Review Article

Calcific Tendinitis of the Rotator Cuff: Management Options Abstract Kentaro Suzuki, MD Aaron Potts, MD Oke Anakwenze, MD Anshu Singh, MD

Calcific tendinitis of the rotator cuff tendons is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. It is thought to be an active, cell-mediated process, although the exact pathophysiology remains unclear. Nonsurgical management continues to be the mainstay of treatment; most patients improve with modalities such as oral anti-inflammatory medication, physical therapy, and corticosteroid injections. Several options are available for patients who fail nonsurgical treatment, including extracorporeal shock wave therapy, ultrasound-guided needle lavage, and surgical débridement. These modalities alleviate pain by eliminating the calcific deposit, and several recent studies have demonstrated success with the use of these treatment options. Surgical management options include arthroscopic procedures to remove calcific deposits and subacromial decompression; however, the role of subacromial decompression and repair of rotator cuff defects created by removing these deposits remains controversial.

C From the Department of Orthopaedics, Kaiser Permanente Southern California, San Diego, CA. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Suzuki, Dr. Anakwenze, Dr. Potts, and Dr. Singh. J Am Acad Orthop Surg 2014;22: 707-717 http://dx.doi.org/10.5435/ JAAOS-22-11-707 Copyright 2014 by the American Academy of Orthopaedic Surgeons.

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alcific tendinitis is a common cause of shoulder pain that is believed to spontaneously improve over time in most cases. Its estimated prevalence in the population ranges from 2.7% to 20%.1,2 Although this condition is typically temporal in nature, pain and symptoms occasionally persist despite nonsurgical measures, and more aggressive management options become necessary. Over the past two decades, several nonsurgical treatments, including extracorporeal shock wave therapy (ESWT) and ultrasound-guided needle lavage (UGNL), have gained popularity. Although these techniques have been shown to be effective, their role in the treatment of calcific tendinitis has not been well defined. Surgical intervention remains a treatment option in refractory cases, although controversy exists regarding the optimal technique.

Epidemiology In a classic study of 6,061 office workers (12,122 shoulders), Bosworth1 found that the prevalence of calcific deposits in a population largely younger than 40 years was 2.7%. Thirty-five percent of the shoulders were symptomatic. Calcific tendinitis typically affects patients aged 30 to 60 years, and women are more commonly affected than men. The right shoulder is more frequently affected than the left, although calcific tendinitis can be present bilaterally.2 Based on radiographic and ultrasound studies, the supraspinatus tendon is most often involved.1,3-7 Although the exact etiology of calcific tendinitis remains unclear, studies have attempted to examine factors that may contribute to its development. Harvie et al8 studied the natural history of the condition and its

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Calcific Tendinitis of the Rotator Cuff: Management Options

Figure 1

Diagram representing the progressive stages of calcific tendinitis.

association with endocrine disorders. The authors found that the prevalence of concomitant endocrine disorders, particularly hypothyroidism, was high in patients with calcific tendinitis. The authors also reported that a high percentage of women (69%) in the study had also been treated for menstrual disorders, which suggests that estrogen may play a role in pathogenesis. Compared with patients without endocrine conditions, those with endocrine abnormalities developed symptoms of calcific tendinitis at a younger age, experienced symptoms for a longer duration, and eventually had a higher rate of surgery.

Pathogenesis The pathogenesis of the condition remains unclear, and different theories have been proposed. Calcific tendinitis should be differentiated from insertional calcific tendinitis, which is believed to be a degenerative process. Similarly, calcific tendinitis

