What are the best management options for calcific tendinosis in bilateral shoulders?

Management Options for Calcific Tendinosis in Bilateral Shoulders

The best management approach for calcific tendinosis in bilateral shoulders should follow a stepwise progression from conservative measures to more invasive interventions, with extracorporeal shock wave therapy (ESWT) being particularly effective before considering surgical options when conservative treatment fails.

Initial Diagnostic Approach

• Standard radiographs should be the first imaging study to confirm calcific deposits in the rotator cuff tendons 1
• Include anterior-posterior (AP) views in internal and external rotation and an axillary or scapula-Y view to properly visualize the calcifications 1
• Ultrasound can be used for dynamic assessment and has high sensitivity for detecting calcifications 2

Phase 1: Conservative Management (0-3 months)

1. Pain Management

   • NSAIDs (e.g., naproxen 500mg twice daily or ibuprofen 1.2-2.4g daily) for short-term pain relief 2, 3
   • May combine with acetaminophen (up to 4g daily) for enhanced pain relief 2
   • Avoid complete immobilization but recommend relative rest for 24 hours after treatment 2, 3

2. Physical Therapy

   • Progressive rehabilitation program including:
     • Protected range of motion exercises (initial phase)
     • Progressive strengthening exercises (intermediate phase)
     • Eccentric training (intermediate to advanced phase) 2, 4, 3
   • Cross-friction massage to the affected tendon 5

3. Therapeutic Modalities

   • Phonophoresis with anti-inflammatory creams 5
   • Iontophoresis 6
   • Ultrasound therapy 3

Phase 2: Minimally Invasive Interventions (if symptoms persist after 3 months)

1. Corticosteroid Injections

   • Subacromial bursal steroid injections using proper aseptic technique 2, 4
   • Limit to 2-3 injections with 4-6 weeks between injections 2
   • Monitor diabetic patients for transient hyperglycemia 2

2. Needle Aspiration/Barbotage

   • Ultrasound-guided needling and lavage of calcium deposits 4, 3
   • Most effective during the resorptive phase of calcification 7
   • Provides both diagnostic and therapeutic benefits 3

3. Extracorporeal Shock Wave Therapy (ESWT)

   • Recommended as an effective treatment option before considering surgery 6, 3
   • Acoustic waves cause fragmentation of calcium deposits with pain relief 3
   • Most beneficial during the formative phase when deposits are more solid 7

Phase 3: Surgical Management (if symptoms persist after 6 months of conservative treatment)

• Arthroscopic excision of calcium deposits 2, 4, 3
• Consider additional subacromial decompression if necessary 6
• Indicated when:
  • Conservative measures fail after 6 months of well-managed treatment
  • Significant functional limitation persists
  • Complications such as rotator cuff tears develop 2, 3

Follow-up and Monitoring

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 2
• Return to full activity when patient demonstrates:
  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side 2

Important Clinical Considerations

• Calcific tendinitis is often self-limiting, with many cases resolving spontaneously 3, 7
• Differentiate between formative phase (solid, well-defined deposits) and resorptive phase (fluffy, ill-defined deposits) as treatment approaches differ 7
• Avoid surgical intervention during the resorptive phase except in exceptional circumstances 7
• Patients with bilateral involvement may require longer treatment periods and careful coordination of interventions to maintain function

Treatment Pitfalls to Avoid

• Overreliance on corticosteroid injections, which provide only short-term relief and don't change long-term outcomes 2
• Premature surgical intervention before adequate trial of conservative measures 2, 3
• Complete immobilization of the shoulder, which can lead to stiffness and prolonged recovery 2
• Failing to recognize the natural cycle of calcification and resorption when selecting treatments 7