What is the recommended treatment for a 93-year-old patient with a 6 mm acromial spur and possible rotator cuff calcific tendinosis?

From the Guidelines

For a 93-year-old patient with a 6 mm acromial spur and possible rotator cuff calcific tendinosis, conservative management is typically recommended as the first-line treatment. This approach prioritizes minimizing risks and optimizing quality of life, given the advanced age of the patient. The treatment should include a combination of pain management with oral NSAIDs, such as ibuprofen (400-600 mg three times daily) or naproxen (250-500 mg twice daily), if not contraindicated by renal function or other medical conditions 1. Acetaminophen (500-1000 mg three to four times daily, not exceeding 3000 mg/day in elderly patients) may be used if NSAIDs are contraindicated.

Key Components of Conservative Management

• Physical therapy focusing on gentle range of motion exercises and strengthening of the rotator cuff muscles should be implemented 2-3 times weekly for 4-6 weeks.
• Local treatments may include topical NSAIDs or lidocaine patches.
• If pain persists, a subacromial corticosteroid injection (such as methylprednisolone 40 mg mixed with lidocaine 1%) can provide significant relief, although the evidence for its long-term benefit is mixed 1.

Considerations for Diagnostic Imaging

Diagnostic imaging, such as MRI or ultrasound, may be considered to confirm the diagnosis, especially if there's a suspicion of rotator cuff tears or other structural issues 1. However, the choice of imaging should be guided by the clinical presentation and the potential impact on management.

Surgical Intervention

Surgery is generally avoided in patients of this advanced age unless there is severe, debilitating pain unresponsive to conservative measures. This conservative approach is recommended because the risks of surgical intervention often outweigh the benefits in elderly patients, and many patients can achieve acceptable pain relief and function through non-operative management 1.

From the FDA Drug Label

In the treatment of conditions such as tendinitis or tenosynovitis, care should be taken following application of a suitable antiseptic to the overlying skin to inject the suspension into the tendon sheath rather than into the substance of the tendon The dose in the treatment of the various conditions of the tendinous or bursal structures listed above varies with the condition being treated and ranges from 4 to 30 mg

The recommended treatment for a 93-year-old patient with a 6 mm acromial spur and possible rotator cuff calcific tendinosis is an injection of methylprednisolone into the tendon sheath, with a dose ranging from 4 to 30 mg. The exact dose will depend on the specific condition being treated. 2

From the Research

Treatment Options for 93-year-old Patient with 6 mm Acromial Spur and Possible Rotator Cuff Calcific Tendinosis

• The recommended treatment for a 93-year-old patient with a 6 mm acromial spur and possible rotator cuff calcific tendinosis may involve conservative management, as most patients can be managed successfully without surgical intervention 3.
• Conservative treatment options include nonsteroidal anti-inflammatory drugs, physical therapy to improve scapular mechanics and decrease dynamic impingement, and ultrasound-guided needle aspiration and lavage techniques, which can provide long-term improvement in pain and function 3, 4.
• Extracorporeal shockwave therapy (ESWT) is also a treatment alternative for chronic rotator cuff tendonitis, which may decrease the need for surgery, with moderate evidence supporting its effectiveness in treating chronic calcific rotator cuff tendonitis 5.
• Ultrasound-guided needling and lavage (barbotage) combined with a subacromial corticosteroid injection may also be considered, with studies showing similar clinical and radiological outcomes compared to isolated subacromial corticosteroid injection at 5-year follow-up 4.
• Surgical treatment, such as arthroscopic management, may be considered for patients who remain symptomatic after conservative treatment, with studies showing satisfactory clinical outcomes and reliable pain relief 6, 7.

Considerations for Treatment

• The patient's age and overall health should be taken into consideration when determining the best course of treatment.
• The size and location of the acromial spur and calcific deposits should also be considered when selecting a treatment option.
• A thorough evaluation of the patient's condition, including radiography, MRI, or ultrasound, is necessary to confirm the diagnosis and guide treatment decisions 3.