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of the rotator cuff tendons is thought to have a different pathophysiologic mechanism than calcific tendinitis at other sites, such as the Achilles or patellar tendons.9 Although theories of a primarily degenerative etiology have been supported in the past, Uhthoff and Loehr3 described an active, cell-mediated process that is now widely accepted. Unlike previous theories in which a necrotic degenerative tendon eventually calcified, Uhthoff and Loehr3 described cartilage metaplasia as a reactionary process in an active biologic environment. They described three main stages of calcification: precalcific, calcific, and postcalcific. The calcific stage was subdivided into three separate phases: formative, resting, and resorptive (Figure 1). The precalcific stage consists of predominantly fibrocartilaginous metaplasia presumably within less vascular areas of the tendon. In the formative phase of the calcific stage, matrix vesicles unite to become calcific deposits that are separated by fibrocartilage or

fibrocollagenous tissue. The resting phase is noticeably dormant, with a lack of inflammation or vascular infiltration. Eventually, resorption occurs and correlates with the appearance of thinwalled vascular channels as well as macrophages and multinucleated giant cells. Following resorption, fibroblasts and granulation tissue appear in the previous site of the deposit.3,9 Tendon overuse may be a factor in the initial development of calcific tendinitis. In a rat model, Archambault et al10 found that the supraspinatus tendon had increased expression of cartilage genes when the tendon was subjected to overuse. Other basic science studies have focused on identifying the key molecular pathways involved in the pathogenesis of calcific tendinitis. Osteopontin, a glycoprotein important in mineralization and bone remodeling, has been found near areas of tendon calcification.11 Cathepsin K, a cysteine endopeptidase, has been identified in multinucleated cells present during resorption and suggests an osteoclastic remodeling process.12 Oliva et al9 found that the expression of transglutaminase 2, osteopontin, and cathepsin K was increased in calcific areas of the supraspinatus tendon. Their specific roles in the pathogenesis of the disease remain unclear. Calcific deposits consist of two different forms of hydroxyapatite: A type and B type.13 These forms are classified based on where the carbonate ion is located in the hydroxyapatite. The composition of an individual deposit can have a mixture of the two types, but each individual phase has a different composition of hydroxyapatite, reinforcing the existence of discrete stages in calcific tendinitis.

Clinical Presentation and Physical Examination Calcific tendinitis presents as shoulder pain that is similar to the clinical

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Kentaro Suzuki, MD, et al

presentation of subacromial impingement. Many patients with calcific tendinitis have decreased active range of motion (ROM) and have adjusted their shoulder mechanics to avoid pain. Scapular mechanics should be closely evaluated and dyskinesia should be addressed. Rotator cuff strength should be evaluated for possible tears. Given the high percentage of asymptomatic calcific deposits, other potential pathologies should be excluded before attributing symptoms solely to calcific tendinitis. The formative phase of calcific tendinitis is characterized by chronic pain. During this phase, deposits have been described as having a chalk-like appearance.14 Pain can vary during the resting phase, but it is often intense during the resorptive phase. During the resorptive phase, patients can present with acute onset of atraumatic shoulder pain that may mimic infection. At this stage, expression of deposits reveals a toothpaste-like material.3 The duration of each stage is highly variable.

Imaging Standard radiographic workup includes plain radiographs, including AP, supraspinatus outlet, and axillary views. Internal and external rotation views can be obtained to further characterize the location of the deposit. The typical calcific deposit will be approximately 1.5 to 2 cm from the insertion near the tendon’s critical zone, an area of decreased vascularity near the insertion of the superior rotator cuff15 (Figure 2). The calcification may be differentiated from dystrophic calcification, which occurs at the tendon’s insertion.3 CT can further characterize the three-dimensional shoulder anatomy but is rarely required for diagnosis of calcific tendinitis. In patients with refractory pain, MRI can be helpful for identifying concomitant November 2014, Vol 22, No 11

Figure 2

AP (A) and supraspinatus outlet (B) radiographs of the shoulder in a 56-yearold woman with refractory shoulder pain for 3 years. Large, dense, segmented calcification (arrows) is present in the superior aspect of the rotator cuff.

