What is the best initial treatment for calcific tendinitis not responsive to conservative management?

Best Initial Treatment for Calcific Tendinitis Not Amenable to Conservative Management

Ultrasound-guided needling (barbotage) is the best initial treatment for calcific tendinitis that has failed conservative management, followed by extracorporeal shock wave therapy (ESWT) if needed, with arthroscopic removal reserved for refractory cases.

Understanding Treatment Progression

The management of calcific tendinitis follows a stepwise approach:

1. Conservative management (first-line):

   • NSAIDs
   • Physical therapy
   • Corticosteroid injections
   • Rest and activity modification

2. Minimally invasive interventions (when conservative management fails):

   • Ultrasound-guided needling/barbotage
   • Extracorporeal shock wave therapy (ESWT)

3. Surgical intervention (for refractory cases):

   • Arthroscopic removal of calcific deposits

Ultrasound-Guided Needling (Barbotage)

When conservative management fails, ultrasound-guided needling (barbotage) should be the first interventional treatment attempted because:

• It shows promising results as noted in recent literature 1
• It's less invasive than surgery
• It allows for fragmentation and aspiration of the calcium deposit
• It can be performed as an outpatient procedure
• It has a shorter recovery time compared to surgery

The procedure involves:

• Ultrasound localization of the calcific deposit
• Local anesthetic administration
• Needle insertion into the deposit
• Fragmentation and aspiration of the calcium
• Possible corticosteroid injection at the end of the procedure

Extracorporeal Shock Wave Therapy (ESWT)

If barbotage fails or is not feasible, ESWT should be considered as the next step:

• ESWT uses acoustic waves to fragment calcium deposits 1
• It's non-invasive
• It can be performed on an outpatient basis
• Multiple sessions may be required (typically 3-5)
• Results may take several weeks to become apparent

Surgical Management

Arthroscopic removal should be reserved for cases that fail both barbotage and ESWT:

• Indicated for patients with persistent symptoms despite minimally invasive treatments
• Particularly appropriate during the formative phase of calcification 2
• Should be avoided during the resorptive phase except in exceptional circumstances 2
• Allows for direct visualization and complete removal of calcific deposits
• Can address any associated pathology (e.g., rotator cuff tears)

Important Clinical Considerations

• Differentiate between formative and resorptive phases of calcification, as this affects treatment decisions 2
• Chronic calcific tendinitis often doesn't respond to conservative treatment and may require more aggressive intervention 3
• Even after surgical treatment, clinical improvement takes time 3
• The natural history includes a self-repair cycle that may be blocked in chronic cases 4

Treatment Algorithm

1. Confirm failure of conservative management (NSAIDs, physical therapy, corticosteroid injections)
2. Assess phase of calcification (formative vs. resorptive) through clinical and imaging findings
3. Proceed with ultrasound-guided needling/barbotage
4. If unsuccessful after 1-2 attempts, consider ESWT (3-5 sessions)
5. If symptoms persist after 3-6 months of these interventions, consider arthroscopic removal

This approach maximizes the chance of symptom resolution while minimizing invasiveness and recovery time, ultimately improving patient quality of life and function.