Calcific Tendinopathy of the Shoulder: Difference between revisions

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== Definition/Description  ==
== Introduction ==
[[File:Dense calcification of the supraspinatus.jpeg|thumb|Calcification of the supraspinatus]]
Calcific tendinopathy (CT) of the shoulder is a common, painful condition identified by the existence of calcium deposits in the rotator cuff tendons.<ref name=":2">Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthopedic research and reviews. 2018;10:63.Available:https://www.dovepress.com/calcific-tendinopathy-of-the-shoulder-clinical-perspectives-into-the-m-peer-reviewed-fulltext-article-ORR (accessed 12.1.2023)</ref> 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>


Calcific tendonitis, or "calcium hydroxyapatite crystal deposition disease”<ref name="Wainner">Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy [serial online]. March 1998;27(3):231-237.</ref>, refers to the deposition of calcium—predominantly hydroxyapatite—in a tendon, most often in those of the rotator cuff. It may be secondary to a local decrease in oxygen tension resulting in fibrocartilaginous metaplasia and resulting calcification.<ref name="Serafini">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.</ref><br>  
== Epidemiology ==
Usually occurs in middle-aged patients between the ages of 30 and 60, with a slight preference for females.<ref name=":0">Radiopedia [https://radiopaedia.org/articles/calcific-tendinitis?lang=gb Calcific Tendinitis] Available: https://radiopaedia.org/articles/calcific-tendinitis?lang=gb<nowiki/>(accessed 12.1.2023)</ref>


<br>
== Pathogenesis ==
 
Current theories indicate that CT may be the result of a cell-mediated process in which calcium deposition occur followed by their spontaneous resorption. However, in a few cases, this self-healing process is disrupted, causing symptoms. Literature now is showing that biological and genetic factors may underlie CTs genesis.. These new finding may explain why most of the therapies currently in use provide partially satisfactory outcomes.<ref name=":2" />
[[Image:Shldr2.jpg]]<ref name="Lam" />&nbsp;[[Image:Shldr3.jpg|Siegal D, Wu J, Newman J, Del Cura J, Hochman M. Calcific tendinitis: a pictorial review. Canadian Association Of Radiologists Journal [serial online]. December 2009;60(5):263-272.]]<ref>Siegal D, Wu J, Newman J, Del Cura J, Hochman M. Calcific tendinitis: a pictorial review. Canadian Association Of Radiologists Journal [serial online]. December 2009;60(5):263-272.</ref><br>
 
== Epidemiology/Etiology  ==
 
'''Etiology is still unclear.'''
 
<u>Possible Causes<ref name="Wainner" /><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.</ref></u>:
 
*Hypovascularization, but has been removed from both poorly and well-vascularized tissues.
*Compression&nbsp;
*Metabolic factors
*Mesodermal defects&nbsp; &nbsp;
*Local degenerative and proliferative changes
 
<u>Unlikely Causes<ref name="Wainner" /></u>:
 
*Infection and trauma
*Blood or urine chemistry
 
<br>Calcific tendonitis occurs in 2.5%–7.5% of healthy shoulders in adults<ref name="Serafini" />, and 39-62% of those being seen in medical centers for shoulder pain<ref name="Wainner" />. It's more commonly seen in women (70% of cases) and most frequently during the 5th decade of life, but has been seen in a 3 year-old and a 72 year-old.<ref name="Serafini" /><ref name="Wainner" />. Right shoulder is more frequently affected but there is no evidence to support predisposing factors.<ref name="Wainner" /><sup></sup>
 
<u>Common locations</u>:&nbsp;<ref name="Serafini" />
 
*Supraspinatus tendon (80% of cases): critical zone -&nbsp;''Most Common''
*Infraspinatus tendon (15% of cases): lower 1/3
*Subscapularis tendon (5%of cases): pre-insertional fibers
 
The consistency of the calcium deposit (seen via imaging) seems to be correlated with pain severity, not the size.&nbsp;<ref name="Wainner" />&nbsp;
 