pathology (eg, rotator cuff tears) that may be contributing to symptoms. Calcific deposits have low signal intensity on all MRI sequences but can demonstrate surrounding edema on fluid-sensitive sequences (Figure 3). The classification systems described by Gärtner and Heyer16 and Molé et al17 are commonly used to categorize disease progression (Table 1). However, these systems demonstrated “insufficient reliability and reproducibility” in a clinical study of calcific tendinitis classification using radiographs and CT scans.18 On ultrasonography, calcific deposits appear hyperechoic. In patients with symptomatic calcific tendinitis, ultrasonography reveals large fragmented deposits, positive power Doppler signal, and widening of the subacromial bursal space.4 Arc-shaped calcified deposits correspond to a dense homogeneous and generally less syptomatic deposit, whereas non–arc-shaped deposits (fragmented/punctuate, nodular, and cystic) tend to be more painful but have a higher rate of spontaneous resorption, similar to Gärtner type II and III deposits.5

Management Nonsurgical Nonsurgical therapy is the mainstay of treatment for calcific tendinitis, with NSAIDs, physical therapy, and corticosteroid injections comprising firstline treatment. Ogon et al19 examined prognostic factors for nonsurgical management of calcific tendinitis in 488 shoulders in which initial nonsurgical therapy failed. The authors defined failure as persistent symptoms for at least 6 months, including 3 months of standardized treatment at their institution. The overall failure rate was 27%, and the probability of failure increased with bilateral or large calcifications, deposits underlying the anterior third of the acromion, and extension of the calcific deposits medial to the acromion. A Gärtner type III calcific deposit was a positive prognostic factor.19 Cho et al6 reported on 87 patients (92 shoulders) with calcific tendinopathy treated nonsurgically, with a mean follow-up of 16 months. Shoulder outcome scores improved, and 66 shoulders (72%) had good to excellent results after treatment with

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Calcific Tendinitis of the Rotator Cuff: Management Options

Figure 3

Coronal T1-weighted (A) and coronal T2-weighted fat-saturated (B) magnetic resonance images of the shoulder in the same patient shown in Figure 2. C, Sagittal T2-weighted fat-saturated magnetic resonance image demonstrating the segmental nature of the deposit and surrounding edema. The calcifications (arrows) have a dark appearance and are visible in the midsubstance of the tendons. Table 1 Common Classifications of Calcific Tendinitis Classification

Type

Description

Gärtner and Heyer16

I II II

Molé et al17 (French Society of Arthroscopy)

A B C D

Well circumscribed, dense Soft contour/dense or sharp/transparent Translucent and cloudy appearance without clear circumscription Dense, homogeneous, sharp contours Dense, segmented, sharp contours Heterogeneous, soft contours Dystrophic calcifications at the insertion of the rotator cuff tendons

only NSAIDs and passive ROM exercises. Deposits in 57 shoulders (62%) either disappeared or decreased in size. Extracorporeal Shock Wave Therapy ESWT has been used in other areas of the body and, over the past 20 years, has become increasingly popular for management of calcific tendinitis of the shoulder. In this treatment modality, a monophasic pressure pulse that has a high peak pressure and a short duration is produced and focused onto a small target via reflectors. The shock waves can be generated through elec-

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trohydraulic, electromagnetic, or piezoelectric mechanisms. The magnitude of the shock wave at its focal point is commonly measured by its energy flux density (EFD), which is frequently reported in millijoules per millimeter squared (mJ/mm2). The overall effect of ESWT is dependent on its EFD, the number of impulses, and distribution of energy. The mechanisms associated with the beneficial effects of ESWT in patients with calcific tendinitis are still being elucidated.20,21 Although the EFD appears to be a spectrum of energy, several efforts have been made to stratify the energy level into two or three groups. Cur-

rently, no consensus exists on what EFD corresponds to a low- or highenergy shock wave. In general, lowenergy shock waves have an EFD of ,0.08 to 0.12 mJ/mm2, whereas high-energy shock waves have an EFD of .0.12 mJ/mm2.20 The deposit can be localized with ultrasonography or fluoroscopy performed with the patient positioned supine, seated, or prone. The shock waves are directed at the deposit and administered according to manufacturer specifications. Local or systemic analgesics are often administered to patients treated with focused highenergy shock waves.

