Calcific Tendinitis of the Shoulder

Acute calcific bursitis/tendinitis
Patients presenting with this extremely painful syndrome require immediate treatment for pain relief. Modalities include:

• An intramuscular injection of narcotic, followed by oral analgesics and nonsteroidal anti-inflammatory medications.
• Ice.
• Sling for 1 or 2 days for pain.
• Subacromial cortico-steroi local anesthetic injection, to ameliorate the raging bursal inflammation.
• Gradual shoulder mobilization.

Since the calcification, noted at presentation, is likely in the resorptive phase and may resolve completely on its own, controversy exists over whether the subacromial injection should include a needling of the lesion under fluoroscopy in the acute phase. Generally this needling and lavage is reserved for more persistent symptoms in the subacute phase.

Subacute calcific tendinitis
One week to three to six months. Less severe inflammatory and/or mechanical inflammatory symptoms continue with persistent maturing calcification on x-ray.

Treatment is directed towards relieving the mechanical abutment of the calcium impinging on the acromion or coracoid and the inflammatory irritation of the still soft calcium leaking into the surrounding tissues. Physical therapy directed at scapulothoracic strengthening and acromial posture are extremely important at this juncture, along with continued oral anti-inflammatories. Other PT modalities such as electroanalgesia, heat, ice have shown unknown effectiveness. Ultrasound was found ineffective in a controlled study by Perron and Malouin. In a controlled study, acetic acid iontophoresis combined with ultrasound provided no better clinical result or shrinkage of calcium deposits than did no treatment. If symptoms persist after a well performed scapulothoracic strengthening program, therapy may need to be directed at the persistent calcification. Nonoperative techniques may be more utilized in the subacute phase and operative intervention in the more chronic cases.

Breaking up the calcific deposit by repeatedly puncturing it with a needle and aspirating and injecting saline under fluroscopic control has been commonly used in the past. Farin reported excellent results in 45 of 61 patients (74%) at one year follow up and resolved or diminished calcification in 74%. Pfister and Gerber reported 76% significant improvement in 62 shoulders.

More recently, extracorporeal shock wave therapy has been used in Europe, Australia and Canada to treat resistant calcific tendinitis in the shoulder. A review of five randomized controlled trials with both high and lower energy ESWT by the Australian Safety and Efficacy Register of New Interventional Procedures/Surgical showed improved functional assessment in all patient groups. Disintegration of calcium ranged from 32% to 77%, depending on the study group and the intensity of the ESWT. Although interesting and encouraging, the role of ESWT at this time for calcific tendinitis is unknown and awaits further study.

Chronic calcific tendinitis
Three to six months and unresponsive to conservative/nonoperative care.

These patients demonstrate persistent pain and persistent calcification in the subacromial space with associated mechanical symptoms. Correlation of the symptoms to the calcification can often be confirmed with an examination under fluroscopy.

Demonstration that the symptoms can be produced by abutment or impingement of the calcium on the acromion or coracoid, more readily leads to successful surgical results.

Ellmann et al reported on an international multicenter study to evaluate arthroscopic treatment of calcific tendinitis. Of 131 patients treated, the average global score was 69.4 out of a possible 75 with the nonoperative other shoulder rating 73.7. The good results had no correlation with age of the patient, size or type of calcification or duration of symptoms. There was no apparent benefit to acromioplaty in this series.

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7/8/2006

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