Treatment of Calcific Enthesopathy with Shockwave Therapy
Direct Recommendation
Extracorporeal shockwave therapy (ESWT) is highly effective for calcific enthesopathy, particularly for calcific rotator cuff tendinopathy, and should be applied with fluoroscopic guidance directly focused on the calcified deposit using high-energy protocols (0.32-0.78 mJ/mm² energy flux density, 2000-4000 impulses per session). 1, 2, 3
Treatment Protocol
Energy Selection and Technique
- High-energy ESWT (0.32 mJ/mm² at 120 Hz) delivers superior outcomes compared to routine physical therapy, with approximately 2000 shockwaves per treatment session 2
- Fluoroscopic focusing directly on the calcified deposit is significantly more effective than targeting the tendon origin, as demonstrated by superior Constant-Murley scores when shock waves are precisely aimed at the calcium deposit 3
- Combined focused and radial shockwave therapy produces the best reduction in calcification size compared to either modality alone 1
Treatment Schedule
- Administer 8-12 sessions over 6 weeks (2 sessions per week) for optimal clinical and ultrasonographic outcomes 2
- Alternative protocol: 4000 impulses divided into two treatment sessions with local anesthesia can be effective when precisely focused 3
Expected Outcomes by Calcification Type
Type II/III Translucent Calcifications (Best Response)
- 70% of patients achieve complaint-free status with translucent calcifications (Gartner and Heyer types II/III) 4
- Pain scores (VAS) improve to 1.5 ± 2.48 in translucent calcifications, significantly better than dense calcifications (3.8 ± 2.46) or non-calcific tendinosis (2.9 ± 2.86) 4
- Functional outcomes (Constant-Murley score) reach 86.9 ± 19.7 in translucent calcifications versus 71.1 ± 17.8 in dense calcifications 4
Type I Dense Calcifications (Moderate Response)
- Dense calcifications respond less favorably, with only 25% achieving complaint-free status 4
- Stone morphology predicts success: rough-appearing external surfaces on imaging are more amenable to fragmentation than smooth contours 5
Non-Calcific Tendinosis (Limited Response)
- Only 15% of non-calcific tendinosis patients achieve complaint-free status with ESWT, indicating this is primarily a treatment for calcific disease 4
Clinical Benefits Demonstrated
Pain and Function
- Significant improvement in pain (NPRS), shoulder function (Constant-Murley score), and quality of life (WORC index) occurs at 6 and 12 weeks post-treatment 2
- Pain reduction and functional improvement are sustained at 1-year follow-up 3
Ultrasonographic Changes
- Significant reduction in calcification size is documented on musculoskeletal ultrasound at 1 week and 3 months post-treatment 1, 2
- Combined focused and radial ESWT produces the greatest decrease in calcification size compared to single modalities 1
Integration with Conservative Management
When to Use ESWT
- ESWT is safe and potentially effective for pain relief and should be considered as an intermediate intervention when initial conservative measures (relative rest, NSAIDs, eccentric exercises) fail to provide adequate relief after 3-6 months 6
- ESWT is a minimally invasive alternative before considering surgical intervention for persistent calcific tendinopathy 7
Complementary Treatments
- Continue eccentric strengthening exercises as the cornerstone of tendinopathy treatment alongside ESWT, as exercises may reverse degenerative changes 6
- Avoid overhead activities and those reproducing pain during the treatment period 6
- Short-term NSAIDs may provide additional acute pain relief, though they do not alter long-term outcomes 6
Critical Technical Considerations
Imaging Guidance
- Fluoroscopic focusing is essential for optimal outcomes - studies demonstrate statistical superiority when shock waves are applied directly to the calcified area rather than anatomical landmarks 3
- Pre-treatment ultrasonography should classify calcification type (Gartner and Heyer classification) to predict treatment response 4
Anesthesia
- Local anesthesia may be used to improve patient tolerance during high-energy protocols 3
Common Pitfalls to Avoid
- Do not use unfocused or imprecisely targeted shockwave therapy - exact fluoroscopic focusing on the calcified deposit is critical for success 3
- Do not expect equivalent results in non-calcific tendinosis - ESWT efficacy is substantially lower (15% complaint-free rate) compared to calcific disease 4
- Do not use ESWT as monotherapy for large or staghorn calcifications - while not specifically addressed for shoulder enthesopathy, evidence from urological calculi suggests poor outcomes with SWL monotherapy for large calcifications 5
- Do not abandon treatment prematurely - full protocols of 8-12 sessions over 6 weeks are necessary for optimal outcomes 2
Surgical Consideration
- Reserve surgical intervention for cases where pain persists despite 3-6 months of well-managed conservative treatment including ESWT, typically involving excision of abnormal tissue and longitudinal tenotomies 6