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Several studies on ESWT for management of calcific tendinitis of the rotator cuff have revealed significant variability in the EFD and the number of impulses and treatments performed.21-23 However, high-energy ESWT has been found to be an effective means of improving overall shoulder function and pain scores.21-23 Refractory calcific tendinitis outside the acute resorptive phase has demonstrated an improved response to ESWT compared with control treatments in studies with short- and medium-term follow-up. Short-term randomized studies of refractory calcific tendinitis treated with ESWT versus placebo treatment showed that patients had a dose-dependent improvement with ESWT.20,22 However, ESWT is not always completely curative, and additional long-term studies are required. In a study of 115 patients with calcific tendinitis treated with ESWT, Daecke et al24 found that, by 4 years after treatment, 20% of patients had undergone surgery on the affected shoulder. Several randomized controlled trials have compared high- and low-energy ESWT and placebo groups.25,26 Gerdesmeyer et al25 randomized 144 patients into three groups of 48 patients each. One group received highenergy (0.32 mJ/mm2) ESWT, one group received low-energy (0.08 MJ/ mm2) ESWT, and the last received a placebo. There was no significant difference in baseline Constant or visual analog scale (VAS) scores among the three groups. The two treatment arms each had two sessions of therapy and equivalent total cumulative energy doses. At 6 months, both the high- and low-energy groups had statistically significant and clinically relevant increases in Constant and VAS scores (P ,0.05) compared with those of the placebo group. The high-energy group substantially outperformed the low-energy group in terms of Constant and VAS scores (Constant score increases of 31 and November 2014, Vol 22, No 11

15 points, respectively, and VAS score decreases of 5.5 and 2.4, respectively). Calcific deposits decreased in size and had a higher rate of resorption in the high-energy group than in the low-energy or placebo groups. At 12 months, the scores of the high-energy group remained clinically (and statistically) superior to those of the lowenergy and placebo groups. There was no statistically significant difference in the scores of the low-energy and placebo groups.25 Peters et al26 reported similar results in a randomized controlled trial of 90 patients treated with high- or lowenergy ESWT or a placebo. The high-energy group required statistically fewer treatments compared with the low-energy group (mean, 1.2 versus 4.1) to relieve pain and restore mobility—a clinically relevant difference. However, the high-energy group reported a higher level of procedural pain than did the low-energy group (no procedural anesthesia required), and the placebo group reported no pain and no benefit from the procedure. Most studies demonstrate a correlation between increased effectiveness of treatment and decreased size of calcific deposits. In contrast, Albert et al21 demonstrated no significant change in resorption rates at a mean follow-up of 4 months in patients treated with high- or lowenergy ESWT. Despite the presence of remaining calcifications, the highenergy group still had statistically significant improvement in Constant scores (and increased pain during treatment) compared with the lowenergy group. In a recent metaanalysis, Ioppolo et al20 reported a higher rate of total and partial resorption of calcific deposits 6 months after ESWT compared with placebo treatment. Complications associated with ESWT have been reported, including pain during the procedure, particularly at higher EFDs. Local reactions, including petechiae, ecchymosis,

hematoma, and erythema, are the most commonly reported adverse reactions. Osteonecrosis of the humeral head associated with high-energy ESWT has also been described in case reports.21-27 Nevertheless, ESWT appears to be an effective, safe, and noninvasive means of managing calcific tendinitis that does not respond to standard nonsurgical treatment. However, limited data are available on long-term outcomes following treatment, and further elucidation is needed with regard to the dosage required for a beneficial effect.

