe pain, disability, and
    frequently nocturnal discomfort.

Mechanical Phase 

  • Tendon impingement being a prominent finding
  • Pain of less severe nature than the acute phase

Differential Diagnosis[edit | edit source]

  • Incidental calcification: found in 2.5-20% of 'normal' healthy shoulders.
  • Degenerative calcification: found tendons with tear history; generally smaller; slightly older individuals
  • Loose bodies: associated chondral defect; associated secondary osteoarthritis[2]

Outcome Measures[edit | edit source]

Medical Management[edit | edit source]

Most current medical treatment approaches for calcifying tendinopathy involve removal or downsizing of the calcium deposit(s). This is usually accomplished by excision or surgery, or by attempting to activate the body’s natural calcium resorption processes. First line treatments, especially in primary care offices, are most often non-steroidal anti-inflammatory drugs, or possibly local steroid injections. These treatments are done with the goal of decreasing pain and inflammation, but there is little evidence that they promote resorption of the calcium deposits. In fact, some researchers believe steroid drugs may actually inhibit the resorption process [11].

Needle aspiration of medium to large (>1.5cm) calcium deposits is easily administered in the outpatient setting, and has evidence showing positive outcomes up to 2 years post treatment. The procedure is done under local anesthesia, with ultrasound guidance. Two needles pierce the deposit; one to evacuate the toothpaste-like calcium, and one to flush the shell with saline. Evidence shows that this process is most effective when the disease is in the acute phase, and the calcium within the deposit is viscous enough to be aspirated by a large bore needle. Once progressed to the chronic stage, the calcium in the deposit is too solid in consistency to be aspirated, thereby limiting the effectiveness of the treatment. [12]

Arthroscopic excision of the deposit is argued by some to be the best treatment option for patients in the chronic stage of calcific tendinopathy. This procedure has an advantage over needle aspiration in that it can remove hardened deposits that can’t be drawn through a needle bore. Performing any surgical procedure local to the affected tendon, like any acute injury, will stimulate the body’s calcium resorption system, which will help rid the tendon of any further deposits left behind after surgery. There is currently debate among surgeons concerning acromioplasty during procedures for deposit excision. Some believe that symptoms caused by calcific tendinopathy is independent from rotator cuff impingement, and therefore the procedure doesn’t need to be performed if a type III acromion is not observed.[13] [11]  Others have demonstrated that even with small diffuse deposits, pain is not relieved from excision alone, and relief only comes after subsequent acromioplasty. [14]

Physical Therapy Management
[edit | edit source]

There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendinopathy. The modality administers high frequency sound waves to the affected area with the intent of breaking up the calcification. Researchers claim that this will cause the body to activate or increase the body’s calcium resorption system, removing the deposit. Depending on the frequency used, the treatment can be painful, but research shows the modality to be most effective at the highest frequency the patient can tolerate.ESWT is a potential alternative to surgery with good mid-term effectiveness and minimal side effects. [15] But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.[16][17]

Most authors report short term symptomatic improvement[18], but long term positive outcomes (past one year) have not been definitively demonstrated in research. [19]

Radial shock wave therapy (RSWT) is another modality that has been used in the treatment of calcific tendinopathy. RSWT is similar to ESWT in that it does not require puncture of the skin for treatment application. While RSWT has been shown to decrease pain and demonstrated at least partial deposit resorption in all subjects, long term positive outcomes (past 6 months) have not been demonstrated. [10]

Shock wave therapy increases shoulder function, reduces pain, and is effective in dissolving calcifications.[20] These results were maintained over the following 6 months.

Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis. [21]


Patients presenting with previously diagnosed calcific tendinopathy may have had medical treatment prior to PT. Limited research exists showing good short and long-term outcomes using an impairment based approach following medical treatment (aspiration or excision). These PT treatments were similar to treatment for adhesive capsulitis or rotator cuff impingment, including PROM/AAROM/AROM, capsule stretching and isometric activation of the affected rotator cuff musculature. Grade II-IV glenohumeral anterior-posterior and caudal glides should also be used when applicable restrictions are found.[8]

References[edit | edit source]

  1. ↑ Orthobullets Calcific TendonitisAvailable:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)
  2. ↑ 2.0 2.1 Radiopedia Calcific Tendinitis Available: https://radiopaedia.org/articles/calcific-tendinitis?lang=gb(accessed 12.1.2023)
  3. ↑ Siegal DS, Wu JS, Newman JS, Del Cura JL, Hochman MG. Calcific tendinitis: a pictorial review. Canadian Association of Radiologists Journal. 2009 Dec;60(5):263-72. Available:https://journals.sagepub.com/doi/10.1016/j.carj.2009.06.008 (accessed 12.1.2023)
  4. ↑ Serafini G, Sconfienza L, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial. Radiology [serial online]. July 2009;252(1):157-164. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 20, 2011.
  5. ↑ 5.0 5.1 Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.
  6. ↑ 6.0 6.1 Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.
  7. ↑ 7.0 7.1 Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. March 1998;27(3):231-237. ( LOE 4 )
  9. ↑ Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.
  10. ↑ 10.0 10.1 Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.( LOE 1b )
  11. ↑ 11.0 11.1 Uhthoff HK, Sarkar K. Calcifying tendinitis. Rockwood Jr CR,fckLRMatsen III FA, editors. The shoulder, vol. 2. Philadelphia: WBfckLRSaunders; 1990, 774–90.
  12. ↑ Lam, F, Bhatia, D, K, J.F. de Beer. Modern management of calcifying tendonitis of the shoulder. Current Orthopaedics; 2006, 20, 446–452.
  13. ↑ Neer CS. Anterior acromioplasty for the chronic impingementfckLRsyndrome of the shoulder. J Bone Joint Surg (Am) 1972;54A:fckLR41–50.
  14. ↑ Resch H, Povacz P, Seykora P. Excision of calcium deposit andfckLRacromioplasty? In: Gazielly DF, Gleyze PTT, editors. The cuff.fckLRParis: Elsevier; 1997. p. 169–71.
  15. ↑ Lee SY1, Cheng B, Grimmer-Somers K. The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. ( LOE 2a )
  16. ↑ Humeral head osteonecrosis after extracorporeal shock-wave treatment for rotator cuff tendinopathy. A case report. Liu HM, Chao CM, Hsieh JY, Jiang CC J Bone Joint Surg Am. 2006 Jun; 88(6):1353-6. ( LOE 4 )
  17. ↑ Osteonecrosis of the humeral head after extracorporeal shock-wave lithotripsy. Durst HB, Blatter G, Kuster MS J Bone Joint Surg Br. 2002 Jul; 84(5):744-6. ( LOE 4 )
  18. ↑ Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. Rebuzzi E, Coletti N, Schiavetti S, Giusto F J Orthop Traumatol. 2008 Dec; 9(4):179-85. ( LOE 1a )
  19. ↑ Harniman, E, Carette, S, Kennedy, C, Beaton, D. Extracorporeal shock wave therapy for calcific and non-calcific tendonitis of the rotator cuff: a systematic review. Journal of Hand Therapy, April 2004; 17(2), 132-151. ( LOE 1a )
  20. ↑ Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Santilli V. Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis. ( LOE 1a )
  21. ↑ Green S1, Buchbinder R, Hetrick S.2003 Physiotherapy interventions for shoulder pain. ( LOE 1a )

 

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