What is the recommended treatment for a patient with calcific tendinopathy of the supraspinatus?

Treatment of Calcific Tendinopathy of the Supraspinatus

Begin with conservative management including relative rest, eccentric strengthening exercises, NSAIDs for pain relief, and cryotherapy, as this approach successfully resolves symptoms in approximately 80% of patients within 3-6 months. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Reduce activities causing repetitive overhead loading of the supraspinatus tendon to prevent further damage and promote healing 1
• Avoid overhead activities and movements that reproduce pain 1
• Critical pitfall: Do not prescribe complete immobilization, as this causes muscular atrophy and deconditioning 2

Pain Management

• Apply ice through a wet towel for 10-minute periods immediately after pain-provoking activities for acute pain relief 1
• Use oral NSAIDs for short-term pain relief, though they do not alter long-term outcomes 1
• Topical NSAIDs provide pain relief with fewer systemic side effects than oral formulations 1

Eccentric Strengthening Exercises (Cornerstone of Treatment)

• Eccentric exercises are the most important component of treatment and may reverse degenerative changes in tendon structure 1
• Continue exercises for at least 3-6 months for optimal results 1
• These exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers 2
• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment including eccentric exercises 3, 1

Intermediate Interventions (If Initial Management Insufficient)

Physical Therapy Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief 1
• Combined needle drilling with xylocaine under ultrasound guidance followed by ESWT physiotherapy protocol showed excellent results, with VAS scores improving from 8.1 to 3.3 and radiological disappearance of calcific deposits in nearly all patients 4
• Phonophoresis with cross-friction massage to the supraspinatus tendon followed by range of motion exercises demonstrated resolution of calcific deposits and symptoms 5

Acetic Acid Iontophoresis

• Iontophoresis treatment (3 visits per week for 5 weeks) demonstrated marked resorption of calcific deposits on radiographs 6

Corticosteroid Injections

• May provide better acute pain relief than NSAIDs in the short term 1
• Do not improve long-term outcomes 1
• Use with extreme caution: Corticosteroids may inhibit healing and reduce tendon strength 1
• Never inject directly into the tendon substance as this predisposes to spontaneous rupture 2

Advanced Interventions (For Refractory Cases)

Ultrasound-Guided Percutaneous Lavage (UGPL)

• Minimally invasive procedure involving needle insertion into calcified deposits under ultrasound guidance to fragment and aspirate calcium 7
• Demonstrates good short- and medium-term outcomes with significant symptomatic relief and restoration of shoulder function 7
• Consider for patients who do not respond to conservative treatments 7
• Challenges exist with dense or small calcifications 7

Surgical Management

• Consider only if pain persists despite well-managed conservative treatment for 3-6 months 1
• Involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1
• Effective in carefully selected patients 1

Diagnostic Confirmation

Clinical Tests

• Hawkins' test: Sensitive (92%) but not specific (25%) for supraspinatus impingement 8
• Neer's test: Sensitive (88%) but not specific (33%) for impingement 8
• Pitfall: These tests are sensitive but not specific, so positive results must be interpreted in clinical context 1

Imaging

• Plain radiographs confirm presence of calcium deposits 3, 6, 4
• Ultrasound is useful for guiding interventional procedures and monitoring calcium deposit resorption 7, 4

Treatment Algorithm

1. Weeks 0-12: Relative rest, activity modification, cryotherapy, oral/topical NSAIDs, and eccentric strengthening exercises 1
2. Weeks 12-24: If inadequate response, add therapeutic ultrasound or ESWT 1
3. After 12-24 weeks: If still refractory, consider ultrasound-guided percutaneous lavage or acetic acid iontophoresis 7, 6, 4
4. After 3-6 months: If conservative management fails completely, consider surgical consultation 1

Common Pitfalls to Avoid

• Inadequate exercise progression: Starting with too aggressive exercises worsens symptoms; active rehabilitation with eccentric exercises must remain the foundation 1
• Premature return to activities: Returning before adequate healing leads to symptom recurrence 1
• Delayed surgical referral: Avoid delaying surgical consultation if symptoms persist despite 3-6 months of appropriate conservative management 1
• Multiple corticosteroid injections: These weaken tendon structure despite providing short-term symptom relief 2