Ultrasound-guided Needle Lavage UGNL is an increasingly popular option for persistent symptomatic calcific tendinitis because it is minimally invasive, effective, and inexpensive. The technique can be performed with the patient in a seated, recumbent, or supine position, using a combination of oral anti-inflammatory pain medication and a local anesthetic. The calcific deposit is localized with ultrasound, and local anesthesia is administered, typically into the subacromial bursa and the surrounding soft tissue. Under ultrasound guidance, a needle is introduced adjacent to or directly into the calcific deposit. Some studies have described the use of a single needle for aspiration and lavage,28,29 whereas others use two needles to maintain an outflow system for lavage.30 A small amount of saline or a mixture of anesthetic and saline is injected adjacent to the calcification, and calcific material is aspirated. Lavage continues until the irrigation is clear. Some authors describe puncturing multiple sites (needling) in an attempt to manually break up the calcific deposit,31,32 whereas others advocate keeping the needle in the same location28 to minimize potential damage to the rotator cuff. Following the procedure, the needle is frequently withdrawn into the subacromial bursa

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Calcific Tendinitis of the Rotator Cuff: Management Options

Table 2 Treatment Options for Calcific Tendinitis and the Associated Advantages, Disadvantages, and Controversies Treatment Extracorporeal shockwave therapy

Ultrasound-guided needle lavage

Surgery

Advantages Noninvasive, highest level of supporting evidence compared with placebo (multiple randomized controlled trials19,21,23,24 Inexpensive, well tolerated with minimal analgesia, mechanical breakdown of deposit Direct visualization of the deposit, direct removal or breakdown of the deposit, ability to address other pathology

under ultrasound guidance, and a steroid is injected. In the literature, controversy exists with regard to the size and number of needles that should be used, initial injection versus aspiration, and the effect of multiple perforations (Table 2). Patients are generally monitored for a short period of time and discharged with optional antiinflammatory medications. UGNL is typically well-tolerated, with pain usually decreasing within 48 hours. Reported complications include vagal/ syncopal reactions and limitations in motion. In a study of 67 patients treated with UGNL, del Cura et al28 reported that two patients had seizures during three syncopal reactions. The authors then began pretreating patients with a mild anxiolytic. Symptomatic bursitis can also occur several months after the procedure.30 Overall clinical outcomes after UGNL have been promising. However, conclusions that can be drawn from existing studies are limited because of the marked heterogeneity of the studied techniques. The outcomes appear to correlate with resolution or reduction of calcific deposits. Patients with type II or B-type calcific tendinitis

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Disadvantages

Controversies

Painful (analgesia often required), local reactions, potentially limited availability, and specialized equipment

Energy flux density, number of pulses, number of sessions

Operator-dependent, invasive, subacromial bursitis may develop postoperatively

Size and number of needles required, number of perforations of the rotator cuff required, the effect of multiple perforations Most invasive/expensive option, Residual calcification, longest recovery time, general subacromial decompression, rotator cuff repair anesthetic risks

(segmented deposits with a soft contour) have a higher rate of reduction/ elimination than do those with type I or A-type (dense and homogeneous deposits). In a recent randomized controlled trial, de Witte et al31 compared needle lavage and subacromial injection with subacromial injection alone and found that, although both groups demonstrated improvement, the needle lavage group had higher Constant scores, and the mean size of the calcification was smaller. After 6 months, 9 of 25 patients in the initial injection group elected to undergo needle lavage, and 2 proceeded with surgery, compared with 4 of 23 patients in the initial needle lavage group undergoing further treatment (3 repeat needle lavage, 1 surgery). Krasny et al32 compared UGNL and ESWT with ESWT alone in 2 groups of 40 patients each; they were scheduled to undergo arthroscopic removal of deposits in 6 months if treatment failed. At a 4-month follow-up, statistically and clinically significant improvement in Constant scores was reported in both groups, with the mean scores of the UGNL and ESWT group improving from 46.3 to 76.8 following treatment, and the scores of

the group treated with ESWT alone improving from 44.2 to 67.3. Compared with ESWT alone, UGNL and ESWT was associated with a statistically significant higher rate of deposit elimination (60% versus 32.5%), less pain during ESWT (VAS scores of 5.8 versus 8.3), and a lower final rate of arthroscopic surgery (20% versus 45%). UGNL is an effective, welltolerated, cost-effective procedure,30 making it a reasonable treatment option when less invasive options fail. Similar to many studies of ESWT, outcomes of UGNL are frequently difficult to interpret because spontaneous improvement is characteristic of the natural history of the disease.

