Calcifying Tendonitis Treatment & Management
- Author: Anthony H Woodward, MD; Chief Editor: Harris Gellman, MD more...
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.
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.
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.
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.
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.
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. 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.
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. 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.
The results of one study demonstrated that positioning the shoulder in hyperextension and internal rotation during ECSW therapy may be a useful technique to achieve resorption of calcific deposits.
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.
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.[26, 27] 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. 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.
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.
An open or an arthroscopic approach may be used for surgical treatment.[30, 31, 32, 33] An arthroscopic procedure provides a better cosmetic result and possibly a shorter rehabilitation, but arthroscopic localization of the calcific deposits is technically demanding. Preoperative ultrasonic localization and probing with a needle are helpful.[34, 35, 6] 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. At an average of 4 years following open subacromial decompression and removal of the calcific deposit, 88% of 122 patients had good results. McKendry et al reported that 60% of patients were pain free 6 weeks following the operation, and 70% were pain free at 12 weeks.
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.
Outcome and Prognosis
In general, it appears that the acute severe symptoms of calcifying tendinitis are likely to resolve spontaneously within 3 weeks. Chronic symptoms also tend to resolve over a period of months to a few years, although some have been reported to persist up to 15 years. Initially, asymptomatic shoulders with calcific deposits have been reported to become painful. This tendency for spontaneous recovery means that the effectiveness of any treatment can be established only with controlled trials.
A 2-year follow-up of 24 patients treated by arthroscopic subacromial decompression who had calcific deposits demonstrated that in 19 patients (79%), the calcific deposits became smaller, although they had not been touched. The postoperative clinical results of these patients were indistinguishable from those of matched patients without calcific deposits who underwent similar decompressions.
Future and Controversies
The role of ECSW for treating calcifying tendinitis is still being evaluated. To date, studies appear to indicate this technique is of value in alleviating the shoulder pain and loss of function caused by calcifying tendinitis.[39, 40]
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