What is the best treatment approach for a patient with soft calcific tendonitis, bursa thickening with calcification and debris, and significant tendon tears in the shoulder?

Treatment Approach for Soft Calcific Tendonitis with Multiple Tendon Tears in the Shoulder

The most effective treatment approach for soft calcific tendonitis with multiple tendon tears and bursal involvement begins with conservative management including rest, physical therapy, NSAIDs, and corticosteroid injections, progressing to more invasive options if these fail.

Initial Assessment and Imaging

• Standard radiographs should include anteroposterior views in internal and external rotation plus an axillary or scapula-Y view to properly assess calcifications and alignment 1
• MRI is the gold standard for comprehensive evaluation of the rotator cuff tears, with 95% sensitivity and specificity for detecting cuff tears, degeneration, chronic tendinopathy, and partial tears 1
• Ultrasound is an alternative imaging option if performed by experienced personnel, especially useful for detecting moderate to full-thickness tears and guiding therapeutic injections 1

Conservative Management (First-Line Approach)

Rest and Activity Modification

• Allow continuation of activities that don't worsen pain while avoiding complete immobilization to prevent muscular atrophy 1
• Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Physical Therapy

• Implement eccentric strengthening exercises which have proven beneficial in tendinopathies 1
• Include stretching exercises to maintain range of motion 1

Pain Management

• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief 1
• Prescribe NSAIDs for pain relief and potential anti-inflammatory benefits 1
• Consider topical NSAIDs as an alternative to reduce risk of gastrointestinal side effects 1

Corticosteroid Injections

• Subacromial corticosteroid injections are indicated for acute pain relief in calcific tendonitis 2, 3
• Ultrasound guidance improves accuracy of injection placement 1, 4
• Methylprednisolone is FDA-approved for soft tissue administration in acute and subacute bursitis and tenosynovitis 2
• Caution: Injections directly into the tendon substance should be avoided as they may inhibit healing and reduce tensile strength 1

Advanced Interventions (Second-Line Approach)

Ultrasound-Guided Percutaneous Treatments

• Ultrasound-guided needling and lavage (barbotage) shows promising results for calcific deposits 5, 4
• Most effective for middle-sized calcifications (12-17mm) and in patients between 30-40 years old 4
• Success rates of approximately 70% with significant symptom reduction at one month 4

Extracorporeal Shock Wave Therapy (ESWT)

• Consider ESWT as a minimally invasive option before surgery for persistent calcific tendonitis 6, 5
• ESWT uses acoustic waves to fragment calcium deposits and provide pain relief 5

Surgical Management (When Conservative Treatment Fails)

Arthroscopic Treatment

• Indicated when conservative measures fail after several months 6, 3
• Allows for direct excision of calcific deposits, repair of tendon tears, and subacromial decompression if necessary 7, 5
• Particularly important in cases with high-grade/full thickness tears like the infraspinatus tear described in this case 7
• Can address both the calcifications and the associated pathologies (tendon tears, bursal thickening) in a single procedure 7

Treatment Algorithm

1. Begin with 4-6 weeks of conservative management (rest, physical therapy, NSAIDs)
2. If inadequate response, proceed to ultrasound-guided corticosteroid injection
3. For persistent symptoms after 3 months, consider ultrasound-guided needling/barbotage or ESWT
4. If symptoms persist or worsen, or in cases with significant functional limitation from high-grade tears, proceed to arthroscopic treatment

Important Considerations

• The presence of a high-grade/full thickness tear of the infraspinatus tendon may necessitate earlier surgical intervention 3, 7
• Thickened subacromial bursa with calcification and impingement suggests more advanced disease that may be less responsive to conservative measures 4
• Multiple tendon involvement (subscapularis, supraspinatus, and infraspinatus) indicates a more complex case that may ultimately require surgical management 7