Calcific tendinitis
of the shoulder

Symptoms

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.

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Incidence

Incidence of Calcific tendinitis of the shoulder is anywhere from 4-20%.

Etiology

The true cause of shoulder calcific tendinitis is unknown.

Cisease mechanism

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

Diagnosis

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.

Differential diagnosis

  • Subacromial bursitis
  • Dystrophic calcifications
  • Supraspinatus tendon rupxure

DIAGNOSTIC MUSCULOSKELETAL ULTRASONOGRAPHY AT NYDNREHAB

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At NYDNRehab we are experts in diagnostic musculoskeletal ultrasonography (MSUS). Our clinic features the highest resolution ultrasound machine available in NYC.

MSUS lets us not only visualize calcific deposits, but it allows us to measure tissue stiffness of the deposits using sonoelastography. The treatment choice often depends on the stage of tissue calcification.

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Please explore more advanced diagnostic option unavailable anywhere else:

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Treatment

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).

Extracorporeal shockwave therapy for calcific tendinitis of the shoulder

ESWT is a non-invasive treatment that delivers high frequency shockwave without breaking skin tissue barrier. Shockwaves are type of sonic waves that travel through the different tissue creating therapeutic affect at the interface of the tissue change such as with tendon to bone or muscle to bone connection. The shockwaves create revascularization of the damaged tissue by which healing is induced. Shockwave are also known to decrease pain signal transmission by their effect on small sensory nerves. It is hypothesized that in case of calcific tendinitis on top of above described effects shockwaves help to soften calcifications and disrupx connection of small nerves with calcified crystals.

Extracorporeal shockwave therapy for shoulder calcific tendinitis can come in three forms:

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Radial Shockwave Therapy

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.

Focused shockwaves

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.

Invaisive treatment options

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.

Surgical options

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.

Conclusion

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.

Treatment at NYDNREHAB

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

Dr.Kalika is a member of ISMST (international society for medical shockwaves) since 2004. We have successfully performed over five hundred procedures with very high rate of success.
130 West 42 Street Suite 1055, New York NY 10036

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

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Complete tear of rectus femoris
with large hematoma (blood)

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Separation of muscle ends due to tear elicited
on dynamic sonography examination

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