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>
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 name=":1">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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== Medical Management    ==
== Medical Management    ==
Nonoperative


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 <ref name="Uhthoff">Uhthoff HK, Sarkar K. Calcifying tendinitis. Rockwood Jr CR,fckLRMatsen III FA, editors. The shoulder, vol. 2. Philadelphia: WBfckLRSaunders; 1990, 774–90.</ref>.
# NSAIDs, physical therapy, stretching & strengthening, steroid injections
# Extracorporeal shock-wave therapy as an adjunct treatment. Most useful in refractory calcific tendonitis in the formative and resting phases
# Ultrasound-guided needle lavage vs. needle barbotage (needle to break up calcium deposit)


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>
Operative: surgical decompression of calcium deposit.<ref name=":1" />
 
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>  ==

Revision as of 08:06, 12 January 2023

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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]

Nonoperative

  1. NSAIDs, physical therapy, stretching & strengthening, steroid injections
  2. Extracorporeal shock-wave therapy as an adjunct treatment. Most useful in refractory calcific tendonitis in the formative and resting phases
  3. Ultrasound-guided needle lavage vs. needle barbotage (needle to break up calcium deposit)

Operative: surgical decompression of calcium deposit.[1]

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. [11] But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.[12][13]

Most authors report short term symptomatic improvement[14], but long term positive outcomes (past one year) have not been definitively demonstrated in research. [15]

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.[16] 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. [17]


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. ↑ 1.0 1.1 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. ↑ Lee SY1, Cheng B, Grimmer-Somers K. The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. ( LOE 2a )
  12. ↑ 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 )
  13. ↑ 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 )
  14. ↑ 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 )
  15. ↑ 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 )
  16. ↑ 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 )
  17. ↑ Green S1, Buchbinder R, Hetrick S.2003 Physiotherapy interventions for shoulder pain. ( LOE 1a )

 

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