What is the best course of treatment for a patient with common flexor tendinitis and a 3 mm dystrophic calcification at the common flexor tendon origin?

Treatment of Common Flexor Tendinitis with Dystrophic Calcification

Begin with conservative management consisting of relative rest, eccentric strengthening exercises, and short-term NSAIDs, while recognizing that the 3 mm calcification represents a degenerative process that typically undergoes spontaneous resorption and does not require surgical removal unless conservative therapy fails after 3-6 months. 1, 2, 3

Understanding the Pathophysiology

The presence of calcification in your patient's common flexor tendon is not simply dystrophic debris but represents a cell-mediated reactive process that typically progresses through formative and resorptive phases, ultimately leading to tendon reconstitution 3, 4. This is a degenerative tendinosis with collagen disorientation and fiber separation, not an acute inflammatory condition, despite the common misnomer "tendinitis" 1.

Initial Conservative Treatment Protocol

Relative Rest and Activity Modification

• Reduce activities that cause repetitive loading of the common flexor tendon origin (gripping, wrist flexion activities) without complete immobilization, as immobilization accelerates muscle atrophy 1, 2
• There are no clear evidence-based recommendations for exact duration of rest, but clinical experience suggests gradual return to activity as symptoms permit 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods multiple times daily for acute pain relief 1, 2

Pharmacologic Management

• NSAIDs provide short-term pain relief but do not alter long-term outcomes or affect the degenerative process 1, 2
• Topical NSAIDs are preferred for localized elbow tendinosis as they provide similar efficacy with fewer systemic side effects 2
• Paracetamol up to 4g/day can serve as first-line oral analgesic due to favorable safety profile 2

Eccentric Strengthening Exercises

• This is the cornerstone of treatment and has proven ability to reverse degenerative changes, reduce symptoms, and increase strength 1, 2, 5
• Implement progressive eccentric loading of the wrist flexors as pain permits 1

Deep Transverse Friction Massage

• Apply to reduce pain and promote healing 2

Advanced Interventions for Persistent Symptoms

Corticosteroid Injections

• Consider for acute pain relief when symptoms are severe, as injections are more effective than oral NSAIDs in the acute phase 1, 2
• Critical caveat: Inject only into the tendon sheath, never into the tendon substance itself, and avoid multiple injections as they may weaken tendon structure and inhibit healing 2, 5
• Corticosteroid injections do not alter long-term outcomes 1, 2

Extracorporeal Shock Wave Therapy (ESWT)

• Safe, noninvasive option for chronic tendinopathy that has failed initial conservative measures, though expensive 1, 2, 5
• Studies show mixed benefit for elbow tendinopathy specifically 1

Orthotics and Bracing

• No conclusive recommendations exist for effectiveness in elbow tendinopathy, so use clinical experience and patient preference to guide therapy 1

Surgical Considerations

Surgery should only be considered for carefully selected patients who have failed 3-6 months of appropriate conservative management 1, 2, 5. However, specific to calcific tendinopathy, surgical timing depends on the radiologic appearance of the deposit 3, 4:

• Surgery may be indicated if the calcification appears dense, homogenous, and well-delineated on radiographs (formative phase) 3, 4
• Postpone surgery if there is radiologic evidence of ongoing resorption (fluffy, fragmented appearance), as spontaneous resorption will almost always occur naturally 3, 4
• Aspiration and lavage should only be performed during the resorptive phase 4

Critical Clinical Pitfalls to Avoid

• Do not proceed to surgery without adequate 3-6 month trial of conservative therapy 1, 2
• Never inject corticosteroids directly into tendon substance 5
• Avoid complete immobilization as it accelerates muscle atrophy and deconditioning 2, 5
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1, 5
• Do not assume the calcification requires removal—it typically undergoes spontaneous resorption 3, 4

Expected Prognosis

Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative outpatient treatment 1, 2. The calcific deposit will likely undergo spontaneous resorption and tendon reconstitution without surgical intervention 3, 4.