What is the treatment for a 55-year-old male with shoulder pain and X-ray evidence of calcium hydroxyapatite deposition near the pectoralis major tendon insertion?

From the Guidelines

For a 55-year-old male with shoulder pain and X-ray findings suggesting calcium hydroxyapatite deposition near the pectoralis major tendon insertion, I strongly recommend a multimodal approach prioritizing relative rest, cryotherapy, and eccentric strengthening to promote healing and pain relief, as supported by the highest quality evidence available 1.

Initial Management

The patient should initially rest the affected shoulder to prevent further damage and promote healing, as recommended by the American Family Physician study 1.

• Apply ice for 15-20 minutes several times daily to reduce inflammation, as cryotherapy provides acute relief of tendinopathy pain 1.
• Take over-the-counter NSAIDs such as ibuprofen 400-600mg three times daily with food for 1-2 weeks to manage pain and inflammation, as NSAIDs are recommended for short-term pain relief 1.

Rehabilitation and Further Management

• Physical therapy focusing on gentle stretching and strengthening exercises should be started once acute pain subsides, with an emphasis on eccentric strengthening, which has been shown to be an effective treatment of tendinopathy and may reverse degenerative changes 1.
• For persistent pain, consider a corticosteroid injection (such as methylprednisolone 40mg with lidocaine) administered by an orthopedic specialist, as locally injected corticosteroids may be more effective than oral NSAIDs in acute-phase pain relief 1.
• Maintain proper posture and avoid activities that worsen symptoms during recovery, and if pain worsens significantly or doesn't improve after 4-6 weeks of conservative treatment, follow up with an orthopedic specialist for reassessment.

Key Considerations

• This condition, known as calcific tendinopathy, results from calcium crystal deposition in tendon tissue, causing inflammation and pain, and the pectoralis major insertion is a less common but recognized site for this condition.
• Most cases resolve with conservative treatment over 3-6 months, but persistent cases may require ultrasound-guided needling or surgical removal of the calcium deposit.
• The patient should be informed that rest prevents ongoing damage, reduces pain, and may promote tendon healing, and that tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 1.

From the FDA Drug Label

The dose for intra-articular administration depends upon the size of the joint and varies with the severity of the condition in the individual patient. In chronic cases, injections may be repeated at intervals ranging from one to five or more weeks, depending upon the degree of relief obtained from the initial injection The doses in the following table are given as a general guide: Size of JointExamplesRange of Dosage Large Knees Ankles Shoulders 20 to 80 mg The injection site for each joint is determined by that location where the synovial cavity is most superficial and most free of large vessels and nerves.

The treatment for shoulder pain in a 55-year-old male with X-ray showing mineralization along the medial proximal humerus, possibly representing calcium hydroxyapatite deposition near the pectoralis major tendon insertion, may involve intra-articular injection of methylprednisolone.

• The recommended dose is 20 to 80 mg, depending on the severity of the condition.
• The injection should be made into the synovial space to obtain the full anti-inflammatory effect.
• Repeated injections may be necessary at intervals of one to five or more weeks, depending on the degree of relief obtained from the initial injection 2.

From the Research

Treatment Options for Shoulder Pain

The patient's X-ray shows mineralization along the medial proximal humerus, which may represent calcium hydroxyapatite deposition near the pectoralis major tendon insertion. Based on the provided studies, the following treatment options are available:

• Ultrasound-guided needling with subacromial corticosteroid injection: This treatment has been shown to be effective in reducing pain and improving function in patients with calcific tendinitis of the shoulder 3, 4, 5.
• Extracorporeal shock wave therapy (ESWT): ESWT has also been shown to be effective in reducing pain and improving function in patients with calcific tendinitis of the shoulder, although it may not be as effective as ultrasound-guided needling in eliminating calcium deposits 3, 6, 5.
• Ultrasound-guided percutaneous lavage (UGPL): UGPL has been shown to be effective in reducing calcium burden and pain in patients with calcific tendinitis of the shoulder, and may be considered a treatment of choice for nonsurgical options 4, 7.
• Combined treatment: Combined treatment with ultrasound-guided needling, subacromial corticosteroid injection, and ESWT may also be effective in reducing pain and improving function in patients with calcific tendinitis of the shoulder 4.

Comparison of Treatment Outcomes

The studies compared the outcomes of different treatment options, including:

• Ultrasound-guided needling vs. ESWT: Ultrasound-guided needling was shown to be more effective in eliminating calcium deposits and improving function in the short term 3, 5.
• ESWT vs. placebo: ESWT was shown to be effective in improving function and reducing pain compared to placebo 6.
• UGPL vs. ESWT: UGPL was shown to be more effective in reducing calcium burden and pain compared to ESWT 4.
• Combined treatment vs. single treatment: Combined treatment with ultrasound-guided needling, subacromial corticosteroid injection, and ESWT may be more effective in reducing pain and improving function compared to single treatment options 4.