What is the best course of treatment for a patient with osteoarthritis and calcification tendinitis of the supraspinatus tendon, presenting with right shoulder pain and difficulty extending the right shoulder, who has been treating pain with Percocet (oxycodone and acetaminophen) and steroids?

Treatment Approach for Shoulder Osteoarthritis with Calcific Tendinitis

This patient should immediately discontinue Percocet, transition to scheduled acetaminophen as first-line pharmacologic therapy, initiate structured physical therapy focusing on rotator cuff strengthening, and consider corticosteroid injection for the acute calcific tendinitis flare. 1, 2, 3

Immediate Medication Changes Required

Discontinue Opioid Therapy

• Stop Percocet immediately as opioid analgesics are not recommended for osteoarthritis management and carry substantial risks without consistent improvement in pain or function 3
• The current opioid use represents inappropriate prescribing for this condition 3

First-Line Pharmacologic Treatment

• Start scheduled acetaminophen up to 4000 mg daily (consider 3000 mg maximum in elderly patients) as the safest and most appropriate initial pharmacologic treatment 3, 4
• Use regular dosing throughout the day rather than "as needed" for better sustained pain control 3, 4
• Acetaminophen provides comparable pain relief to NSAIDs in mild to moderate osteoarthritis with significantly safer profile 3

Second-Line Options If Acetaminophen Fails

• Apply topical NSAIDs (diclofenac gel) to the shoulder before considering oral NSAIDs, as they provide minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications 3, 4
• Only prescribe oral NSAIDs or COX-2 inhibitors at lowest effective dose for shortest duration if topical treatments fail 1, 3
• Mandatory co-prescription of proton pump inhibitor with any oral NSAID for gastroprotection 1, 3, 4

Management of Calcific Tendinitis Component

Corticosteroid Injection for Acute Flare

• Consider intra-articular or subacromial corticosteroid injection for the moderate to severe pain from calcific tendinitis, particularly effective for acute flares 1, 3
• While evidence is insufficient (Grade I), corticosteroid injections are widely used in clinical practice for symptomatic flares of shoulder pain 2

Physical Therapy Modalities

• Iontophoresis with acetic acid has demonstrated marked resorption of calcific deposits in case reports and may be considered as conservative treatment option 5
• Extracorporeal shock wave therapy (ESWT) is a minimally invasive alternative before considering surgery for chronic calcific tendinitis 6

Essential Non-Pharmacologic Core Treatments

Structured Physical Therapy Program

• Exercise-based physical therapy is the foundation of treatment, focusing on decreasing pain, increasing range of motion, and rotator cuff strengthening 2
• Local muscle strengthening and general aerobic fitness exercise programs must accompany any pharmacologic management 1, 3
• This is mandatory before escalating to more invasive treatments 3

Additional Conservative Measures

• Local heat or cold applications 1
• Assistive devices as needed 1
• Patient education to counter misconceptions about osteoarthritis progression 4

Surgical Considerations If Conservative Treatment Fails

Timing for Surgical Referral

• Arthroscopic removal of calcium deposits should be considered only after prolonged conservative treatment failure (typically several months) 6, 7, 8
• Arthroscopic calcium removal with multiple punctures in the calcific spot has shown satisfactory results in 94% of cases at 2-year follow-up 7
• Additional subacromial decompression during arthroscopy may reduce postoperative pain 8

Advanced Surgical Options

• Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty if severe osteoarthritis becomes refractory to non-surgical treatment, providing superior pain relief and functional outcomes 2
• Critical caveat: TSA should NOT be performed if irreparable rotator cuff tears are present—reverse total shoulder arthroplasty should be considered instead 2
• Refer before prolonged and established functional limitation develops 1

Critical Pitfalls to Avoid

• Never continue opioid therapy for osteoarthritis—no evidence of benefit and substantial harm 3
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor) 1, 3, 4
• Never exceed 4000 mg daily acetaminophen (3000 mg in elderly) to prevent hepatotoxicity 3, 4
• Do not offer mesenchymal stem cell injections as there is no evidence for efficacy or safety in shoulder osteoarthritis 2
• Do not extrapolate biologics evidence from knee or hip to the shoulder, as biomechanics and disease characteristics differ fundamentally 2
• Assess cardiovascular, gastrointestinal, and renal risk factors before any oral NSAID, particularly in patients over 50 years 4