Surgical Surgery has long been the treatment option of choice for recalcitrant shoulder pain related to calcific tendinitis. After nonsurgical measures have failed, open or arthroscopic procedures can be considered, although arthroscopy is currently the favored method because it is minimally invasive and provides results equivalent to those of open techniques.33 Several arthroscopic techniques have been

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used to address calcifications, including direct deposit removal and subacromial decompression. Calcification removal techniques vary with regard to the type of tendon incision and the instrumentation used to remove the deposit. Several studies have reported on the outcomes of arthroscopic removal of calcific deposits.34,35 In a study of 54 patients who underwent arthroscopic removal of calcific deposits, the overall results were successful; 92% of patients had excellent results at a 2-year follow-up.35 Currently, several controversies exist regarding surgical management of calcific tendinitis, including the extent of calcification removal, the long-term impact on the tendon, and when or if a subacromial decompression is beneficial. Additional high-quality studies on different treatments for calcific tendinitis are needed before conclusions can be drawn regarding their relative effectiveness.

Subacromial Decompression The role of subacromial decompression in the management of calcific tendinitis is controversial. Primary indications for the procedure include evidence of coracoacromial (CA) ligament fraying or erosions on the undersurface of the acromion.36 Porcellini et al37 found that an acromioplasty is frequently not required because removal of the deposit alone can often alleviate the symptoms of mechanical impingement. In a recent study, Maier et al38 evaluated 93 patients (99 shoulders) at an average 3-year follow-up after arthroscopic removal of calcific deposits without acromioplasty or rotator cuff repair. The authors reported that 91% of patients had good to excellent results. Marder et al39 performed a retrospective case-control study of 50 patients with calcific tendinitis treated surgically by two different surgeons. One cohort underwent acromioplasty November 2014, Vol 22, No 11

and subacromial decompression performed by one surgeon, whereas the second cohort underwent removal of the deposit alone performed by another surgeon. The average time to return to work was longer for the subacromial decompression group (18 weeks versus 11 weeks). Overall longterm outcomes were similar in both groups.

Residual Calcifications Many authors have found that residual calcifications do not have a negative impact on outcomes at final follow-up.35,38,40 In contrast, Porcellini et al37 found that patients with residual calcifications had a lower Constant score at 2- to 5-year follow-up (mean, 36 months), which suggests the need for maximal removal of calcifications. At follow-up, residual deposits that were present immediately after surgery tend to have resorbed or decreased in size, correlating with the natural history of the disease.35,37 Solid deposits are more difficult to remove, whereas softer deposits are more amenable to complete elimination.38 Even when complete removal of the deposit is attempted, the integrity of the tendon is rarely compromised. In a study of arthroscopic removal of calcific deposits of the rotator cuff, El Shewy’s41 criterion for tendon repair was the presence of a cuff defect that measured .50% of the cuff’s thickness, and he repaired only 2 of 56 tendons based on this criterion. At 7-year follow-up, only two tendons had required repair. In a study of calcific tendinitis of the shoulder treated arthroscopically, Balke et al36 reported that, postoperatively, 11 of 48 shoulders had partial-thickness tears of the supraspinatus tendon on ultrasonography. In a study of 54 patients with calcific tendinitis of the supraspinatus tendon, Seil et al35 reported that 36 patients (66%) had tendon changes (flattening or heterogeneous

appearance) at 2 years postoperatively but had excellent clinical results.

