From the Guidelines
The next step in managing degenerative shoulder joint changes with suspected calcific tendinitis and subacromial impingement should be a multimodal approach combining conservative treatments. I recommend starting with a course of oral NSAIDs such as naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 10-14 days, combined with physical therapy focusing on rotator cuff strengthening and scapular stabilization exercises twice weekly for 6-8 weeks, as supported 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. A subacromial corticosteroid injection (such as 40mg methylprednisolone with 4-5ml of 1% lidocaine) can be considered if pain persists after 2-3 weeks of initial treatment, as locally injected corticosteroids may be more effective than oral NSAIDs in acute-phase pain relief 1. Activity modification is essential - avoid overhead movements and heavy lifting during the recovery period. If symptoms don't improve after 6-8 weeks of conservative management, advanced imaging with MRI should be obtained to better evaluate the extent of tendon calcification and rule out rotator cuff tears. This approach addresses both pain and inflammation while promoting tissue healing and improved biomechanics of the shoulder joint to reduce impingement. Key considerations include:
- Relative rest and reduced activity to prevent further damage and promote healing and pain relief 1
- Eccentric strengthening as an effective treatment of tendinopathy and may reverse degenerative changes 1
- Topical NSAIDs as an alternative to oral NSAIDs, with potentially fewer systemic side effects 1
From the Research
Next Steps in Management
The patient's shoulder joint changes with suspected calcific tendinitis and subacromial impingement require a comprehensive management plan. The following steps can be considered:
- Clinical correlation to rule out impingement, as suggested in the impression [@\1@]
- Evaluation of the patient's history and physical examination findings to determine the best course of treatment [@\1@]
- Consideration of treatment options for calcific tendinitis, such as physical therapy, pain management, extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage (UGPL), and operative debridement [@\3@]
- Assessment of the patient's symptoms and functional limitations to determine the most appropriate treatment approach
Considerations for Calcific Tendinitis
- Calcific tendinitis is a self-limiting condition that affects otherwise-healthy tendon with deposition of calcium hydroxyapatite crystals between healthy tenocytes [@\3@]
- The most efficacious and frequently utilized treatment for shoulder calcific tendinitis is UGPL due to its ability to effectively reduce calcium burden and pain while limiting soft-tissue damage [@\3@]
- However, more evidence regarding the treatment and course of calcific tendinitis is needed before determining the most appropriate treatment at all potential sites of calcific tendinitis [@\3@]
Relationship between Calcifying Tendinitis and Subacromial Impingement
- Little correlation exists between calcifying tendinitis and additional findings associated with subacromial impingement [@\4@]
- A prospective radiography and magnetic resonance imaging study found that 83% of the calcifications were located in the supraspinatus or the adjoining part of the subscapularis tendon [@\4@]
Arthritis at the Shoulder Joint
- Primary osteoarthritis of the shoulder joint is uncommon because it is a non-weight-bearing joint [@\5@]
- Significant osteoarthritis of the glenohumeral joint is unusual in the absence of trauma, and the detection of advanced degenerative changes in patients without a known history of trauma should alert the clinician to search for other disorders [@\5@]