eMedicine Specialties > Orthopedic Surgery > Systemic Diseases

Calcifying Tendonitis: Treatment

Author: Anthony H Woodward, MD, Consulting Surgeon, Department of Orthopedic Surgery, Private Practice
Contributor Information and Disclosures

Updated: Oct 23, 2007

Treatment

Medical Therapy

General considerations

Treatment of calcifying tendinitis varies with the clinical and radiologic phase of the calcification. Although the resorptive phase is usually self-limited, patient pain may be severe, and the need for relief may be urgent. Needling, aspiration, and lavage are more likely to be successful in this phase. In the formative or resting phases, symptoms are milder and chronic. Lavage is less likely to be successful; however, extracorporeal shock wave therapy (ECSW) may be indicated in this phase.

In a matched-pair analysis of 100 patients who were monitored for 3-5 years, Wittenberg et al demonstrated that operative treatment gave significantly better and faster pain relief, more resolution of the calcium deposits, and fewer rotator tears than conservative treatment.9

Nonoperative treatment is widely recommended and reported to be successful in most cases. For example, Wolk and Wittenberg reported that 70% of their 159 patients had a good result within 49 months after nonoperative treatment and that, by 104 months, the calcific deposits were no longer detectable by ultrasonography in 82% of cases.10

Medications

Analgesics of the appropriate strength are indicated. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed. The analgesic properties of these agents are presumably useful, but the effectiveness of their anti-inflammatory properties for treatment of calcifying tendinitis has not been established.

Physical therapy

Exercises are prescribed to maintain or regain the patient's shoulder range of motion and all muscle strength. Physical therapy modalities are frequently employed with unknown effectiveness. Such modalities include electroanalgesia, ice therapy, and heat. Ultrasound is ineffective according to a controlled study quoted by Perron and Malouin.11

Iontophoresis

Although uncontrolled studies of acetic acid iontophoresis have reported successful results, in a controlled study, acetic acid iontophoresis combined with ultrasound provided no better clinical results or shrinkage of the calcific deposits than did no treatment.11

Extracorporeal shock wave therapy

ECSW uses sound waves that are focused to a point within the target tissue. The mechanism of action of ECSW on calcifying tendinitis is unknown. It is probably not simply a mechanical disintegration of the calcific deposit; a tissue response is required to absorb the calcium deposit.

The results of ECSW depend on the energy of the waves and on the number of pulses. The optimal dose has not yet been established. The advantages of ECSW are its noninvasiveness and low complication rates, although hematomas develop in most patients (80% for all musculoskeletal areas). However, the procedure is painful, and the use of high-energy shock may require anesthesia.

Loew et al reported a large series of patients treated with ECSW, using either electrohydraulic or electromagnetic generators and different dosages.12 With different protocols, 30-70% of patients obtained pain relief, and in 20-77% of cases, the calcific deposit disappeared or disintegrated. The best results were observed following 2 applications of high-energy shock waves.12

Rompe et al reported that good or excellent results were achieved in 52% of patients who received low-energy ECSW and in 68% of those who received high-energy ECSW.13 Partial or complete disintegration of the calcific deposit was observed in 50% and 64% of patients receiving low- and high-energy ECSW, respectively. The higher energy could be applied only after regional anesthesia had been induced. Clinical results are significantly better if the calcific deposit disappears. Similarly, Seil et al obtained at least some resorption of the calcium deposits in patients given 2 low-energy applications (32%) and high-energy applications (48%) of ECSW.14

A meta-analysis of 24 papers by Heller and Niethard that reported the results of ECSW for a variety of musculoskeletal conditions, not just for calcifying tendinitis, suggested that ECSW was as effective as established methods of treatment.15

Injections, needling, and lavage

Breaking up the calcific deposits by repeatedly puncturing them with a needle, aspirating the calcific material, usually with the help of repeatedly injecting and aspirating saline, is a commonly advised treatment. Some operators use 2 needles to facilitate the lavage of the subacromial space. Arthroscopic treatment is similar. The deposit can be localized by fluoroscopy or by ultrasonography.

According to some reports, injection of a local anesthetic alone gives good results, as does needling. In one study, 13 of 23 patients obtained a good result from needling and aspiration; in another study, good results were achieved with needling and an injection of a corticosteroid. 

The use of corticosteroid injections is controversial. In separate reports, Harmon and Murnaghan found no difference in results, whether a corticosteroid was injected with the local anesthetic or not.16,17 There is some suggestion that a corticosteroid injection provides more prolonged analgesia following the injection.

