Calcific tendonitis supraspinatus tendon
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Calcifying tendinitis is a relatively common problem. It is usually picked up on imaging studies. It can also be diagnosed by direct inspection at the time of arthroscopy.
Calcifying tendinitis may be an incidental finding in an otherwise asymptomatic shoulder. However, it may also be the cause of severe shoulder pain.
Calcific deposits are found in 3-20% of painless shoulders and 7% of painful shoulders; this suggests that calcification may not necessarily be the exact cause of pain in a painful shoulder.
The supraspinatus tendon is affected most frequently. Calcification is seen with decreasing frequency in the infraspinatus, teres minor, and subscapularis tendons. Also, more than one tendon may be involved. Genderwise, women are affected slightly more frequently than are men, and the right shoulder is affected slightly more often than is the left. Why this is the case is still a subject of debate. Both shoulders can have calcific deposits in 13-47% of people.
According to most studies, housewives and clerical workers account for most cases.
The calcific deposit is usually situated 1-2 cm proximal to the tendon insertion on the greater tuberosity.
The cause of calcifying tendinitis is not known.
Calcifying tendinitis, in contrast to degenerative tendinopathy, may resolve spontaneously.
Interestingly, calcifying tendinitis is not often associated with rotator cuff tears.
Treatment includes anti-inflammatory drugs, glucocorticoid injections, percutaneous needle aspiration, and surgery. Ultrasound therapy is sometimes used for a number of painful musculoskeletal disorders.
Ebenbichler and colleagues conducted a placebo-controlled study to evaluate the efficacy of pulse ultrasound therapy for calcific tendonitis.
The randomized, double-blind study was conducted in Vienna, Austria, and included 54 patients (61 shoulders). The diagnosis of calcific tendonitis was based on x-ray and ultrasound evidence of calcific tendonitis.
The primary outcome of the study was an x-ray change in the calcium deposits at the end of the 24 treatments and at a nine-month follow-up visit. Secondary outcomes included an assessment of pain in the shoulder, active range of motion, strength of the shoulder and the patient's ability to perform activities of daily living. A pain score was also used to evaluate outcome.
The ultrasound therapy group included 32 shoulders, and the sham treatment group included 29 shoulders. The mean age of patients in the ultrasound group was 49 years and the mean age of those in the sham group was 54 years.
The ultrasound group had calcium deposits resolved in six shoulders (19 percent) and were decreased by at least 50 percent in nine shoulders (28 percent). In the placebo treatment group, calcium deposits did not resolve in any patient and decreased by at least 50 percent in three (10 percent) of the shoulders. At the nine-month follow-up evaluation, calcium deposits had resolved in 13 (42 percent) of the shoulders in the ultrasound treatment group. An additional seven shoulders (23 percent) were found to demonstrate improvement. In contrast, in the sham treatment group dissolution of the deposits occurred in two shoulders (8 percent) and improvement was noted in three shoulders (12 percent).
Clinical improvement was significantly more common in the ultrasound therapy group than in the sham treatment group. Twenty-nine shoulders (91 percent) in the ultrasound group demonstrated improvement, compared with 15 shoulders (52 percent) in the sham treatment group. The ultrasound group had a greater decrease in pain and more improvement in quality of life.
The authors conclude that ultrasound therapy is of definite benefit in patients with symptomatic calcific tendonitis. It helps eliminate the calcifications and provides at least short-term symptomatic relief.
The other therapy that has been studied is the use of ultrasound guided percutaneous needle lavage. This minimally invasive treatment appears to be very effective with results better than that seen using ultrasound treatment.
Removal of the calcium deposits is accomplished by inserting two into the area and rinsing with sterile saline. Lavage breaks the calcium particles loose. Then they can be removed with the needles. Getting rid of the calcium deposits speeds up the healing.
Extracorporeal shock wave lithotripsy (ESWT) may be also be an alternative to surgery. ESWT uses sonic pulses of short duration to "pulvere" deposits. ESWT is an established technique for the treatment of renal calculi and has since been used in orthopaedics.
Physical therapy can be instituted after any of these treatments to improve the range of motion in the shoulder. Strengthening exercises will help improve strength of the rotator cuff.
A truly effective treatment for tendonitis is available in the form of percutaneous needle tenotomy with autologous tissue grafting. This is a minimally invasive procedure using a small needle with ultrasound guidance. Blood is drawn from a patient and spun in a special centrifuge in order to harvest the platelet rich plasma component. Platelets are cells that contain multiple growth and healing factors. The patient then has the skin over the inflamed bursa anesthetized with local lidocaine. A small needle is introduced into the bursa and multiple tiny holes are made. The platelet rich plasma is then injected. Healing then occurs.
Most surgeries to correct calcific tendonitis of the shoulder are arthroscopic surgeries.
In rare instances, open surgery is necessary. In open surgery, the doctor gets to the calcium deposit by cutting through muscles and other surrounding tissues. The tendon itself is then cut to allow removal of the calcium deposits. The doctor then rinses the area to get rid of calcium crystals and stitches the muscles and skin together.
Visit our sister site to learn the latest in tendonitis treatment.
Tendonitis and PRP a site that discusses the use of platelet-rich plasma for the treatment of tendon injuries.
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