Approach Considerations
Conservative management is the first line of treatment. This includes analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), transcutaneous electrical nerve stimulation (TENS), corticosteroid injection, physical therapy, ultrasound-guided needling (UGN), and extracorporeal shock wave therapy (ESWT).
If conservative treatment modalities fail, surgical removal of the deposits is the remaining option. Failure of nonoperative therapy has been defined as persistence of symptomatic calcific tendinitis after a minimum of 6 months of nonoperative treatment. [16]
Medical Care
Conservative care
Symptomatic management may include analgesics of the appropriate strength (NSAIDs are often prescribed), physical therapy using cold or heat, exercises to maintain or restore the patient's shoulder range of motion and all muscle strength, and corticosteroid injections.
Ultrasound-guided needling is safe but has not been proven to be more effective than an ultrasound-guided subacromial corticosteroid injection. Yoo et al combined needle decompression with corticosteroid injection and reported that 25 of 35 shoulders showed improvement after 6 months. A poor result was associated with persistence of the calcific deposit. [17]
In one study of 125 patients treated nonoperatively, approximately 50% had obtained good clinical results after 6 months. [18] A prospective study in 420 patients with chronic calcifying tendinitis found that 27% had persistent symptoms after conservative treatment consisting of physical therapy, analgesics, NSAIDs, and corticosteroid injections. Higher failure rates correlated with bilateral disease, medial location of deposits, and larger deposits. [16]
A retrospective review of 159 patients determined that over 49 months, 70% of patients obtained good results after four different conservative treatment modalities. After an average of 9 years, 82% of calcific deposits were no longer visible on ultrasonography. [19]
Extracorporeal shock wave therapy
ESWT uses sound waves that are focused to a point within the target tissue. The results of one study demonstrated that positioning the shoulder in hyperextension and internal rotation during ESWT may be a useful technique to achieve resorption of calcific deposits. [20] ESWT with three-dimensional, computer-assisted navigation to localize calcific deposits provides significantly better results, compared with localization through patient-to-therapist feedback. [21]
The advantages of ESWT are its noninvasiveness and low complication rates, although hematomas develop in most patients (80% for all musculoskeletal areas). An assessment of minimally invasive treatments concluded that ESWT is safe and effective. [22] In a single-blind randomized study comparing ESWT with simulated treatment in 70 patients, ESWT provided a significant decrease in pain, while patients receiving sham treatments received no benefit. Complete resorption of the calcific deposit occurred in 31% of patients who received ESWT. [23] Earlier recovery makes ESWT 5-7 times more cost-effective than surgery.
ESWT is painful, however, and the use of high-energy shock may require anesthesia. Nevertheless, high-energy ESWT is the most thoroughly investigated minimally invasive treatment option. In the short term to midterm it has proved to be safe and effective. [22]
ESWT can use low energy (< 0.08 mJ/mm2) or high energy (> 0.28 mJ/mm2). Better results have been reported with high-energy therapy. In a randomized trial in 80 patients, symptoms were significantly improved with high-energy ESWT, whereas low-energy ESWT had no significant effect. [24] A meta-analysis of 5 randomized controlled trials concluded that high-energy ESWT provided better clinical and radiologic results than low-energy ESWT. [25]
ESWT compared with other treatments:
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TENS treatment: In a randomized trial comparing ESWT treatment in 33 shoulders with TENS treatment in 30 shoulders, both groups improved but ESWT was more effective. [26]
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Surgery: In a prospective study that compared surgical extirpation in 29 patients with ESWT in 50 patients, at 12 months good or excellent results were reported in 75% of operated patients versus 60% of those receiving ESWT. At 24 months, 90% of surgical patients had good or excellent results compared with 64% of those receiving ESWT. [27] In a retrospective comparison of arthroscopic extirpation in 22 cases and ESWT (0.10 to 0.13 mJ/mm 2) in 24 cases, University of California Los Angeles (UCLA) rating system scores and patient reports of excellent or good outcomes showed no significant differences at 24 months ( P = 0.38). [28]
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Kinesio taping: In a randomized controlled trial, ESWT followed by application of kinesio tape provided better improvement than ESWT alone at 12 weeks follow-up. [29]
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Needling: A prospective randomized controlled trial in 80 patients demonstrated greater symptomatic improvement with ultrasound-guided needling in combination with high-energy ESWT than with ESWT alone, after a mean of 4 months, with disappearance of the calcific deposit occurring in 60% versus 33% of shoulders, respectively. [30] A randomized controlled trial in 81 patients determined that ESWT and ultrasound-guided needling combined with subacromial corticosteroid injection were equally successful in relieving symptoms at 1-year follow-up, but calcification size decreased more after needling than after ESWT. [31]
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Ultrasound-guided percutaneous lavage: A meta-analysis of 8 randomized controlled trials with 617 cases provided limited evidence that lavage was superior to ESWT. [32]
Injections
Subacromial corticosteroid injections are often given for calcifying tendinitis. Yoo et al reported that 6 months after ultrasound-guided needle decompression and subacromial corticosteroid injection, 25 of 35 shoulders showed improvement. A poor result was associated with persistence of the calcific deposit. [17]
