Treatment of Calcific Peritendinitis at the Humeral Head with Pain and Reduced ROM
Conservative management with relative rest, NSAIDs, physical therapy including eccentric strengthening exercises, and cryotherapy should be the initial treatment approach, with surgery reserved only for patients who fail 3-6 months of conservative therapy. 1
Initial Conservative Management (First-Line Treatment)
Immediate Pain Control and Activity Modification
- Relative rest to reduce repetitive loading of the affected tendon while avoiding complete immobilization that could lead to stiffness 1, 2
- Cryotherapy using melting ice water through a wet towel for 10-minute periods provides acute pain relief and is widely accepted 1, 2
- NSAIDs (oral or topical) for short-term pain relief, though they have no effect on long-term outcomes 1, 2
- Topical NSAIDs are effective and may have fewer systemic side effects 1
Physical Therapy Interventions (Critical Component)
- Eccentric strengthening exercises are effective treatment that may reverse degenerative changes 1, 2
- Range of motion exercises for the glenohumeral joint and scapulothoracic region to restore mobility 3, 4
- Progressive loading exercises to stimulate collagen production and guide normal tissue alignment 2
- Physical therapy referral is beneficial for appropriate instruction in exercises that address ROM limitations 5
Important caveat: The natural history of calcific tendinitis includes a self-healing cycle where the tendon repairs itself, and calcium deposits often spontaneously resorb during the resorptive phase 6, 7. Conservative management should capitalize on this natural process 4.
Second-Line Interventions (If Initial Treatment Insufficient)
Corticosteroid Injections
- Locally injected corticosteroids may be more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1, 2
- Should be used with caution as they may inhibit healing and reduce tendon strength 2
- Subacromial infiltration with corticosteroids is appropriate in later stages of chronic presentation 7
Advanced Conservative Modalities
- Extracorporeal shock wave therapy (ESWT) appears to be a safe, noninvasive, effective but expensive means of pain relief for chronic tendinopathies 1, 2
- Ultrasound-guided percutaneous aspiration and lavage should be performed only during the resorptive phase (when deposits are soft and liquefied), not during the formative phase 6, 8
- This technique achieved pain resolution and full ROM recovery in 60% of patients with chronic calcific tendinitis 8
- Therapeutic ultrasonography and phonophoresis are of uncertain benefit 1, 3
Surgical Management (Last Resort)
Surgery is an effective option in carefully selected patients who have failed 3-6 months of conservative therapy 1, 2. Key considerations:
- Surgical removal may be indicated during the formative phase (hard, radiopaque calcifications), but only under exceptional circumstances during the resorptive phase 6
- Surgery typically involves excision of the calcium deposit and abnormal tissue, with possible release of scarring 2
- Should be reserved for patients with persistent pain and functional limitations despite well-managed conservative treatment for 6-12 months 2
Treatment Algorithm Based on Calcium Deposit Phase
Formative Phase (Hard, Radiopaque Deposits)
- Conservative management for 3-6 months minimum 1
- If conservative treatment fails, surgical removal may be considered 6
Resorptive Phase (Soft, Liquefied Deposits)
- Conservative management is paramount as spontaneous resorption is likely 6, 7
- Ultrasound-guided aspiration and lavage can be performed if symptoms are severe 6, 8
- Surgery should only be considered under exceptional circumstances 6
Critical pitfall: Differentiating between formative and resorptive phases is paramount for management decisions 6. Plain radiography and ultrasound are essential to characterize the calcium deposits and guide treatment selection 8, 7.