First-Line Treatment for Calcific Tendinosis of the Shoulder
Conservative management with NSAIDs and relative rest is the first-line treatment for symptomatic calcific tendinosis of the shoulder, as most patients with acute calcific tendinitis respond well to conservative therapy and rarely require surgery. 1
Initial Conservative Management
Begin with NSAIDs at maximum tolerated doses for short-term pain relief, though they do not alter long-term outcomes. 2, 3 Topical NSAIDs may provide comparable pain relief with fewer systemic side effects. 2, 3
Implement relative rest by reducing activities that aggravate symptoms, avoiding complete immobilization which can lead to muscle atrophy and deconditioning. 2, 3, 4
Apply ice through a wet towel for 10-minute periods to provide immediate short-term analgesia. 2, 4
Rehabilitation Protocol
Eccentric strengthening exercises are the cornerstone of treatment and have proven beneficial in reversing degenerative tendon changes. 2, 3, 4 Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 3
Deep transverse friction massage is recommended to reduce pain. 2, 3
When to Escalate Treatment
If conservative management fails after 3-6 months, consider advanced interventions before proceeding to surgery. 3, 1
Advanced Non-Surgical Options:
Corticosteroid injections provide better acute pain relief than oral NSAIDs but do not alter long-term outcomes. 2, 3, 4 These should be injected into the subacromial bursa, never directly into the tendon substance. 4
Ultrasound-guided percutaneous irrigation of calcific deposits (US-PICT) is an effective minimally invasive option. 5
Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathies, though it can be expensive. 2, 3, 4, 6
Critical Pitfalls to Avoid
Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment, as patients with acute calcific tendinitis respond well to conservative measures. 1, 7
Avoid multiple corticosteroid injections as they may weaken tendon structure despite providing short-term relief. 4
Be aware that calcific lesions >1 cm have a 2.8× increased likelihood of failing conservative treatment and may require earlier surgical consideration. 8
Recognize that most patients requiring surgical removal of calcium deposits (82.8%) will need concomitant rotator cuff repair, which is important for preoperative counseling. 8
Surgical Indications
Arthroscopic calcium removal with subacromial bursectomy is indicated when conservative management fails after 4-6 months of appropriate treatment. 1, 8, 7 Patients who undergo surgery demonstrate significant improvements in pain scores, shoulder function, and range of motion. 8