Senior Author’s Preferred Technique Patients are initially treated nonsurgically, with NSAIDs, physical therapy focused on ROM, and subacromial corticosteroid injections. They are also counseled about the natural history of the disease and told that peak pain and inflammation often occur during the acute resorptive phase. We recommend a 3- to 6-month period of nonsurgical treatment before considering more aggressive options. Based on the available literature, we cannot recommend UGNL over ESWT or vice versa because no direct comparative studies have been performed. If a 3-month course of conservative treatment fails, UGNL is offered. After preparation and injection of the subacromial space with 0.25% bupivacaine hydrochloride, an 18-gauge needle is passed into the calcific focus under ultrasound guidance. The calcific focus is pierced and aspirated approximately 3 to 5 times to manually break up the focus, aspirate the offending hydroxyapatite, and stimulate a healing response. If these measures fail after 6 months, an arthroscopic decompression is our treatment of choice. Surgery can be performed with the patient in the beach chair or lateral decubitus position, depending on surgeon preference. Supplemental regional anesthesia is frequently administered at our institution. The location of the deposit is examined on preoperative orthogonal radiographs, which frequently obviates the need for fluoroscopic localization intraoperatively. If the focus is small, such that localization will be difficult, a sterile fluoroscope is prepared and brought into the surgical field, and the focus is localized and tagged with a spinal needle prior to insertion of the arthroscope. A standard diagnostic arthroscopy is performed to exclude other

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Calcific Tendinitis of the Rotator Cuff: Management Options

Figure 4

A, Arthroscopic image of the shoulder demonstrating an intra-articular calcific deposit (CD) embedded in a tendon, with surrounding hyperemia. B, Arthroscopic image of the shoulder demonstrating an intra-articular CD with no evidence of a rotator cuff tear. C, Arthroscopic image of the subacromial space demonstrating penetration of the deposit with a spinal needle and the beginning of the classic “snowstorm” appearance, numerous small deposits being released into the subacromial space. The needle is used to subsequently lavage the deposit, with excellent expression of the calcification. D, Arthroscopic image demonstrating the previous location of the deposit following expression of the debris. The rotator cuff tendon is still largely intact. No repair was performed. AC = acromion, BT = biceps tendon, HH = humeral head, SS = supraspinatus

potential etiologies of the patient’s symptoms. If the deposit is visualized from the articular side, a passing suture is used to tag its location (Figure 4, A and B). If the deposit cannot be visualized, we proceed to the subacromial space. A probe is used to sound the tendon in the region of the deposit. A spinal needle is then used to penetrate the bursal side of the tendon in line with the fibers (Figure 4, C). The location of the deposit will influence the placement of the lateral portal to maximize visualization of the lesion. Care

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is taken while puncturing the tendon to avoid iatrogenic compromise and violation of the articular side of the tendon, which may seed the glenohumeral joint with inflammatory calcific deposits. A small linear incision is made in the tendon, and a probe or switching stick is used to release the deposit. We remove as much of the deposit as possible and then use an oscillating shaver attached to suction to eliminate floating debris (Figure 4, D). The integrity of the cuff is then examined, and a rotator cuff repair is performed,

if necessary. Typically, the deposits are present on the subacromial aspect of the tendon and frequently extend into the subacromial space. In general, we repair only fullthickness defects that violate the articular aspect of the tendon. The repairs tend to be single-row repairs because the defects are commonly small and V-shaped without the retraction encountered in degenerative or traumatic rotator cuff tears. The literature on rotator cuff repairs in the setting of calcific tendinitis is limited and suggests that repairs may increase the risk of postoperative stiffness and delay symptomatic improvement.7 Therefore, rotator cuff repair is reserved for situations in which the tear is likely to alter the mechanical function of the tendon. An acromioplasty is performed if there is evidence of mechanical irritation of the CA ligament or a large traction spur. Postoperative recovery consists of a sling for comfort and oral analgesics. Patients begin physical therapy early postoperatively and are allowed to start early active/passive ROM, with gradual return to activities as tolerated. Postoperative radiographs are frequently obtained at 1-month follow-up to monitor the progress of the calcification (Figure 5).

