Calcific tendonitis supraspinatus tendon
The incidence of calcification of the rotator cuff in the general population without shoulder symptoms is 3-20% according to different reports. The highest incidence is in adults aged 30-50 years. Among Europeans and Americans, no examples of patients older than 71 years were found, but a study of Taiwanese shoulders disclosed that most subjects were older than 60 years. American surgeons believe that the incidence of symptomatic calcifying tendinitis has declined in the last 20 years. The supraspinatus tendon is affected most often. Calcification is observed with decreasing frequency in the infraspinatus, teres minor, and subscapularis tendons. More than one tendon may be involved. Women are affected slightly more frequently than are men, and the right shoulder is affected slightly more often than is the left. Both shoulders had or developed calcific deposits in 13-47% of subjects. Housewives and clerical workers account for most cases. The cause of calcifying tendinitis is not known. It generally is agreed that it is not caused by trauma, and it rarely is part of a systemic disease. The pathophysiology of calcifying tendinitis is controversial. The early hypothesis of Codman and others was that calcification is a consequence of age-related tendon degeneration; however, this is not supported by the following observations: • The peak incidence of calcifying tendinitis occurs at an earlier age than that of degeneration (at least outside of Taiwan). The randomized, double-blind study was conducted in Vienna, Austria, and included 54 patients (61 shoulders). The diagnosis of calcific tendonitis was based on radiographic and ultrasonographic evidence of calcific tendonitis. The diameter of the calcification had to exceed 5 mm, and all patients had to have pain or restricted range of motion in the affected shoulder for at least four weeks. Exclusion criteria were a prior history of shoulder surgery, a corticosteroid injection within the past three months or the regular use of analgesics or anti-inflammatory drugs. Ultrasound therapy was administered five times per week for three weeks, followed by three times weekly for three weeks, for a total of 24 treatments. Each session lasted 15 minutes. The primary outcome of the study was a radiographic 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. Radiologic evaluation of the ultrasound group revealed that the calcium deposits had resolved in six shoulders (19 percent) and had decreased by at least 50 percent in nine shoulders (28 percent). In the sham 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 resolution 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. These findings are consistent with several other studies. The authors note that the way in which ultrasound stimulates resorption of calcium deposits is not known. It may increase blood flow and metabolism in the affected area, thus facilitating disintegration of calcium deposits. Your doctor's first goal will be to control your pain and inflammation. Initial treatment is likely to be rest and anti-inflammatory medication, such as ibuprofen. The anti-inflammatory medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone can be very effective at temporarily easing inflammation and swelling. When the calcium deposits are being reabsorbed, the pain can be especially bad. Your doctor may suggest trying to remove the calcium deposit by inserting two large needles into the area and rinsing with sterile saline. (Saline is simply a saltwater solution.) This procedure is called lavage. Sometimes lavage breaks the calcium particles loose. Then they can be removed with the needles. Getting rid of the calcium deposits can help speed up the healing. Even when lavage fails to remove calcium deposits, it reduces pressure in the tendon, leading to less pain. Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, therapy focuses on easing your pain and inflammation. Treatments may include heat or ice. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder. Later, strengthening exercises will help you improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities. You may need therapy treatments for up to six or eight weeks. Most patients are able to get back to their activities with full use of their arm within this time. the pain and loss of movement continue to get worse or interfere with your daily life, you may need surgery. Surgery for calcific tendonitis does not require patients to stay in the hospital overnight. It does require anesthesia. Most surgeries to correct calcific tendonitis of the shoulder are arthroscopic surgeries. The arthroscope is a special TV camera that can be inserted into the shoulder joint through a small incision in the skin. Other small incisions allow the surgeon to insert small surgical instruments into the joint as well. The surgeon uses the arthroscope to locate the calcium deposit in the rotator cuff tendon. Once the deposit is found, the surgeon uses the small instruments to remove the calcium deposits and rinse the area. Loose calcium crystals must be removed. They can be very irritating to the surrounding tissues. Extracorporeal shock wave lithotripsy (ESWT) may be an alternative to surgery. ESWT allows controlled sonic pulses of short duration to produce transient pressure disturbances in the shoulder with the aim of fragmenting deposits. The procedure aims to improve shoulder function and reduce pain. The mechanism of ESWT on calcifying tendonitis is unknown. ESWT is an established technique for the treatment of renal calculi and has since been used in orthopaedics. FLASH
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.
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