What is the treatment for calcific tendinitis?

Treatment of Calcific Tendinitis

Calcific tendinitis should be treated with a stepwise approach beginning with conservative management, including relative rest, cryotherapy, NSAIDs, and eccentric strengthening exercises, progressing to more invasive interventions only when conservative measures fail. 1

Initial Conservative Management

First-Line Treatments

• Relative Rest: Reduce activities that aggravate the tendon to prevent further damage while avoiding complete immobilization

  • Continue activities that don't worsen pain
  • Complete immobilization should be avoided to prevent muscle atrophy 1

• Cryotherapy: Apply ice through a wet towel for 10-minute periods

  • Effective for short-term pain relief
  • Helps reduce swelling and blunt inflammatory response in acute cases 1

• NSAIDs:

  • Effective for short-term pain relief but don't affect long-term outcomes
  • Topical NSAIDs can reduce pain with fewer systemic side effects 1
  • Particularly beneficial in acute inflammatory phases

• Eccentric Strengthening Exercises:

  • Proven beneficial in tendinopathies
  • Stimulates collagen production and guides normal alignment of newly formed collagen fibers
  • Should be combined with stretching exercises 1

Second-Line Treatments

When first-line treatments fail to provide adequate relief after 4-6 weeks:

Corticosteroid Injections

• May be more effective than oral NSAIDs for acute pain relief
• Do not alter long-term outcomes
• Should be used with caution as they may inhibit healing and reduce tendon strength 1
• Particularly useful during the resorptive phase of calcific tendinitis 2

Ultrasound-Guided Procedures

• Needling and Aspiration:
  • Ultrasound-guided percutaneous treatment with aspiration and fragmentation of calcific deposits
  • Particularly effective for soft calcifications
  • Can be combined with corticosteroid injection 3
  • Leads to complete radiographic resolution in approximately 67% of patients 4

Extracorporeal Shock Wave Therapy (ESWT)

• Safe, noninvasive treatment for chronic calcific tendinitis
• Uses acoustic shock waves to reduce pain and promote tendon healing
• Effective for pain reduction with pooled mean difference in VAS of -3.83 4
• Improvement in function with pooled mean difference in Constant-Murley Score of 18.30 4

Third-Line Treatment

Surgical Management

• Reserved for patients who have failed 3-6 months of conservative therapy 1
• Surgical techniques include:
  • Arthroscopic removal of calcific deposits
  • Open surgical techniques when necessary
• Results in larger improvements in functional outcome scores compared to non-operative interventions
  • Pooled mean difference in Constant-Murley Score of 38.35 4
• Leads to complete radiographic resolution in approximately 85% of patients 4

Treatment Algorithm Based on Phase of Disease

Understanding the phase of calcific tendinitis is crucial for optimal management:

1. Formative Phase (hard, well-defined calcifications):

   • Conservative management as first line
   • ESWT if conservative treatment fails
   • Surgical removal may be considered if all other treatments fail 2

2. Resorptive Phase (soft, ill-defined calcifications):

   • Conservative management with emphasis on pain control
   • Ultrasound-guided aspiration and lavage particularly effective
   • Surgery rarely indicated in this phase 2

Common Pitfalls and Caveats

1. Misdiagnosis: Calcific tendinitis can mimic rotator cuff tears or impingement syndrome. Proper imaging (plain radiography, ultrasonography) is essential for accurate diagnosis 1.

2. Overtreatment: Surgical intervention should be reserved for cases that fail conservative management, not as initial treatment 1, 4.

3. Inappropriate Timing: Interventional procedures like needling and aspiration are most effective during the resorptive phase when calcifications are softer 2.

4. Incomplete Treatment: When performing ultrasound-guided procedures, extensive fragmentation of calcifications is important to facilitate resorption of residual deposits 3.

5. Neglecting Rehabilitation: Post-treatment rehabilitation with appropriate strengthening exercises is essential for full functional recovery.