What is the treatment for crystal deposits in the shoulder?

Treatment for Crystal Deposits in the Shoulder

For acute crystal-induced shoulder pain, immediately perform joint aspiration with intra-articular corticosteroid injection combined with ice application and temporary rest—this approach alone is sufficient for most patients and provides rapid symptom relief. 1, 2

Acute Crystal Arthritis Management

First-Line Treatment (Monoarticular/Oligoarticular)

• Joint aspiration with intra-articular long-acting glucocorticosteroid injection is the optimal and safest treatment for acute shoulder crystal deposits 1, 2
• Apply ice or cool packs to the affected shoulder 1, 2
• Implement temporary rest of the joint 1, 2
• These non-pharmacological measures combined with intra-articular injection are often sufficient without requiring systemic medications 1

Systemic Treatment Options (When Injection Not Feasible)

If intra-articular injection cannot be performed:

• NSAIDs with gastroprotection (e.g., proton pump inhibitor)—particularly important in older patients who comprise the majority of crystal deposition cases 1, 2
• Low-dose colchicine: 0.5 mg up to 3-4 times daily (with or without 1 mg loading dose)—avoid traditional high-dose regimens due to 100% incidence of side effects 1, 2
• Short tapering course of oral corticosteroids, parenteral corticosteroids, or ACTH for patients with contraindications to NSAIDs or colchicine 1, 2

Important caveat: Glucocorticosteroid injections showed significantly faster pain relief (NNT=3 on day 1) compared to oral NSAIDs in crystal-induced arthritis, though differences equalized by day 3 1

Chronic or Recurrent Crystal Deposits

Prophylaxis Against Recurrent Attacks

• Low-dose oral colchicine (0.5-1 mg daily) reduces attack frequency from 3.2% to 1% per year 1, 2
• Low-dose NSAIDs with gastroprotection as alternative 1, 2

Chronic Inflammatory Arthritis Treatment (in order of preference)

1. Oral NSAIDs with gastroprotection and/or colchicine (0.5-1.0 mg daily) 1, 2
2. Low-dose corticosteroids 1, 2
3. Methotrexate (5-10 mg/week) for refractory cases—showed excellent response with significant decrease in pain (p<0.0001) and joint counts in resistant cases 1
4. Hydroxychloroquine (NNT=2 for clinical response) 1, 2

Special Considerations for Shoulder

Hydroxyapatite (Calcific Tendinitis)

For basic calcium phosphate crystal deposits specifically in the shoulder:

• Needling with or without aspiration of calcific deposits 3
• Steroid injections into affected tendons or bursae 3, 4
• Surgical removal may be necessary for chronic pain unresponsive to conservative measures 3, 4
• The supraspinatus tendon is most commonly affected 3

Milwaukee Shoulder Syndrome

This severe destructive arthropathy from basic calcium phosphate crystals requires aggressive management with the treatments above, though evidence is limited 5

Underlying Metabolic Disorders

Screen for and treat associated conditions 1, 2:

• Hyperparathyroidism (3-fold increased risk with CPPD) 1
• Hemochromatosis 1, 2
• Hypomagnesemia 1, 2

Critical Pitfalls to Avoid

• Never use intravenous colchicine—high risk of serious toxicity and fatality 1, 2
• Avoid traditional high-dose colchicine regimens (1 mg loading then 0.5 mg every 2 hours)—causes side effects in 100% of patients 1
• Exercise extreme caution with NSAIDs in elderly patients—CPPD predominantly affects older individuals with renal impairment and comorbidities 1
• Do not treat asymptomatic chondrocalcinosis—no treatment modifies crystal formation or dissolution 1, 2
• Start treatment early—delayed treatment significantly reduces effectiveness 2

Concurrent Osteoarthritis

If osteoarthritis coexists with crystal deposits, manage according to standard OA guidelines—treatment objectives and options remain identical 1

Special warning: Use caution with intra-articular high molecular weight hyaluronan as it may induce acute crystal attacks 1