What is the recommended management of supraspinatus calcific tendinitis?

Management of Supraspinatus Calcific Tendinitis

Start with NSAIDs and relative rest as first-line treatment, followed by ultrasound-guided needle aspiration with corticosteroid injection if conservative measures fail after 6-8 weeks, and reserve arthroscopic removal for refractory cases after 3-6 months of failed conservative management. 1

Initial Conservative Management (First 6-8 Weeks)

Pharmacological Treatment

• NSAIDs are the cornerstone of initial treatment, providing short-term pain relief and should be used up to maximum dose while considering individual risk factors 1, 2
• Topical NSAIDs serve as an alternative to oral formulations for patients with gastrointestinal concerns 1
• Analgesics including paracetamol and opioid-like drugs may be added for residual pain after NSAIDs prove insufficient 3

Activity Modification

• Implement relative rest by avoiding overhead activities and movements that reproduce pain 1, 2
• Reduce repetitive loading of the damaged tendon while maintaining some activity to prevent deconditioning 1
• Apply cryotherapy with ice through a wet towel for 10-minute periods immediately after pain-provoking activities 1, 2

Physical Therapy

• Combine pharmacological treatment with physical therapy throughout all stages of disease 3
• Active physical therapy and supervised exercise is superior to passive physical therapy and unsupervised exercise 3
• Gradual progression is essential—avoid aggressive exercises early in the treatment course 1, 2

Second-Line Interventions (After 6-8 Weeks of Failed Conservative Treatment)

Ultrasound-Guided Needle Aspiration

• Ultrasound-guided drilling of calcific deposits using local anesthetic provides reliable treatment with 60% achieving complete pain resolution and full range of motion 4, 5
• The technique involves positioning a 16G needle inside the calcification under ultrasound guidance, fragmenting and aspirating the deposits 5
• After aspiration, inject 0.5-1 mL triamcinolone acetonide (40 mg) into the soft tissues or subacromial bursa—never into the tendon substance itself 1, 5
• This approach achieved calcification disappearance in 58.5% of patients and significant debulking (>60%) in 38.5% 5

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT is safe and potentially effective for pain relief, though expensive 1, 2, 6
• Combining needle drilling with ESWT physiotherapy protocol (five sessions within one month) improved VAS scores from 8.1 to 3.3 and DASH scores from 27 to 5 4
• ESWT can be used as an alternative minimally invasive treatment before considering surgery 6

Alternative Conservative Modalities

• Phonophoresis with topical anti-inflammatory cream followed by cross-friction massage demonstrated calcific deposit resolution in case reports, though evidence is limited 7

Critical Warnings About Corticosteroid Use

• Local glucocorticoid injections directed to the site of musculoskeletal inflammation may be considered in select cases 3, 1
• However, corticosteroid injections should be used with extreme caution as they may provide acute pain relief but do not improve long-term outcomes, may inhibit healing, and can reduce tendon strength predisposing to rupture 2
• Never inject corticosteroids into the tendon substance itself—only peritendinous injection may be considered 1, 2
• Long-term systemic glucocorticoids should not be used 3, 1

Surgical Referral (After 3-6 Months of Failed Conservative Treatment)

Indications for Surgery

• Pain persists despite 3-6 months of well-managed conservative treatment 1, 2
• Significant functional limitations persist despite conservative measures 2

Surgical Approach

• Arthroscopic removal of calcific deposits with rotator cuff repair (without acromioplasty) is the preferred surgical technique 8
• This approach achieved significant improvement with mean Constant scores increasing from 23.9 to 85.3, UCLA scores from 15.8 to 32.2, and VAS pain scores from 8.7 to 0.8 8
• Surgical techniques include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 2
• 96.2% of patients were satisfied with arthroscopic removal and repair without acromioplasty at mean 35-month follow-up 8

Prognostic Factors

• Workers' compensation status correlates with less favorable outcomes and should be discussed during surgical counseling 3, 2
• Preoperative infraspinatus fatty degeneration and muscle atrophy, as well as supraspinatus muscle atrophy, correlate with worse healing and clinical outcomes 3, 2

Monitoring and Follow-Up

• Reassess response to conservative treatment at 6-8 weeks 1
• Continue conservative management for a minimum of 3-6 months before considering surgical referral 1, 2
• Monitor for development of muscle atrophy, which indicates chronicity and worsens surgical outcomes 1
• Do not delay surgical referral beyond 6 months of failed conservative treatment, as chronic tears may develop muscle atrophy and fatty degeneration that worsen surgical outcomes 1, 2

Critical Pitfalls to Avoid

• Never inject corticosteroids into the tendon substance—only peritendinous injection with extreme caution 1, 2
• Do not start with aggressive exercises; gradual progression is essential to prevent symptom exacerbation 1, 2
• Do not delay surgical referral beyond 6 months if conservative treatment fails 1, 2
• Do not use long-term systemic glucocorticoids 3, 1
• Avoid routine use of MRI or radiographic studies for follow-up unless clinically indicated 3