What are the management options for calcific tendonitis?

Management of Calcific Tendonitis

Begin with conservative management including NSAIDs, rest, and physical therapy, reserving corticosteroid injections for persistent symptoms and surgery only after 3-6 months of failed conservative treatment.

Initial Conservative Approach

First-line treatment should focus on non-invasive modalities that address pain and inflammation while allowing natural resorption of calcium deposits. 1

Non-Pharmacological Management

• Apply ice or cool packs to reduce tissue metabolism and blunt the inflammatory response 2
• Implement relative rest to decrease repetitive loading of the affected tendons, avoiding complete immobilization which can lead to muscular atrophy 2
• Initiate physical therapy focusing on range of motion and strengthening exercises 1

Pharmacological Management

• Prescribe oral NSAIDs with gastroprotective treatment if indicated for acute pain relief 2, 1
• Consider topical NSAIDs as an alternative with fewer systemic side effects 2
• Continue NSAID therapy for 2-3 weeks, with most patients showing significant improvement within 48-72 hours 3

Second-Line Interventions

If conservative measures fail after several weeks to months, proceed with more invasive options before considering surgery.

Corticosteroid Injection

• Perform subacromial bursal steroid injection for persistent symptoms 4
• Use ultrasound guidance when available to identify anatomical variations such as septations or subcompartmentalization 2
• Avoid direct injection into the tendon substance as this may inhibit healing, reduce tensile strength, and predispose to rupture 2

Needle Aspiration

• Consider needle irrigation-aspiration of the calcium deposit, particularly during the resorptive phase when the deposit is soft and fluid-like 5
• Aspiration and lavage should only be performed during the resorptive phase, not the formative phase 5

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT represents a minimally invasive alternative before proceeding to surgery 4
• This modality has been postulated as effective for calcific tendinitis of the shoulder 4

Surgical Management

Reserve surgery exclusively for cases that fail to respond to a well-managed 3-6 month trial of conservative treatments. 2

Indications for Surgery

• Chronic or intermittent pain persisting after several months of conservative treatment 4
• Failure of all non-operative measures including oral anti-inflammatory medication and physical therapy 6

Surgical Technique

• Perform arthroscopic localization and debridement of the calcium deposit 6
• Evaluate the rotator cuff for partial- and full-thickness tears before and after debridement of calcifications 6
• Repair tears ≥5 mm in depth using tendon-to-tendon or tendon-to-bone technique; debride and leave alone tears <5 mm 6
• Subacromial decompression can be added if necessary, though debridement alone without decompression is often sufficient 6
• Open surgical procedures remain an option for curettage of the calcium deposit 4

Phase-Specific Considerations

Understanding the phase of calcific tendonitis is paramount for appropriate management decisions. 5

Formative Phase

• Calcium deposits are firm and chalk-like 5
• Surgical removal may be indicated if conservative treatment fails 5

Resorptive Phase

• Calcium deposits become soft and fluid-like as the body attempts natural resorption 5
• Surgery should only be performed under exceptional circumstances during this phase 5
• This is the optimal time for aspiration and lavage procedures 5

Common Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance - this inhibits healing and increases rupture risk 2
• Do not perform aspiration during the formative phase - the deposit is too firm and the procedure will be ineffective 5
• Do not proceed to surgery without a minimum 3-6 month trial of conservative treatment 2
• Do not overlook anatomical variations - failure to identify multiple compartments or septa may lead to incomplete response to injection therapy 2
• Do not immobilize completely for extended periods - this causes muscular atrophy and deconditioning 2