*Asymptomatic:&nbsp;appear granular or cheesy,&nbsp;and have sharply defined borders.
*Symptomatic:&nbsp;enlarge, liquify, and have less well-defined borders.<br>&nbsp; &nbsp; &nbsp; &nbsp; "dry powder", "chalk-like", "semi-liquid toothpaste", "milky" and "creamy"<br>


== Localisation ==
<sup></sup>
*Supraspinatus tendon (80% of cases): critical zone -&nbsp;''Most Common''
*Infraspinatus tendon (15% of cases): lower 1/3
*Subscapularis tendon (5%of cases): pre-insertional fibers<ref name="Serafini">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.</ref>
{{#ev:youtube|ycphj08OJt0}}
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


<u>Clinical presentation varies.<ref name="Cacchio" /></u><br>
The chief patient complaints to expect in calcific tendinopathy are:


Calcific tendonitis is a self-limiting condition.<ref name="Serafini" />&nbsp;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" />  
* 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.


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>
{| width="400" cellspacing="1" cellpadding="1" border="1"
 
<br>
 
{| width="400" border="1" cellpadding="1" cellspacing="1"
|-
|-
! scope="col" colspan="2" bgcolor="#33cc00" | Stages<ref name="Wainner" />
! 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>
|-
|-
| align="center" bgcolor="#66ff66" | Stage Name  
| bgcolor="#66ff66" align="center" | Stage Name
| align="center" bgcolor="#66ff66" | 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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== Differential Diagnosis  ==
== Differential Diagnosis  ==


&nbsp;<u>Pathologies which present similiar to Calcific Tendonitis of the Shoulder:</u><u></u>
* Incidental calcification: found in 2.5-20% of 'normal' healthy shoulders.
 
* Degenerative calcification: found tendons with tear history; generally smaller; slightly older individuals
*Subdeltoid Bursitis<ref name="Loew" />
* Loose bodies: associated chondral defect; associated secondary osteoarthritis<ref name=":0" />
*[[Subacromial Impingement]]&nbsp;<ref name="Loew">Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons ... [Et Al.] [serial online]. July 1996;5(4):314-319.</ref>
*[[Rotator Cuff Tears]]<br>
*<u>[[Adhesive Capsulitis]]&nbsp;<ref name="Wainner" /></u>
*[[Gout|Gout]]&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>


== Outcome Measures  ==
== Outcome Measures  ==
*[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]]


<u>Outcome measures to track treatment efficacy:</u>
== Medical Management    ==
Nonoperative


*VAS Pain scale<ref name="Cacchio" />
# NSAIDs, physical therapy, stretching & strengthening, steroid injections
*UCLA Shoulder Rating Scale<ref name="Cacchio" /><br>
# [[Tendinopathy Treatment Adjuncts|Extracorporeal shock-wave therapy as an adjunct treatment]]. Most useful in refractory calcific tendonitis in the formative and resting phases
*[[DASH Outcome Measure]]<br>
# Ultrasound-guided needle lavage vs. needle barbotage (needle to break up calcium deposit)
*Radiology/MRI changes<ref name="Case Studies">Takahashi M, Ogawa K. Calcific tendinitis of the rotator cuff showing a contracted state of abduction: a report of four cases. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons. January 1997;6(1):72-76.</ref>


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


[[Image:Outcome.jpg]]<br>
== Physiotherapy ==
Physiotherapy techniques include


Images:&nbsp;<ref name="Lam" />  
* Range of motion exercises to avoid articular stiffness
* Strength exercises to restore normal shoulder/scapular mechanics.
* [[Scapular Dyskinesia|Scapular dyskinesia]] can cause subacromial impingement and a rehabilitation program that addresses this issue has been shown to reduce shoulder pain<ref name=":2" />. See link for detail.