Comparative Studies Several studies have compared the effectiveness of surgery with that of other treatments. Wittenberg et al42 performed a matched-pair analysis of 100 patients who underwent surgical or nonsurgical treatment. During open surgery, the CA ligament was resected in every case and an acromioplasty was performed only 20% of the time. The authors found that patients in the surgical cohort demonstrated higher rates of satisfaction and functional scores at 3- to 5-year follow-up. The authors

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concluded that removal of the calcific deposit was an important part of the procedure. Rompe et al43 compared the use of surgery versus ESWT for management of calcific tendinitis. The surgery cohort included 29 patients treated with open procedures, and the ESWT group included 50 patients, with treatment selected based on an insurance company’s willingness to pay for ESWT. Only patients with Gärtner type I or II calcific tendinitis were included in the study. ESWT consisted of one treatment of 3,000 impulses at 0.60 mJ/mm2. Although the ESWT cohort had a quicker recovery and return to work, both groups had significant improvement at 1-year follow-up. At 2-year follow-up, patients who underwent surgery had higher University of California Los Angeles (UCLA) scores than did patients treated with ESWT. In addition, the rate of resorption was higher in patients with Gärtner type II deposits than in those with type I deposits. In patients with type II deposits, similar results were achieved with surgery and ESWT. However, in patients with type I deposits, surgery resulted in statistically and clinically superior results, with 75% and 92% good to excellent results compared with 48% and 53% good to excellent results with ESWT at 1- and 2-year followup, respectively. Several studies have reported on the outcomes of arthroscopic removal of calcific deposits.34,35 Rebuzzi et al34 compared arthroscopic surgery with ESWT for management of chronic calcific tendinitis of the shoulder. Arthroscopic removal of calcifications was performed in 22 cases and ESWT was performed in 24 cases, with treatment determined by insurance company reimbursement. ESWT consisted of an average of three sessions of 1,500 pulses at an EFD of 0.10 to 0.13 mJ/mm2. At 2-year follow-up, there was substantial November 2014, Vol 22, No 11

Figure 5

AP (A) and supraspinatus outlet (B) radiographs of the shoulder obtained 2.5 months following surgery demonstrating near complete resolution of the calcification. The patient’s pain improved significantly.

improvement in the UCLA scores in both groups, with the amount of resorption correlating with the overall patient outcome. The authors concluded that the two treatments result in equivalent outcomes. However, the study was limited by the small number of cases, the near significant difference in the starting groups (P = 0.09 for initial UCLA scores, indicating the two groups may not be completely similar), and the lack of a power analysis.

Summary Calcific tendinitis is frequently encountered by musculoskeletal specialists. The initial treatment is nonsurgical, and patients should be educated about the condition. The natural history of improvement over time is a significant confounder of the available clinical studies because the results frequently depend on the stage of the disease and the period of followup. Further elucidation of the mechanisms behind the disease process is necessary to guide treatment strate-

gies. Large, well-designed, controlled studies that compare treatment options during similar stages of disease are necessary to draw conclusions regarding optimal treatment.

References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 19, 21, 23, 25, 26, 31, and 32 are level I studies. References 5, 6, 8, 20, 22, 24, 30, 33, and 43 are level II studies. References 1, 4, 7, 34, 39, and 42 are level III studies. References 5, 28, 29, 35-38, 40, and 41 are level IV studies. Reference 27 is level V expert opinion. References printed in bold type are those published within the past 5 years. 1. Bosworth BM: Calcium deposits in the shoulder and subacromial bursitis: A survey of 12,122 shoulders. JAMA 1941;116(22): 2477-2482. 2. Speed CA, Hazleman BL: Calcific tendinitis of the shoulder. N Engl J Med 1999;340 (20):1582-1584. 3. Uhthoff HK, Loehr JW: Calcific tendinopathy of the rotator cuff: Pathogenesis, diagnosis,

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Calcific tendinitis of the rotator cuff: management options.

Calcific tendinitis of the rotator cuff tendons is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain...
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