Needling can be combined with lavage, in which the subacromial space is flushed with saline after the calcific deposits are broken up by repeated needling. Farin et al demonstrated excellent results with needling and lavage in 45 of 61 patients (74%) at 1-year follow-up.18 The calcification had disappeared or diminished in 74% of cases. Pfister and Gerber reported that this procedure was completed successfully in 76% of 62 shoulders in their case series, and it produced significant improvement.19

Radiotherapy

Historically, radiation therapy was used for calcifying tendinitis. In a controlled trial, no difference in results was demonstrated, whether or not a lead shutter was placed in front of the x-ray source. Due to its possible adverse consequences, radiation is no longer used to treat calcifying tendinitis.

Surgical Therapy

An open or an arthroscopic approach may be used for surgical treatment.20,21,22 An arthroscopic procedure provides a better cosmetic result and possibly a shorter rehabilitation,9 but arthroscopic localization of the calcific deposits is technically demanding. Preoperative ultrasonic localization and probing with a needle are helpful.23,24 Once the calcific deposit is localized, it can be needled and aspirated under arthroscopic control or teased out of the tendon with a hook through a longitudinal (coronal) incision in the tendon. The subacromial space is then thoroughly irrigated.

In an open procedure, the tendon is similarly incised, the deposit is curetted out, and adjacent tendon edges are debrided and, if necessary, reapproximated. Postoperatively, a sling is used for 3 days. Range-of-motion exercises are then started.

Gschwend reported eventual good arthroscopic results in 90% of cases.25 At an average of 4 years following open subacromial decompression and removal of the calcific deposit, 88% of 122 patients had good results.25 McKendry et al reported that 60% of patients were pain free 6 weeks following the operation, and 70% were pain free at 12 weeks.25

American and European multicenter experiences have revealed excellent results from arthroscopic treatment. The necessity for routinely adding acromioplasty is debated, but it has been reported that 10% of patients in whom acromioplasty was omitted later required a second operation.26

Complications

Calcification can recur following surgical treatment. Rupp et al reported a 16% incidence of recurrence,4 and Wittenberg et al reported an 18% incidence.9

More on Calcifying Tendonitis

Overview: Calcifying Tendonitis
Workup: Calcifying Tendonitis
Treatment: Calcifying Tendonitis
Follow-up: Calcifying Tendonitis
References
[ CLOSE WINDOW ]

References

  1. Gärtner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res. May 1990;254:111-20. [Medline].

  2. Riley GP, Harrall RL, Constant CR, Cawston TE, Hazleman BL. Prevalence and possible pathological significance of calcium phosphate salt accumulation in tendon matrix degeneration. Ann Rheum Dis. Feb 1996;55(2):109-15. [Medline]. [Full Text].

  3. Re LP Jr, Karzel RP. Management of rotator cuff calcifications. Orthop Clin North Am. Jan 1993;24(1):125-32. [Medline].

  4. Rupp S, Seil R, Kohn D. [Tendinosis calcarea of the rotator cuff] [German]. Orthopade. Oct 2000;29(10):852-67. [Medline].

  5. Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J Am Acad Orthop Surg. Jul 1997;5(4):183-191. [Medline].

  6. Farin PU. Consistency of rotator-cuff calcifications. Observations on plain radiography, sonography, computed tomography, and at needle treatment. Invest Radiol. May 1996;31(5):300-4. [Medline].

  7. Loew M, Sabo D, Mau H, Perlick L, Wehrle M. [Proton spin tomography imaging of the rotator cuff in calcific tendinitis of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1996;134(4):354-9. [Medline].

  8. Loew M, Sabo D, Wehrle M, Mau H. Relationship between calcifying tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. J Shoulder Elbow Surg. Jul-Aug 1996;5(4):314-9. [Medline].

  9. Wittenberg RH, Rubenthaler F, Wölk T, et al. Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients. Arch Orthop Trauma Surg. 2001;121(1-2):56-9. [Medline].

  10. Wölk T, Wittenberg RH. [Calcifying subacromial syndrome--clinical and ultrasound outcome of non-surgical therapy] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1997;135(5):451-7. [Medline].

  11. Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. Apr 1997;78(4):379-84. [Medline].

  12. Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. J Bone Joint Surg Br. Sep 1999;81(5):863-7. [Medline]. [Full Text].

  13. Rompe JD, Bürger R, Hopf C, Eysel P. Shoulder function after extracorporal shock wave therapy for calcific tendinitis. J Shoulder Elbow Surg. Sep-Oct 1998;7(5):505-9. [Medline].

  14. Seil R, Rupp S, Hammer DS, et al. [Extracorporeal shockwave therapy in tendionosis calcarea of the rotator cuff: comparison of different treatment protocols] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1999;137(4):310-5. [Medline].

