What is the treatment for a patient with normal glenohumeral and acromioclavicular (AC) joint alignment, preserved glenohumeral joint space, mild AC joint degenerative changes, and faint calcifications near the supraspinatus tendon, indicating minor calcific tendinopathy?

Treatment of Minor Calcific Tendinopathy of the Supraspinatus

Begin with relative rest (avoiding activities that reproduce pain) combined with eccentric strengthening exercises for at least 3-6 months, as this conservative approach constitutes the cornerstone of treatment and can reverse degenerative changes in the tendon structure. 1

Conservative Management Protocol

Initial Phase (First 3-6 Months)

• Activity modification is crucial—reduce or eliminate activities causing repetitive strain on the supraspinatus tendon to prevent further damage and promote healing 1
• Eccentric strengthening exercises should be initiated and continued for the full 3-6 month period, as they can reverse degenerative tendon changes 1
• NSAIDs can be used for symptomatic pain relief, though they do not improve long-term outcomes 1
• Physical therapy should focus on progressive loading without reproducing pain 2

Understanding the Natural History

The faint calcifications noted on your X-ray represent minor calcific tendinopathy, which is characterized by calcium hydroxyapatite crystal deposition in the tendon 3. This condition progresses through distinct phases: formative, resorptive, and post-calcific 3. The resorptive phase typically causes the most severe symptoms when calcium becomes soft and unstable 4. However, many cases resolve spontaneously as the tendon reconstitutes itself after calcium disappearance 3.

Diagnostic Considerations

• The Hawkins test (forced internal rotation with arm at 90° flexion) is 92% sensitive but only 25% specific for impingement 1
• The Neer test (full forward flexion between 70-120°) is 88% sensitive but only 33% specific 1
• Plain radiographs (which you already have) are sufficient for initial diagnosis, though they cannot demonstrate soft tissue changes of tendinopathy 1
• MRI without contrast is 95% sensitive and specific for detecting rotator cuff tears, degeneration, and chronic tendinopathy if symptoms persist or diagnosis is uncertain 1, 5

Intermediate Treatment Options (If Conservative Fails After 3-6 Months)

Minimally Invasive Interventions

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, though costly 1. When combined with ultrasound-guided needle drilling, it shows excellent results with VAS scores improving from 8.1 to 3.3 and DASH scores from 27 to 5 6
• Ultrasound-guided percutaneous lavage (UGPL) with needle aspiration and irrigation is effective during the resorptive phase when calcium is soft 3, 7. This technique fragments and aspirates calcium deposits, providing significant symptomatic relief 7
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2, 1

Important Timing Considerations

Do not perform aspiration and lavage during the formative phase—this should only be done during the resorptive phase when calcium is soft. 3 Surgical removal may be indicated during the formative phase only if conservative treatment fails, but only under exceptional circumstances during the resorptive phase 3.

Surgical Referral Criteria

• Consider surgical evaluation if pain persists despite well-managed conservative treatment for 3-6 months 1
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 2, 1
• Surgical referral should not be delayed beyond 3-6 months of failed conservative treatment 1

Critical Pitfalls to Avoid

• Starting exercises too aggressively can worsen symptoms—progression must be gradual 1
• Premature return to activities before adequate healing leads to symptom recurrence 1
• Excessive corticosteroid use does not improve long-term outcomes and can weaken the tendon 1
• Attempting aspiration during the formative phase when calcium is hard and stable is ineffective and should be avoided 3
• Missing associated rotator cuff pathology, particularly in older patients who commonly have concurrent rotator cuff tears 8

Monitoring and Follow-up

• Pain typically presents insidiously related to load, initially during activity but can progress to rest pain if untreated 1
• Palpation provokes well-localized tenderness similar to activity-related pain 1
• Radiographic follow-up can document calcium deposit resolution, which occurs in most successfully treated cases 6