What is the best course of treatment for a patient with degenerative changes, calcific tendinitis, and a mild decrease in bone mineralization in the shoulder?

Treatment for Shoulder with Degenerative Changes, Calcific Tendinitis, and Decreased Bone Mineralization

Conservative management should be the first-line treatment for a patient with degenerative shoulder changes, calcific tendinitis, and mild decrease in bone mineralization, focusing on pain management, rehabilitation exercises, and activity modification. 1

Initial Conservative Management

Pain Management

• First-line medication: Acetaminophen (up to 4g/day) 1
• Second-line medication: NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate 1
• Alternative options:
  • Topical NSAIDs to reduce pain while avoiding gastrointestinal side effects 1
  • Methocarbamol for acute muscle spasms (short-term use only, ≤7 days) 1

Physical Therapy and Rehabilitation

• Relative rest: Reduce activities that load the damaged tendon 2
• Exercise program:
  • Eccentric strengthening exercises (most beneficial for tendinopathies) 1
  • Gentle passive and active-assisted range of motion exercises 1
  • Sport-specific or activity-specific exercises as appropriate 1
  • Focus on restoration of intramuscular trapezius muscle balance 1

Supportive Measures

• Protective devices: Sling for protection to prevent further trauma and reduce pain 1
• Bracing: Can reinforce and protect tendons during activity and help correct biomechanical problems 1

Advanced Interventions (if conservative management fails)

Injection Therapies

• Ultrasound-guided intrasheath anesthetic injections 1
• Corticosteroid injections for short-term pain relief (use with caution as they don't alter long-term outcomes) 1

Therapeutic Modalities

• Therapeutic ultrasound: May decrease pain and increase collagen synthesis rate 1
• Extracorporeal Shock Wave Therapy (ESWT): Potentially effective but requires further research 1
• Ultrasound-guided percutaneous lavage (UGPL): Most efficacious treatment for calcific tendinitis of the shoulder 3

Natural History and Prognosis

Calcific tendinitis is typically a self-limiting condition that affects otherwise healthy tendon with deposition of calcium hydroxyapatite crystals 3. It follows a two-phase disease process:

• Chronic initial phase: Calcific deposit forms in the rotator cuff tendon with inconsistent pain that may persist for years 4
• Acute phase: Deposit undergoes spontaneous resolution with severe pain for 2-3 weeks, ultimately resulting in a normally functioning shoulder joint 4

Surgical Considerations

Surgical intervention should be considered if:

• Pain persists despite 3-6 months of well-managed conservative treatment 1
• Tears exceed 50% of tendon thickness 1
• Quick recovery is required 1

Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1.

Special Considerations

• Diabetic patients: May respond less to conservative measures and require different treatment strategies 1
• Patients with rheumatoid arthritis: May benefit from early surgical intervention to prevent tendon rupture 1
• Bone mineralization concerns: The mild decrease in bone mineralization should be further evaluated to rule out systemic conditions affecting bone health

Monitoring and Follow-up

• Regular reassessment of pain, function, and quality of life
• Follow-up imaging to monitor calcific deposits and degenerative changes
• X-ray appearance of calcific deposits can provide prognostic information 4:
  • Type I: Clearly circumscribed with dense appearance (chronic phase)
  • Type II: Intermediate appearance
  • Type III: Translucent and cloudy appearance without clear circumscription (acute resorptive phase)

Remember that clinical correlation is essential, as imaging findings may not always correlate with symptoms. Up to 34% of asymptomatic patients may have tendon pathology on imaging 1.