Is calcified tendinopathy treatable?

Treatment of Calcified Tendinopathy

Calcified tendinopathy is treatable through a combination of conservative measures, minimally invasive procedures, and surgery in refractory cases, with extracorporeal shock wave therapy (ESWT) and ultrasound-guided needle lavage showing particular effectiveness for symptom relief and calcium deposit removal. 1, 2

Understanding Calcific Tendinopathy

Calcific tendinopathy is characterized by reactive calcification affecting tendons, most commonly in the rotator cuff with a prevalence of 2.7-22% 2. It progresses through distinct phases:

• Formative phase: Calcium deposit formation
• Resorptive phase: Spontaneous breakdown of deposits

Identifying the current phase is crucial for determining appropriate treatment 3.

Treatment Algorithm

First-Line Conservative Management

1. Pain management:

   • NSAIDs for short-term pain relief 4
   • Ibuprofen 1.2-2.4g daily, possibly combined with paracetamol (up to 4g daily) 4
   • Cold application for 20-30 minutes, 3-4 times daily 4
   • Compression wrap for comfort 4

2. Activity modification:

   • Relative rest and avoidance of painful activities 4
   • Technique modification to minimize repetitive tendon stress 1

3. Physical therapy:

   • Daily stretching exercises
   • Gentle submaximal and aerobic exercise
   • Eccentric strengthening exercises (may reverse degenerative changes) 4
   • Phased rehabilitation approach (initial, intermediate, advanced) 4

4. Orthotics and braces:

   • May help correct biomechanical problems 1

Second-Line Interventions

1. Extracorporeal Shock Wave Therapy (ESWT):

   • Uses acoustic shock waves to promote tendon healing
   • Safe and effective for calcific tendinopathy 1, 2

2. Ultrasound-guided procedures:

   • Needle lavage/aspiration of calcific deposits
   • Particularly effective during the resorptive phase 3, 2, 5
   • Can be combined with corticosteroid injection 5

3. Corticosteroid injections:

   • Provide short-term relief but don't change long-term outcomes
   • Limited use recommended (2-3 injections, 4-6 weeks between injections) 4
   • Should be avoided near patellar and quadriceps tendons due to rupture risk 4

4. Therapeutic ultrasound:

   • May decrease pain and increase collagen synthesis
   • Evidence for consistent benefit is weak 1

Third-Line Treatment

Surgical intervention:

• Consider if pain persists despite 3-6 months of well-managed conservative treatment 4
• Typically involves excision of abnormal tendon tissue and longitudinal tenotomies 1
• Most appropriate during the formative phase, rarely during resorptive phase 3
• Surgical removal should be avoided during active resorption 3

Treatment Effectiveness by Location

• Rotator cuff: Most common location; responds well to ESWT and ultrasound-guided lavage 2
• Gluteus medius: Responds to ultrasound-guided needle lavage and corticosteroid injection 5
• Rectus femoris: Rare location; may respond to conservative management with NSAIDs, physical therapy, and rest 6

Monitoring and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate pain, range of motion, and functional improvement 4
• Consider MRI or ultrasound for persistent symptoms 4

Important Caveats

1. Phase-specific treatment: Surgical removal is appropriate during the formative phase but rarely during the resorptive phase 3

2. Avoid prolonged immobilization: Immobilization beyond 3 weeks can lead to contractures 4

3. Combined approaches may be superior: A protocol combining ultrasound-guided drilling with ESWT showed significant improvement in both pain scores and radiological resolution of deposits 2

4. Spontaneous resolution: Many calcific deposits will resolve spontaneously over time, particularly during the resorptive phase 3