HOW I MANAGED TO TREAT MY SHOULDER CALCIFIED TENDINITIS

[Abstract]

Calcified tendinitis of the shoulder is a common disorder. Conservative treatment is usually successful. Anti inflammatory medication, physiotherapy, and range of motion exercise may help to speed the recovery of calcified tendinitis. This case was affecting the supraspinatus tendon; the calcification was diagnosed by the radiography and sonography. Monthly ultrasound showed the regression of the calcification size.

Conclusion;

It is possible to eliminate most of calcified tendinitis of the shoulder by combination of treatments that include physiotherapy / ultrasound therapy, massage therapy, anti-inflammatory medication and regular exercise (stretching) of shoulder muscles and tendons. It is difficult to completely eliminate the central part of the calcification as this part is the chronic calcified tendinitis that scared the tissue.

Keywords:

Calcified tendinitis, ultrasound, rotator cuff, and shoulder pain treatment

Introduction

Supraspinatus tendon might look normal (Figure 1) on ultrasound but it still contain small amount of calcium deposit. When the rotator cuff gets injured, the calcium deposits increases, sometimes in form of calcium phosphate and visible calcification in the form of crystalline hydroxypatite (1, 2). Calcification may be found in 1% of painful shoulders and in 3-20% of painless shoulder (3). Calcifying tendinitis is a morphological condition, it may be discovered by an imaging study and cause no symptoms; the Etiology is not fully understood (3, 4). (Figure 4)

Frequency

The incidence of rotator cuff calcification without shoulder symptom is 3-20% and the highest is found in age 30-50 years (4). The supraspinatus tendon is affected most often and although more than one tendon may be involved. Women are affected slightly more than men; housewives, clerical workers and sonographers have higher incidence of injury (4).

Patho-physiology

According to early hypothesis by Dr Codman, a combination of age-related tendon degeneration and repetitive movement injuries may be the cause of calcified tendinitis. Calcifying tendinitis occurs in viable healthy tissue, and dystrophic calcification appears in necrotic tissue (5).

Other researchers (Uhthoff and Loehr) proposed that calcifying tendinitis is a disease that progresses through correlating pathological and clinical stages (5).

• Formative Phase: A trigger of portion of the tendon undergoes fibro cartilaginous transformation and calcification occurs appears as chalk.
• Resting Phase: The calcify deposit enters a resting period. If large enough the deposit may cause mechanical symptoms.
• Re-absorptive Phase: An inflammatory reaction following shoulder injury, multinuclear giant cells and macro-phages (moncites and netrophils-WBC) absorb the deposit during this phase. The calcification now resembles tooth paste and sometimes it leaks into the subacromial bursa causing bursitis.

Post-calcify Phase: After the re absorption of the calcification fibroblast reconstitutes the collagen pattern of the tendon (5).

Pain in calcifying tendinitis (5)

The pain may be present in the following ways:

1. Chronic, mild pain with intermittent flares and the condition may be informative phase.
2. Mechanical symptoms may arise from a large calcify deposit which may block elevation of the shoulder.
3. Sever (acute) pain is attributed to the inflammatory response of the Re-absorptive phase.

Case Report

The author of this paper is the case study, male age 55. He practiced radiography from 1975 until 1985 and sonography from 1984 until this day. He is a right handed, 190 lbs with severe pain on his right shoulder and has restricted movement of the shoulder. The pain was constant and worsens during shoulder movement and at bed time. The physician suggested ultrasound of the shoulder to rule out rotate cuff injury. The physical examination revealed limitation of active and passive range of shoulder motion, mild tenderness on the greater tuberosity and the area of right supraspinatus tendon insertion. Right shoulder showed calcification in the supraspinatus tendon (figure 1). The pain was aggravated by elevation of the arm above shoulder level or by lying on the shoulder. The pains waken the patient from sleep in early stages, other complaints includes stiffness, snapping, weakness of right shoulder.

The pain increases from 70-110 0 arc of motion. The patient has a mild hypothyroidism and taken 0.025 mg lithotroxin since 2003. Parathyroid function tests was normal, (parathyroid gland is responsible of calcium regulating level in the body).

Plain x-rays

Demonstrate calcified deposits, right shoulder in true posterior (AP) and lateral views (Figure 2). The AP view with the shoulder in internal and external rotation and supraspinatus outlet views should be sufficient to demonstrate rotator cuff tendon calcification and that what the x-ray showed in this case (6).

• The patient refused the arthrogram procedure and needling to treat the calcification.
• The ultrasound examination was done by the patient as he is the only sonographer working in his area; he used L-12-5 MHz Philips transducer (IU22 ultrasound machine) to scan the supraspinatus, subcapsularis, and biceps tendons only. Calcification deposits was noted near the supraspinatus insertion, the calcification was tabulated monthly and measurement were taken at the same level using the same transducer each time. Sagittal, oblique and transverse sections of the right shoulder calcification were obtained and measured See (table 1), (Figures 4-10).

Result

At the first 6 months there was no change in the shoulder pain level as the patient still working from 8 am to 5 pm and that might be a contributing factor to the pain.

