How to treat calcified tendons?

Treatment of Calcified Tendons

For calcified tendons, begin with 3-6 months of conservative management including relative rest, NSAIDs, ice therapy, and eccentric strengthening exercises before considering more invasive interventions such as extracorporeal shock wave therapy, ultrasound-guided needle aspiration, or arthroscopic removal. 1, 2

Understanding Calcific Tendinopathy

Calcific tendinopathy is a cell-mediated process where calcium deposits form within living tendon tissue, most commonly in the rotator cuff. 3 The condition follows a natural healing cycle with distinct phases:

• Formative phase: Calcium deposits are building up within the tendon 3
• Resorptive phase: The body actively breaks down and reabsorbs the calcium deposits, often accompanied by acute pain and increased vascularity 3, 4

Understanding which phase the patient is in determines the treatment approach. 3

Initial Conservative Management (First 3-6 Months)

Start all patients with conservative treatment regardless of calcium deposit size or location. 1, 2, 5

Relative Rest and Activity Modification

• Reduce activities that load the affected tendon repetitively while maintaining some activity to prevent muscle atrophy 1, 2
• Complete immobilization must be avoided as it causes deconditioning 1, 6
• For athletes and manual laborers, modify technique to minimize repetitive stresses 2

Pain Management

• NSAIDs (oral or topical) provide effective acute pain relief 1, 2
• Topical NSAIDs eliminate gastrointestinal hemorrhage risk while providing equivalent pain relief to oral formulations 2, 6
• Ice therapy applied through a wet towel for 10-minute periods reduces pain and blunts inflammatory response 1, 2

Physical Therapy

• Eccentric strengthening exercises are the cornerstone of rehabilitation, stimulating collagen production and guiding proper fiber alignment 1, 2
• Stretching exercises are widely accepted and beneficial 1, 2
• Deep transverse friction massage may reduce pain when combined with eccentric exercises 2

Monitoring Response

• Use color Doppler ultrasound to assess vascularity around the calcium deposit 4
• Grade ≥1 color flow signals indicate active resorptive phase with high likelihood of spontaneous resolution with conservative treatment 4
• Grade <1 color flow signals suggest chronic formative phase where calcium is less likely to resorb spontaneously 4

Second-Line Interventions (After 6 Weeks to 3 Months)

Corticosteroid Injections

• Use with extreme caution: Provide short-term pain relief but do not improve long-term outcomes 2, 6
• Inject into the subacromial bursa, NOT directly into the tendon substance, as intratendinous injection inhibits healing and may predispose to rupture 2, 6, 5
• Consider only for acute exacerbations during the resorptive phase 5

Ultrasound-Guided Needle Aspiration

• Highly effective during the resorptive phase when color Doppler shows grade ≥1 vascularity 4
• Perform fine-needle multiple punctures or aspiration of the calcium deposit under ultrasound guidance 3, 4
• Should NOT be performed during the formative phase 3
• This technique showed significant improvement with >50% size reduction of calcific plaques in appropriate patients 4

Advanced Treatment Options (After 3-6 Months of Failed Conservative Care)

Extracorporeal Shock Wave Therapy (ESWT)

• Safe, noninvasive, and effective for chronic calcific tendinopathy 1, 2, 7
• Particularly useful before considering surgery 7
• Can be expensive but provides pain relief in refractory cases 1, 2

Arthroscopic Removal

• Reserved for patients who fail 3-6 months of comprehensive conservative treatment 1, 2, 8
• Technique involves arthroscopic localization and debridement of the calcium deposit 8
• Evaluate the rotator cuff for partial or full-thickness tears before and after debridement 8
• Subacromial decompression is NOT routinely necessary unless other pathology is present 8
• Yields excellent functional results and high patient satisfaction when appropriately indicated 8

Open Surgical Removal

• Consider only during the formative phase under exceptional circumstances when arthroscopic approach is not feasible 3
• Should NOT be performed during the resorptive phase as spontaneous resolution is expected 3

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the tendon substance as this weakens the tendon and increases rupture risk 2, 6
• Do not perform needle aspiration during the formative phase (color Doppler grade <1) as the calcium is too solid to aspirate effectively 3, 4
• Avoid surgery during the resorptive phase as the calcium will likely resolve spontaneously with conservative care 3
• Do not rush to surgery without at least 3-6 months of well-managed conservative treatment 1, 2, 8
• Avoid multiple corticosteroid injections as they may have cumulative deleterious effects on tendon healing 6

Expected Outcomes

Approximately 80% of patients with calcific tendinopathy fully recover within 3-6 months with appropriate conservative treatment. 2 After spontaneous disappearance of calcium deposits or surgical removal, the tendon reconstitutes itself. 3