November 24, 2019
Management of Calcific Tendinopathy cover

Calcific Tendinopathy of the Rotator Cuff

Calcific tendinopathy refers to calcium deposits in tendons. By far, this occurs most commonly in the rotator cuff occurring in up to 20% of painful shoulders. There two primary mechanisms through which deposition occurs. One involves ‘calcific tendinitis’ where calcification occurs acutely within a healthy, well vascularized rotator cuff and tends to resolve spontaneously. The other, ‘dystrophic calcification’, occurs in non-viable, poorly vascularized cuff which worsens over time and is associated with other degenerative changes such as tears.
Management is generally conservative, although about ¼ of patients do not respond to non-operative management and require surgical intervention [1]. Initial therapy includes medications including NSAIDS, acetaminophen and topical medications including topical nitroglycerin or Glyceryl Trinitrate. Physical therapy is aimed at maintaining range of motion and strength of the rotator cuff. Corticosteroid injections (CSI) alone are controversial as this is generally not believed to be an inflammatory process with some studies showing positive, none or negative effects [2]. The role of CSI is probably in an acute, painful “attack” or flare.
There are a variety of other treatment modalities available. Therapeutic ultrasound and dry needling have been proposed although to date there is no published literature. Leduc et al found acetic acid iontophoresis combed with physical therapy was no different from physical therapy alone [3]. There is one case report of platelet rich plasma (PRP) which showed resolution of symptoms at 1 year after two injections [11], however no published studies yet exist.
extracorporeal shockwave therapy calcific tendinopathy

Image 1. Example of extracorporeal shockwave therapy (shockwave-therapy.co.uk)

Extracorporeal Shock Wave Therapy (ESWT) has been used to treat patients with calcific tendinitis. A systematic review found high-energy ESWT was effective for improving shoulder pain and function with two sessions to be most effective [4]. Another study compared ESWT to arthroscopy and found no difference in recurrence of calcium deposits or UCLA shoulder scale [5]. High energy ESWT appears to be better than low energy ESWT [6]. Complications include bone marrow edema, humeral head necrosis [7].
barbotage ultrasound calcific tendinopathy
Image 2. Demonstration of barbotage setup (adopted from youtube.com)
Ultrasound-guided needle lavage or barbotage is a technique that involves using ultrasound to guide a large-bore needle into the calcium deposits to break them up, irrigate and lavage them out of the pathologic tension. A systematic review found that it was safe with a high rate of success and low risk of complications [8]. There is some controversy in the literature about what size needle should be used and whether a 1- or 2- needle approach is superior. Following the procedure, corticosteroids can help with pain as supposed by a 2016 meta-analysis [9]. It is also worth noting that combining barbotage with ESWT was superior to ESWT alone [10].
Finally, surgical intervention is reserved for patients who fail conservative treatment. Predictors of failure include bilateral or large calcifications, deposits underlying the anterior third of the acromion, extension of calcific deposits medial to the acromion [12]. There is both an open and arthroscopic technique, although open has fallen out of favor. Patients respond well to arthroscopic removal of calcifications [13].
In summary, management of calcific tendinopathy of the rotator cuff provides some excellent non-surgical options including extracorporeal shock wave therapy and barbotage. Unproven techniques include therapeutic ultrasound and regenerative therapies such as platelet rich plasma. In patients who fail conservative measures, arthroscopy is an excellent surgical option.

References

1. Cho NS, Lee BG, Rhee YG: Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: Does the initial radiologic aspect affect the final results? J Shoulder Elbow Surg 2010;19(2):267–272.]
2. Merolla, Giovanni, et al. “Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment.” Journal of Orthopaedics and Traumatology 17.1 (2016): 7-14.
3. Leduc, Bernard E., et al. “Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial.” Archives of physical medicine and rehabilitation 84.10 (2003): 1523-1527.
4. Bannuru RR, Flavin NE, Vaysbrot E, Harvey W, McAlindon T. High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: a systematic review. Ann Intern Med. 2014;160:542–549.
5. Rebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. J Orthop Traumatol. 2008;9:179–185.
6. Peters J, Luboldt W, Schwarz W, Jacobi V, Herzog C, Vogl TJ: Extracorporeal shock wave therapy in calcific tendinitis of the shoulder. Skeletal Radiol 2004;33(12):712–718
7. Liu HM, Chao CM, Hsieh JY, Jiang CC. Humeral head osteonecrosis after extracorporeal shock-wave treatment for rotator cuff tendinopathy. A case report. J Bone Joint Surg Am. 2006;88:1353–1356.
8. Gatt DL, Charalambous CP. Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients. Arthroscopy. 2014;30:1166–1172.
9. Arirachakaran, Alisara, et al. “Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs.” European Journal of Orthopaedic Surgery & Traumatology 27.3 (2017): 381-390.
10. Peters J, Luboldt W, Schwarz W, Jacobi V, Herzog C, Vogl TJ: Extracorporeal shock wave therapy in calcific tendinitis of the shoulder. Skeletal Radiol 2004;33(12):712–718
11. Seijas R, Ares O, Alvarez P, et al. Platelet-rich plasma for calcific tendinitis of the shoulder: a case report. J Orthop Surg 2012; 20:126–130
12. Ogon P, Suedkamp NP, Jaeger M, Izadpanah K, Koestler W, Maier D: Prognostic factors in nonoperative therapy for chronic symptomatic calcific tendinitis of the shoulder. Arthritis Rheum 2009;60(10):2978–2984
13. El Shewy MT. Arthroscopic removal of calcium deposits of the rotator cuff: a 7-year follow-up. Am J Sports Med. 2011;39:1302–1305