What is the management of calcific tendinosis?

From the Guidelines

Calcific tendinosis management should prioritize conservative approaches, including relative rest, reduced activity, and eccentric strengthening exercises, as these methods promote healing and pain relief with minimal risk of adverse effects. When considering treatment options, it's essential to weigh the potential benefits and risks, focusing on minimizing morbidity, mortality, and improving quality of life. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief is supported by evidence, although they have no effect on long-term outcomes 1. Key considerations in managing calcific tendinosis include:

• Relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by the American Family Physician 1.
• Eccentric strengthening as an effective treatment that may reverse degenerative changes, with evidence rating B 1.
• Cryotherapy for acute relief of tendinopathy pain, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective, rated B 1.
• The potential use of locally injected corticosteroids for acute-phase pain relief, although they do not alter long-term outcomes, rated B 1.
• Extracorporeal shock wave therapy as a safe, noninvasive, and effective means of pain relief for chronic tendinopathies, rated B 1. Given the evidence, a multimodal approach incorporating these conservative measures should be the initial strategy for managing calcific tendinosis, reserving more invasive procedures like surgery for severe cases unresponsive to conservative treatment. It's also important to consider the natural course of calcific tendinosis, which may involve spontaneous resolution over time as the body reabsorbs calcium deposits, although this process can be prolonged 1. Ultimately, the goal of treatment should be to minimize pain, promote healing, and improve function, with a focus on evidence-based practices that prioritize patient outcomes and quality of life.

From the Research

Calcific Tendinosis Management

• Calcific tendinosis is a common cause of shoulder pain, and its management can be achieved through various conservative and surgical methods 2, 3.
• Conservative management techniques, such as therapeutic exercise, physical therapy, and medication, have been shown to be effective in improving pain and function, and facilitating a decrease in the size or presence of calcium deposits 2, 4.
• Ultrasound-guided needling with subacromial corticosteroid injection has been found to be more effective than extracorporeal shock wave therapy (ESWT) for function restoration and pain relief in patients with calcific tendinitis of the shoulder 5.
• A network meta-analysis of RCTs found that combined ultrasound-guided needling and subacromial corticosteroid injection significantly decreased shoulder pain, improved clinical outcomes, and decreased the size of calcium deposits, while also lowering risks of adverse events 6.
• The diagnosis of calcific tendinosis is typically confirmed with radiography, MRI, or ultrasound, and treatment options should be based on the stage of the calcium deposits and the patient's status in the healing continuum 3, 4.

Treatment Options

• Conservative treatment options include:
  • Therapeutic exercise and physical therapy to improve scapular mechanics and decrease dynamic impingement 2, 4
  • Nonsteroidal anti-inflammatory drugs and multiple modalities to manage pain and inflammation 4
  • Ultrasound-guided needle aspiration and lavage techniques to provide long-term improvement in pain and function 4
• Surgical treatment options may be necessary for patients with chronic calcific tendinitis who do not respond to conservative treatment 3

Clinical Outcomes

• Clinical improvement takes time, even after surgical treatment, and successful management of calcific tendinosis requires attention to outcomes and an understanding of the pathophysiology, prognostic factors, and physical interventions based on the current stage of the calcium deposits and the patient's status in the healing continuum 2, 3.
• The size and morphology of the deposits can be evaluated by radiography, and clinical outcomes can be assessed using various scoring systems, such as the American Shoulder and Elbow Surgeons assessment and the Simple Shoulder Test 5, 6.