What are the treatment options for calcific tendinitis of the supraspinatus tendon?

Treatment of Calcific Tendinitis of the Supraspinatus Tendon

Begin with a structured 3-6 month conservative protocol combining relative rest, eccentric exercises, and NSAIDs, reserving extracorporeal shock wave therapy (ESWT) or ultrasound-guided needle aspiration for refractory cases before considering surgery. 1

Initial Conservative Management (First-Line, 0-3 Months)

Activity Modification and Rest

• Reduce overhead activities and movements that reproduce pain to prevent ongoing tendon damage 1
• Continue activities that do not worsen symptoms, but avoid complete immobilization which causes muscle atrophy 2
• Apply ice through a wet towel for 10-minute periods immediately after pain-provoking activities for acute pain relief 1

Pharmacologic Management

• Use oral NSAIDs for short-term pain relief, recognizing they provide no long-term benefit and do not alter disease progression 1
• Topical NSAIDs offer an alternative with fewer systemic side effects 1

Exercise Therapy (Cornerstone of Treatment)

• Initiate eccentric strengthening exercises as the primary intervention to reverse degenerative tendon changes 1
• Continue exercises for at least 3-6 months for optimal results 1
• Progress gradually to avoid symptom exacerbation—starting too aggressively is a common pitfall 1
• Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers 2

Intermediate Interventions (3-6 Months if Conservative Fails)

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT is safe, noninvasive, and effective for pain relief in calcific tendinitis, with evidence showing reduction in calcification size and improved function 1, 3, 4
• Radial ESWT protocols typically use 2000 shocks at 3 bars pressure and 10 Hz frequency, resulting in pain relief, increased range of motion, and decreased calcification size on radiographs 4
• Though expensive, ESWT should be considered before surgical intervention 1

Ultrasound-Guided Needle Aspiration Combined with ESWT

• For persistent calcific deposits, ultrasound-guided drilling of the calcium deposit using local anesthetic followed by ESWT physiotherapy provides excellent results 5
• This combined approach showed complete or near-complete radiographic resolution of calcifications with VAS scores improving from 8.1 to 3.3 and DASH scores from 27 to 5 5
• Five ESWT sessions over one month following needle aspiration is the recommended protocol 5

Therapeutic Ultrasound and Phonophoresis

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Phonophoresis (ultrasound-driven medication delivery) combined with cross-friction massage over approximately 20 sessions has demonstrated complete radiographic resolution of calcifications 6

Corticosteroid Injections (Use with Extreme Caution)

• Corticosteroid injections may provide better acute pain relief than NSAIDs but do not improve long-term outcomes 1
• Avoid injecting directly into the tendon substance—only peritendinous injection may be considered 7
• Corticosteroids may inhibit healing and reduce tendon strength, potentially predisposing to rupture 1, 7

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

Indications for Surgery

• Refer to orthopedic surgery if pain persists despite 3-6 months of well-managed conservative treatment 1, 7
• Significant functional limitations despite conservative measures warrant surgical consultation 7

Surgical Technique

• Arthroscopic or open excision of abnormal tendon tissue and calcium deposits with longitudinal tenotomies to release scarring and fibrosis 1, 8
• Additional subacromial decompression may be performed if necessary 3
• Surgery is effective in carefully selected patients who have failed conservative therapy 1

Diagnostic Imaging Considerations

When to Image

• Plain radiographs may show calcific deposits but are not required for typical presentations 2
• Reserve advanced imaging (ultrasound or MRI) for unclear diagnosis, recalcitrant pain despite adequate conservative management, or preoperative planning 2
• Ultrasound is sensitive and specific (95%) for detecting rotator cuff pathology and can guide interventional procedures 2
• MRI is highly sensitive (95%) and specific (95%) for detecting cuff tears, degeneration, and chronic tendinopathy 2

Critical Pitfalls to Avoid

• Do not misdiagnose the condition—the underlying pathology is degenerative tendinopathy (tendinosis), not acute inflammation (tendinitis) 1
• Do not start with aggressive exercises; gradual progression is essential to prevent symptom worsening 1, 7
• Do not delay surgical referral beyond 6 months of failed conservative treatment, as chronic cases may develop muscle atrophy and fatty degeneration that worsen surgical outcomes 7
• Do not inject corticosteroids into the tendon substance itself 7
• Do not allow premature return to overhead activities before adequate healing, as this leads to symptom recurrence 1

Expected Outcomes

• Approximately 80% of patients achieve full functional recovery within 3-6 months with appropriate conservative management 9
• Complete normalization of tendon strength often requires longer than 6 months 9
• Combined ultrasound-guided needle aspiration with ESWT shows excellent clinical and radiographic results in refractory cases 5