In a study by Cacchio et al that used injection of disodium ethylenediaminetetraacetic acid (EDTA) by phonophoresis in 40 patients, the visual analog scale (VAS) pain score fell from 7 pretreatment to 3 at 1 week; in the 40 patients who received a sham injectino, the VAS score remained at 7. At 1 year, the VAS score was 2 in the treatment group and still 7 in the control group. Calcification disappeared completely in 63% of the treatment group but in 0% of controls. [33]
Needling
Needling involves breaking up the calcific deposits by repeatedly puncturing them with a needle. The deposit can be localized by fluoroscopy or by ultrasonography. A systemic review of the efficacy of ultrasound-guided needling (UGN) concluded that, due to the variation in studies and the low quality of evidence, the efficacy of UGN could not be firmly established. [34]
In a prospective observational study, 86 patients were treated by ultrasound-guided percutaneous needling followed by corticosteroid injection. They were then advised to follow a specific rehabilitation protocol that focused on mobility, strength, and function. Subjects who performed exercises regularly after the procedure had a better result than those who were less compliant. [35]
Barbotage
Barbotage is a procedure in which saline is repeatedly injected then aspirated from the subacromial space in an attempt to wash out the calcific deposit. A meta-analysis of eight randomized controlled trials involving 617 cases indicated that ultrasound-guided percutaneous lavage provided better pain relief and clearance of the calcific deposit than ESWT. [32] In a case series by Pfister and Gerber, barbotage was completed successfully in 76% of 62 shoulders and produced significant improvement, with reduced pain intensity at 2- and 6-months follow-up. [36]
Farin et al reported on treatment of 61 shoulders by multiple punctures of the calcific deposit followed by lavage. One year later, clinical results were excellent in 74% and calcification had disappeared or decreased in size in 74%. [37]
Serafini et al reported reported a significant decrease in symptoms for 1 year after barbotage.in 219 patients, compared with 68 controls. At 5 years and 10 years, however, there was no difference between the two groups. [38]
Surgical Care
An open or an arthroscopic approach may be used for surgical treatment. [39, 40, 41, 42] Although favorable results have been described with open removal of calcific deposits, arthroscopy has become the preferred technique, yielding results similar to open surgery but with less morbidity. [1]
A study that compared arthroscopic needling with complete removal of the calcium deposit and tendon repair found both techniques effective in treating pain and in improving function in chronic calcifying tendinitis recalcitrant to conservative treatment. [43]
A systematic review of six studies involving 294 operated shoulders found no difference in outcome following acromioplasty with removal of calcific deposit, acromioplasty alone, or isolated removal of the calcific deposit. [44]
A study comparing 28 patients treated by arthroscopy with aspiration and lavage of deposits with 12 patients treated with arthroscopic complete excision and tendon repair found no difference between the two groups at 6 months and 12 months. Only a few patients had residual calcification—all of which was less than 10 mm—and there was no correlation between residual calcification of the tendon and Constant shoulder scores. [43]
In a retrospective review, 14 patients treated by arthroscopic curettage (eight had additional subacromial decompression) were followed for an average of 41 months. All patients improved; the average UCLA score postoperatively was 34, which is in the good/excellent category. Analysis of the results showed no difference with or without subacromial decompression. [45]
In a retrospective case series, 30 patients were followed on average for 3 years after arthroscopic removal of the calcific deposit. Pain decreased significantly, with mean VAS scores falling from 8.7 to 0.8. [46]
Maier et al followed 93 patients for a mean of 3 years after arthroscopic removal of a calcific deposit. An excellent clinical result was achieved in 90% of patients. Complete removal of the calcific deposit was achieved in 83%. [47]
A review by Porcellini et al of arthroscopic treatment in 95 shoulders of 63 patients found that at 24 months, outcome strongly correlated with the presence of residual calcium deposits; consequently, these authors recommend complete removal of residual calcium deposits in the tendon. [48] Other studies have found that the presence of some residual calcium deposits does not affect the clinical result. [47, 49]
Yoo et al treated 35 patients by complete removal of the calcific deposits. In 18 this resulted in a complete tear of the very rotator cuff tendon which was repaired with a suture anchor technique. Pain relief was achieved within six months for 30 patients. 10 patients developed secondary frozen shoulder. [50]
In a retrospective case series, 23 of 24 athletes treated with arthroscopic excision of the calcific deposit returned to sports at a mean of 5 months after their operation, all but one to competition at the same level. [51] When 54 of 58 patients treated by arthroscopic removal of calcific deposits were followed at intervals, maximum pain relief was achieved at 3 months by 31%, at 6 months by another 17%, at 9 months by another 20% and at 12 months by another 28%; 78% returned to work within 6 weeks. [41]
Arthroscopy compared to conservative treatment: Wittenberg et al. [8] in a study of 100 patients treated with surgery or conservative measures reported better outcome in patients treated with surgery. This study also showed that surgery group of patients treated surgically have earlier recovery - within 5 months average for ADLS in contrast with 20 months for patients treated conservatively.
Factors affecting surgical outcome include the following:
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Complete removal: most studies report better results with more complete removal of the calcific deposit.
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Subacromial decompression does not seem to be required.
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Excision of the calcific deposits may leave a defect in the rotator cuff that requires repair, and that may be followed by stiffness and slower recovery.
