What is the recommended management for adult calcific tendinitis of the rotator cuff?

Management of Calcific Tendinitis of the Rotator Cuff

Begin with conservative management consisting of NSAIDs, physical therapy, and a single corticosteroid injection, which provides short-term pain relief and functional improvement in most patients. 1

Initial Conservative Approach (First-Line Treatment)

The American Academy of Family Physicians recommends starting with a structured conservative regimen that includes: 1

• NSAIDs for pain control to manage the inflammatory component and reduce symptoms 1, 2
• Physical therapy with supervised exercise focusing on rotator cuff strengthening and scapular stabilization 2
• Relative rest by reducing repetitive overhead activities that load the affected tendon, while avoiding complete immobilization to prevent muscle atrophy 1
• A single corticosteroid injection with local anesthetic for short-term improvement in both pain and function 1, 2

This conservative approach is successful in approximately 90% of patients with calcific tendinitis. 3

Duration and Progression of Conservative Treatment

• Continue conservative management for 3-6 months before considering more invasive interventions 4
• Exercise programs should include range of motion exercises, rotator cuff strengthening, and scapular stabilization 2
• The natural history of calcific tendinosis includes spontaneous resolution in many cases, making patience with conservative treatment appropriate 1

Critical Pitfalls to Avoid

The American Academy of Orthopaedic Surgeons recommends avoiding multiple corticosteroid injections, as evidence supports only a single injection for short-term benefit, and multiple injections may compromise rotator cuff integrity and affect subsequent repair attempts. 5, 1

Additional pitfalls include:

• Avoid premature surgical intervention given the high rate of spontaneous resolution 1
• Do not use platelet-rich plasma (PRP) due to limited evidence supporting its routine use for rotator cuff tendinopathy 1, 2
• Avoid complete immobilization, which leads to muscle atrophy and deconditioning 1

Second-Line Interventions for Persistent Symptoms

If conservative management fails after an appropriate trial period, consider:

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, causing fragmentation of calcium deposits 4, 6, 7
• Ultrasound-guided percutaneous needle lavage and aspiration shows promising results, particularly for soft and middle-sized calcifications (12-17mm) in younger adults (30-40 years old) 8, 7
• Success rates for ultrasound-guided double-needle lavage reach 70% at 1 month, with better outcomes in soft calcifications and younger patients 8

Surgical Management

Arthroscopic excision of calcium deposits remains the definitive management for patients who fail conservative treatment after 3-6 months or those with complications such as rotator cuff tears. 4, 7

Surgical indications include:

• Persistent pain despite well-managed conservative treatment for 3-6 months 2, 4
• Significant functional limitations that impact daily activities 2
• Chronic or intermittent pain after several months of conservative treatment 6

Surgery typically involves excision of abnormal tendinous tissue and calcium deposits, with additional subacromial decompression if necessary. 4, 6

Diagnostic Imaging Considerations

• Plain radiography may show calcific deposits, sclerosis, or spur formation of the acromion 1
• Ultrasound is useful for detecting calcification, guiding interventional procedures, and showing tendon thickening 1
• MRI is sensitive (95%) and specific (95%) for detecting rotator cuff tears and degeneration, but may be unnecessary if calcification is clearly visible on plain films 1, 4

Prognostic Factors

• Younger age (30-40 years) is associated with better outcomes after percutaneous treatment 8
• Middle-sized calcifications (12-17mm) respond better to percutaneous interventions than very large or very small deposits 8
• Soft calcifications on ultrasound and radiographic imaging have better treatment responses 8
• Older age is associated with higher failure rates and poorer outcomes after any rotator cuff intervention 1
• Diabetes is associated with higher retear rates and poorer quality of life scores 1