What is the recommended treatment for mild supraspinatus calcific tendinosis?

Treatment of Mild Supraspinatus Calcific Tendinosis

NSAIDs are strongly recommended as the first-line treatment for mild supraspinatus calcific tendinosis, followed by physical therapy and extracorporeal shock wave therapy (ESWT) if symptoms persist.

Initial Treatment Approach

First-Line Treatment: NSAIDs

• NSAIDs are strongly recommended as initial pharmacological management for tendon pain 1
• Ibuprofen at 1.2g daily is considered the safest option
• Can be increased to 2.4g daily if inadequate relief is achieved
• May be combined with paracetamol (up to 4g daily) for enhanced pain relief

Physical Therapy

• Strongly recommended as a core component of treatment 2
• Should emphasize active interventions over passive ones:
  • Daily stretching exercises
  • Gentle submaximal and aerobic exercise
  • Avoidance of excessive resistive and eccentric exercise
  • Land-based therapy is conditionally preferred over aquatic therapy due to greater accessibility

Second-Line Interventions

Extracorporeal Shock Wave Therapy (ESWT)

• Effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy 3
• Higher energy levels (0.20 mJ/mm²) appear more effective than lower energy levels (0.10 mJ/mm²) for pain relief and functional improvement 3
• Typically administered in multiple sessions (e.g., once weekly for 4 weeks)

Corticosteroid Injections

• May provide short-term relief but do not change long-term outcomes 1
• Limited use recommended:
  • Maximum of 2-3 injections
  • 4-6 weeks between injections

Advanced Interventions for Persistent Cases

Ultrasound-Guided Needling/Aspiration

• Ultrasound-guided drilling of the calcific deposit combined with physiotherapy and ESWT shows promising results 4
• This combination therapy has demonstrated significant improvement in pain scores and function
• Most calcific deposits disappeared after this treatment in one study 4

Surgical Intervention

• Consider if pain persists despite 3-6 months of well-managed conservative treatment 1
• Arthroscopic removal of calcium deposits is effective but should be reserved for cases that fail conservative management 5
• Be aware that the rate of partial supraspinatus tendon tears may be higher after calcium removal 5

Rehabilitation Protocol

Phased Rehabilitation Approach

1. Initial Phase (0-4 weeks)

   • Focus on pain control and protected range of motion
   • Rest and activity modification

2. Intermediate Phase (4-8 weeks)

   • Progressive strengthening exercises
   • Eccentric training may be beneficial for tendon healing 6

3. Advanced Phase (8-12 weeks)

   • Occupation-specific training
   • Functional hand and shoulder exercises

Monitoring and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels (using Visual Analog Scale or Numeric Rating Scale)
  • Range of motion
  • Functional improvement (using scales like DASH or Constant Murley Scale)
• Consider imaging (MRI or ultrasound) for persistent symptoms 1

Common Pitfalls to Avoid

1. Overreliance on passive treatments - Active physical therapy interventions should be emphasized over passive ones 2

2. Continuous NSAID use in stable patients - On-demand treatment with NSAIDs is conditionally recommended over continuous treatment for stable symptoms 2

3. Multiple corticosteroid injections - Limit to 2-3 injections with 4-6 weeks between injections to avoid tendon weakening 1

4. Premature return to full activity - Return to full activity should only be permitted when the patient demonstrates complete resolution of pain, full range of motion, and strength symmetry >90% compared to the uninjured side 1