What is the recommended treatment approach for a patient with calcific tendinosis of the rotator cuff?

Treatment of Calcific Tendinosis of the Rotator Cuff

Begin with conservative management consisting of NSAIDs, physical therapy, and a single corticosteroid injection, which provides short-term pain relief and functional improvement in most patients; if symptoms persist after 6-12 months, progress to extracorporeal shock wave therapy (ESWT) or ultrasound-guided needle aspiration and lavage before considering arthroscopic removal. 1, 2

Initial Conservative Management (First-Line Treatment)

The treatment algorithm for calcific tendinosis differs from standard rotator cuff pathology because calcifications have a natural tendency toward spontaneous resolution, making exhaustive conservative treatment essential before invasive options 2.

Non-Invasive Treatment Protocol

• Relative rest: Reduce repetitive overhead activities that load the affected tendon, but avoid complete immobilization to prevent muscle atrophy and deconditioning 1
• NSAIDs: Use for pain control and to manage any inflammatory component 1, 3
• Physical therapy: Focus on improving scapular mechanics and decreasing dynamic impingement, which addresses the biomechanical factors contributing to symptoms 3
• Single corticosteroid injection with local anesthetic: Moderate evidence supports this for short-term improvement in both pain and function 1

Duration: Continue conservative management for at least 6-12 months before progressing to more invasive options 4

Second-Line Treatment: Non-Invasive Advanced Modalities

If initial conservative measures fail after 6-12 months, escalate to more aggressive non-invasive treatments before considering surgery.

High-Energy Focused Shock Wave Therapy (ESWT)

• ESWT has a high degree of recommendation for rotator cuff calcifications, supported by meta-analyses and systematic reviews 2
• This modality uses acoustic shock waves to impart structural alterations that reduce pain and promote tendon healing 1
• ESWT appears safe and effective, though optimal treatment protocols continue to be refined 1

Third-Line Treatment: Minimally Invasive Procedures

Ultrasound-Guided Needle Aspiration and Lavage (Barbotage)

This technique provides long-term improvement in pain and function and should be attempted before surgical intervention 3, 5.

• Perform under local anesthesia with continuous three-dimensional ultrasound visualization 5
• Place two 18-gauge needles within the calcification 5
• Inject and aspirate saline solution repeatedly until the aspirate is free of calcific particles 5
• Patients may experience complete pain relief within minutes to days, with full range of motion recovery 5
• This avoids radiation exposure compared to fluoroscopic guidance 5

Fourth-Line Treatment: Surgical Intervention

Indications for Arthroscopy

Arthroscopy is indicated only in patients with chronic and persistent calcific tendinitis who have failed all conservative and minimally invasive treatments for at least 6-12 months 4.

Arthroscopic Technique

• Perform arthroscopic debridement of the calcific deposit 4
• Evaluate for and address any associated shoulder instability, which was present in 40% of arthroscopic cases in one series 4
• Short- and medium-term results are consistently positive, though adhesive capsulitis is a potential complication 4

Diagnostic Imaging Considerations

• Plain radiography: May show calcific tendinosis, sclerosis, or spur formation of the acromion 1
• Ultrasound: Useful for detecting calcification and guiding interventional procedures; shows tendon thickening and decreased echogenicity 1
• MRI: Sensitive (95%) and specific (95%) for detecting rotator cuff tears, degeneration, and partial tears, but may be unnecessary if calcification is clearly visible on plain films 1

Critical Pitfalls to Avoid

• Do not rush to surgery: The natural history of calcific tendinosis includes spontaneous resolution in many cases, making premature surgical intervention inappropriate 2
• Do not use platelet-rich plasma (PRP): Limited evidence does not support routine use of PRP for rotator cuff tendinopathy 1
• Do not use hyaluronic acid injections: Limited evidence supports their use in rotator cuff pathology 1
• Avoid multiple corticosteroid injections: Evidence supports only a single injection for short-term benefit; long-term effects of repeated injections on rotator cuff prognosis remain unclear 1

Prognostic Factors

• Older age: Associated with higher failure rates and poorer outcomes after any rotator cuff intervention 1, 6
• Diabetes: Associated with higher retear rates and poorer quality of life scores 1, 6
• Comorbidities: Generally associated with poorer patient-reported outcomes 1