  15. Heller KD, Niethard FU. [Using extracorporeal shockwave therapy in orthopedics--a meta-analysis] [German]. Z Orthop Ihre Grenzgeb. Sep-Oct 1998;136(5):390-401. [Medline].

  16. Henningan SP, Rome AA. Calcifying tendinitis. In: Ianotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Managament. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.

  17. Uhthoff HK, Sarkar K. Calcifying tendonitis. In: Rockwood CA, Matsen FA III, eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1990.

  18. Farin PU, Räsänen H, Jaroma H, Harju A. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage. Skeletal Radiol. Aug 1996;25(6):551-4. [Medline].

  19. Pfister J, Gerber H. Chronic calcifying tendinitis of the shoulder-therapy by percutaneous needle aspiration and lavage: a prospective open study of 62 shoulders. Clin Rheumatol. May 1997;16(3):269-74. [Medline].

  20. Boyer T. [Arthroscopic treatment of calcifying tendinitis of the rotator cuff] [French]. Chir Main. Nov 2006;25 Suppl 1:S29-35. [Medline].

  21. Jacobs R, Debeer P. Calcifying tendinitis of the rotator cuff: functional outcome after arthroscopic treatment. Acta Orthop Belg. Jun 2006;72(3):276-81. [Medline].

  22. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy. May 2006;22(5):521-7. [Medline].

  23. Kayser R, Hampf S, Seeber E, Heyde CE. Value of preoperative ultrasound marking of calcium deposits in patients who require surgical treatment of calcific tendinitis of the shoulder. Arthroscopy. Jan 2007;23(1):43-50. [Medline].

  24. Rupp S, Seil R, Kohn D. Preoperative ultrasonographic mapping of calcium deposits facilitates localization during arthroscopic surgery for calcifying tendinitis of the rotator cuff. Arthroscopy. Jul-Aug 1998;14(5):540-2. [Medline].

  25. Rubenthaler F, Wittenberg RH. [Intermediate-term follow-up of surgically managed tendinosis calcarea (calcifying subacromion syndrome--SAS) of the shoulder joint] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 1997;135(4):354-9. [Medline].

  26. Weber SC. Arthroscopic treatment of calcific tendonitis. Presented at: The 16th Annual Meeting of the San Diego Shoulder Arthroscopy Course; June 1999; San Diego, Calif.

  27. Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg. May-Jun 1998;7(3):213-7. [Medline].

  28. Albert JD, Meadeb J, Guggenbuhl P, et al. High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. J Bone Joint Surg Br. Mar 2007;89(3):335-41. [Medline].

  29. Sabeti M, Dorotka R, Goll A, Gruber M, Schatz KD. A comparison of two different treatments with navigated extracorporeal shock-wave therapy for calcifying tendinitis - a randomized controlled trial. Wien Klin Wochenschr. 2007;119(3-4):124-8. [Medline].

  30. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy. 1992;8(2):183-8. [Medline].

  31. Jim YF, Hsu HC, Chang CY, Wu JJ, Chang T. Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study. Skeletal Radiol. 1993;22(3):183-5. [Medline].

  32. Perlick L, Korth O, Wallny T, et al. [The mechanical effects of shock waves in extracorporeal shock wave treatment of calcific tendinitis--an in vitro model] [German]. Z Orthop Ihre Grenzgeb. Jan-Feb 1999;137(1):10-6. [Medline].

  33. Rompe JD, Zöllner J, Nafe B, Freitag C. [Significance of calcium deposit elimination in tendinosis calcarea of the shoulder] [German]. Z Orthop Ihre Grenzgeb. Jul-Aug 2000;138(4):335-9. [Medline].

  34. Sistermann R, Katthagen BD. [Complications, side-effects and contraindications in the use of medium and high-energy extracorporeal shock waves in orthopedics] [German]. Z Orthop Ihre Grenzgeb. Mar-Apr 1998;136(2):175-81. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

calcifying tendinitis, calcific tendinitis, calcified tendinitis, calcareous tendinitis, tendinosis calcarea, calcific tendinopathy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Anthony H Woodward, MD, Consulting Surgeon, Department of Orthopedic Surgery, Private Practice
Anthony H Woodward, MD is a member of the following medical societies: American Association of Orthopaedic Medicine and Oregon Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jegan Krishnan, MBBS, FRACS, PhD, Chair, Senior Clinical Director, Department of Orthopedic Surgery, Flinders Medical Centre and Repatriation General Hospital, Flinders University of South Australia
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul E Di Cesare, MD, Chair and Professor, Department of Orthopedic Surgery, University of California Davis School of Medicine
Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and Sigma Xi
Disclosure: stryker Consulting fee Consulting; smith and nephew Consulting fee Speaking and teaching

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.