What are the treatment options for calcific tendinitis of the shoulder?

Treatment Options for Calcific Tendinitis of the Shoulder

Subacromial corticosteroid injections should be used as first-line treatment for persistent or recurrent calcific tendinitis of the shoulder, followed by ultrasound-guided needling and lavage (barbotage) for cases that don't respond to initial treatment. 1, 2

Diagnosis and Assessment

• Diagnosis requires a combination of clinical tests 2:

  • Pain with specific shoulder movements (Hawkins' test and Neer's test)
  • Tenderness at the affected tendon
  • Limited range of motion

• Imaging should be pursued after 6 weeks of persistent symptoms:

  • Ultrasound is the recommended first-line imaging to detect calcifications and assess tendon integrity 2
  • MRI may be used to evaluate for associated pathology (95% sensitive and specific for detecting tendon tears) 1

Treatment Algorithm

Step 1: Conservative Management (0-6 weeks)

• Rest and activity modification to prevent ongoing damage 1
• Cryotherapy (ice applications through wet towel for 10-minute periods) for acute pain relief 1
• NSAIDs (oral or topical) for pain management 1
• Gentle stretching and mobilization techniques 1
• Eccentric strengthening exercises 1

Step 2: For Persistent Symptoms (6+ weeks)

• Subacromial corticosteroid injection 1, 2
  • Particularly effective for inflammation in the subacromial region 1
  • Provides short-term pain relief but may not alter long-term outcomes 1

Step 3: For Refractory Cases (12+ weeks)

• Ultrasound-guided needling and lavage (barbotage) 3, 2

  • Most effective for larger calcific deposits 3
  • Technique: 18G needle insertion into deposit under ultrasound guidance, followed by saline lavage to dissolve and aspirate calcium 3
  • Often combined with subacromial corticosteroid injection 3
  • Superior clinical outcomes compared to other treatments at 1-2 years follow-up 3

• Extracorporeal shock wave therapy (ESWT) 2

  • Alternative to barbotage, especially for tendinosis calcarea 2
  • Less effective than barbotage but still superior to conservative treatment alone 3

Step 4: For Severe Recalcitrant Cases

• Arthroscopic surgical removal of calcifications 3
  • Reserved for cases that fail all other treatment options
  • Effective but more invasive than other treatments

Special Considerations

• Location matters: While most calcifications occur in the supraspinatus tendon, they can also occur in other rotator cuff tendons like the subscapularis 4
• Ultrasound therapy has shown effectiveness in resolving calcifications and providing short-term clinical improvement 5
• Avoid overhead pulley exercises as they may worsen symptoms 1
• For patients with spasticity-related shoulder pain, botulinum toxin injections into specific muscles (subscapularis, pectoralis) may be beneficial 1

Treatment Pitfalls to Avoid

1. Delaying appropriate imaging beyond 6 weeks of symptoms
2. Injecting corticosteroids directly into the tendon substance (rather than peritendinous or in subacromial space)
3. Complete immobilization of the shoulder, which can lead to stiffness and muscle atrophy
4. Overlooking the need for eccentric strengthening exercises, which are crucial for tendon healing
5. Rushing to surgical intervention before adequate trials of conservative and minimally invasive treatments

Remember that while calcific tendinitis is often self-limiting, appropriate treatment can significantly reduce pain, improve function, and accelerate recovery.