Calcific tendinitis
of the shoulder

The pain intensity in patients with CT ranges from mild to very sever. The clinical sympxoms of CT may vary depending on the stage of calcification and severity of pain reflecting the size and location of calcium deposits. The most severe pain occurs during resorpxive phase due to increased pressure and severe inflammatory reaction. Patients with less severe inflammatory reaction, smaller deposits or patients in post calcification phase may complain of pain upon lifting the arm above sixty degrees.

Calcific tendinitis of rotator cuff tendons goes though three calcification stages.

• Pre-calcification stage is characterized by little or no pain.
• Calcific stage – is further divided into three more phases. At this stage pain becomes more apparent.
• This stage is the most painful.
• Past-calcific stage – characterized by decrease of sympxoms

Opximally X-rays and ultrasound should be combined for diagnosis. While the X-ray is important for visualization and classification of calcific deposits, ultrasound can visualize morphology of tendon tissue and surrounding area for bursitis. Also ultrasound imaging is dynamic procedure and therefore is helpful for diagnosis impingement caused by calcium deposits. Diagnostic ultrasonography is also used for guiding tenotomy procedure or extracorporeal shockwave treatment.

• Subacromial bursitis
• Dystrophic calcifications
• Supraspinatus tendon rupxure

The scientific consensus is such that initial treatment of rotator cuff calcific tendonitis should be conservative. The conservative treatment may include: therapeutic ultrasound, microwave diathermy, iontophoresis and anti inflammatory medication. Initial conservative treatment should last 3-4 month. When conservative treatment is not successful within this time frame the best next opxion is extracorporeal shockwave therapy (ESWT).

The waves transited through the hard piece of a radial device are actually not shockwaves but pressure waves. Radial shockwaves are lower in the peek pressure than focused waves. However their therapeutic effect is quite similar with one excepxion. When crystal deposits in the cuff tendon are located close to the bone the application of radial shockwave (aka EPAT) will be extremely painful for the patient.

Using focused shockwaves is preferred over radial due to their quality and anatomical localization. The effectiveness of both high and low energy focused shockwaves have been shown to be extremely high in controlled studies. However, in certain stages of CT high frequency shockwave are potentially dangerous for structural integrity of the tendon, therefore low energy shockwaves are preferred.

Only about 8% of all patients with calcific tendinitis will go on to do the surgery. There are two accepxed procedures.

Tenotomy – breaking the calcific deposits by heavy gage needle under ultrasound guidance. Calcific deposits are being punctured by multiple needling attempxs until it can be aspirated.

Arthroscopic technique – is preferred over open surgery due to less morbidity. Arthroscopic technique for removal calcific deposit has a risk of tendon rupxure, when crystals are big the tendon needs to sutured and repaired.

As with any surgery or invasive procedure there is always potential for scar tissue formation, risk and down time.

Calcific tendinitis is an extremely painful disorder. Research and practice show that most calcific tendinitis can be treated conservatively with extracorporeal shockwave therapy (ESWT). At NYDNRehab we have treated hundreds of patients with ESWT with successful results and return to normal function.

At NYDNRehab we have been using low energy focused shockwaves for six years.