== Examination  ==
See [[Therapeutic Exercise for the Shoulder]]


As Calcific tendinitis 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 PA , Saville J , Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal of Manipulative &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Physiological Therapeutics 1999; vol 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>
There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendinopathy.  See above link.<ref>Lee SY<sup>1</sup>, Cheng B, Grimmer-Somers K.  
The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. ( LOE 2a )
</ref> But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.<ref>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 )
</ref><ref>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 )
</ref>See [[Tendinopathy Treatment Adjuncts]]


Since imaging is the only way to diagnose calcific tendinitis, 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 tendinitis 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 <br>  ==
Most current medical treatment approaches for calcifying tendonitis 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>.
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 tendonitis. 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 tendonitis 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>
== <div id="Shockwave">Physical Therapy Management</div>  ==
There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendonitis. 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. Long term positive outcomes (past one year) have not been definitively demonstrated in research.&nbsp;<ref name="Harniman">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.</ref>
Radial shock wave therapy (RWST) is another modality that has been used in the treatment of calcific tendonitis. 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.&nbsp;<ref name="Cacchio" />
<br>Patients presenting with previously diagnosed calcific tendonitis 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" />
== Key Research  ==
Lam et al 2006 is a concise evidence summary encompassing most of the research surrounding diagnosis and medical management of calcific tendonitis. 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 tendonitis 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 tendinitis 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 tendinititis 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 tendinitis. 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>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1pmF_x0TvNeI2ekn1Vdoessjm4LLNhQfJoSh9D3W85ii7L6sCS|charset=UTF-8|short|max=10</rss><br> </div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  
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&nbsp;  


[[Category:Texas_State_University_EBP_Project]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Shoulder]] [[Category:Condition]]
[[Category:Texas_State_University_EBP_Project]]  
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]  
[[Category:Shoulder]]  
[[Category:Conditions]]
[[Category:Conditions]]
 
[[Category:Shoulder - Conditions]]
[[Category:Sports Medicine]]
[[Category:Tendinopathy]]

Latest revision as of 09:53, 12 January 2023

Original Editors Mary Harris, Tom Lawlor, Patrick Bales, Misty Hillin, Rick Wetherald as part of the Texas Evidence Based Practice Project.

Top Contributors - Mary Harris, Thomas Lawlor, Karina Leahy, Rick Wetherald, Patrick Bales, Admin, Lucinda hampton, Fasuba Ayobami, Kim Jackson, Tony Lowe, 127.0.0.1, Anthony Mertens, Wanda van Niekerk, Naomi O'Reilly and WikiSysop

 

Introduction[edit | edit source]

Calcification of the supraspinatus

Calcific tendinopathy (CT) of the shoulder is a common, painful condition identified by the existence of calcium deposits in the rotator cuff tendons.[1] 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.[2]

Epidemiology[edit | edit source]

Usually occurs in middle-aged patients between the ages of 30 and 60, with a slight preference for females.[3]

Pathogenesis[edit | edit source]

Current theories indicate that CT may be the result of a cell-mediated process in which calcium deposition occur followed by their spontaneous resorption. However, in a few cases, this self-healing process is disrupted, causing symptoms. Literature now is showing that biological and genetic factors may underlie CTs genesis.. These new finding may explain why most of the therapies currently in use provide partially satisfactory outcomes.[1]

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[3]

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.[2]

Physiotherapy[edit | edit source]

Physiotherapy techniques include

  • Range of motion exercises to avoid articular stiffness
  • Strength exercises to restore normal shoulder/scapular mechanics.
  • Scapular dyskinesia can cause subacromial impingement and a rehabilitation program that addresses this issue has been shown to reduce shoulder pain[1]. See link for detail.

See Therapeutic Exercise for the Shoulder

There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendinopathy. See above link.[11] But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.[12][13]See Tendinopathy Treatment Adjuncts

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthopedic research and reviews. 2018;10:63.Available:https://www.dovepress.com/calcific-tendinopathy-of-the-shoulder-clinical-perspectives-into-the-m-peer-reviewed-fulltext-article-ORR (accessed 12.1.2023)
  2. ↑ 2.0 2.1 Orthobullets Calcific TendonitisAvailable:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)
  3. ↑ 3.0 3.1 Radiopedia Calcific Tendinitis Available: https://radiopaedia.org/articles/calcific-tendinitis?lang=gb(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 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. ↑ 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 )

 

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