The diameter of the calcification in the right shoulder did not change but the length of the calcification started to reduce in size by 2 mm for the first 3 months then the diameter of the calcification started to reduce by rate of 1 to 2 mm a month. At the 8th month the pain was moderate and the range of shoulder motion improved, by the 11th month the pain was mild and almost full range of the shoulder was possible. By the 12th month the calcification reduced from 28 x 8 mm to 8 x 3 mm and by 16th month the calcification was 0.2 -0.4 in length x 0.1 mm in width.

Table 1

Right supraspinatus sonography: The measurement of the cluster calcification by millimeter

Pain level (1-very painful, 2-moderate, 3- minor pain)

 

Medications used:

The physician prescribed anti inflammatory pills. (Do not take any medication without asking your doctor first) . I am not a medical doctor.

Apo-Ketorolac (Torudol) 10 mg once a day for one month, and increase to 20 mg for 3 months, then medication switched to Diclofenac sodium (voltaren) 75 mg one pill every 12 hours for 3 months, and then one pill a day for 9 months.

These medications are non steroidal anti-inflammatory, analgesics pills (NSAIDS). The patient took 200 mg of ibuprofen pill daily in the afternoon with food.

The physician also requested a physiotherapy / ultrasound treatment. An assessment was done by the physiotherapist Mr. Joe Gerbrandtas he started 3 sessions a week for the first 2 months; each session was 20 minutes in duration included an therapeutic ultrasound for five minutes for 15 sessions, then light stretching and strengthening the shoulder muscles and was asked to do the stretching and exercise at home, twice a day 10 minutes each and increased to 20 minutes.

Physiotherapy:

The physiotherapist notes were documented and it reads “On examination no rotator cuff tear was present; however, impingement testing was positive. Shoulder movements revealed poor scapular muscle control and endurance. The scapula would “wing” when loaded in work related positions and impinge on the rotator cuff tendons by decreasing the acromio-humeral space. Internal rotation of the shoulder was also limited”

Physiotherapy treatment was focused on restoring scapular positioning to improve acromio-humeral space, thus lessening impingement on the rotator cuff. Good scapular control exercises include depression and retraction of the scapula and maintaining scapular position against the thoracic wall to prevent any winging thus reducing strain on the supraspinatus muscle. The sleeper stretch was used to restore internal rotation range of motion. Ice and therapeutic ultrasound were used to minimize swelling and pain. Since good scapular position is critical to recovery, cover roll tape was used to cue correct scapular position throughout the day

Physiotherapy exercise focused on trapezium (lower fibers) and serratus anterior strength and control. To strengthen the lower trapezium, prone and seated retraction (with depression) exercises were used to control winging of the scapula. To improve scapular position against the thorax, push-up plus exercises strengthened the serratus anterior muscle.

Discussion

The therapeutic sonography did not resolve the calcification it was helpful to tenderize the shoulder muscles and relive the pain. Treatment of calcifying tendinitis depends upon the phase of the calcification, some physician prefer needling aspiration, and lavage in Re-absorptive phase. In the chronic phase (formative or resting) and lavage is less likely to be successful; and physician may suggest extracorporeal shock wave therapy (ECSW) in this phase (6, 7), (Figure 3). Computed tomography (CT) scanning may be used to accurately localize the calcified deposit, but the radiation factor makes it unnecessary (6).

Magnetic resonance imaging (MRI) is one of the reliable modality for shoulder pathology. The calcify deposit causes decreased signal intensity on T1- weighted images and if edema is present around the calcification, increased signal intensity around the calcification present on T2-weighted images. MRI is not necessary to detect calcifying tendinitis, although it is accuracy is more than 95% (7, 8).

The extra-corporeal shock wave therapy (ECSW) uses sound waves that are focused to a point within the target tissues. The mechanism of (ECSW) action on calcification is to reduce the plaques to smaller clusters to be absorbed by the tissue and it is non invasive technology with low complication rates. The procedure is painful and may require anesthesia (9).

Surgical Therapy

An open or an arthroscopic approach may be used for the treatment of calcify tendinitis. A sling is used for 3 days, range of motion exercises are then started.

The use of ergonomically friendly sonography machine reduce repetitive injury, physio therapy with moderate stretching and exerciser and the use of anti-inflammatory medication can speedup recovery of calcified tendinitis. Message therapy can elevate the shoulder pain with the use of Diclofenac ointment rub while messaging the area. For most sonographers the calcium deposit most commonly develops in the supraspinatus tendon. Acute calcified tendinitis is usually signaled by the rapid onset of pain that is unrelated to shoulder position or activity. The cause of calcium deposits within the rotator cuff tendon is not entirely understood. The best treatment for shoulder pain for the patient was rest, ice and heat application after work, ointments rub with message therapy, mild stretching, and strengthening shoulder muscles, and the use of prescribed anti-inflammatory medications. Cortisone injection might be helpful for some people and in limited time but it is not advisable.

Self Care for shoulder tendinitis

The shoulder has the most freedom of movement of any joint in the body. This freedom is possible through an unstable joint that is supported by hard working rotator cuff muscles. These muscles originate from the various sides of the shoulder blade and wrap around the shoulder joint to form an adjustable but secure support for the shoulder joint.

When the rotator cuff muscles are weak, tense, tired or overworked, it is common for them to develop trigger points that can cause aching in the shoulder joint as well as pain and tenderness all the way down the arm. Trigger points can be worked out through precise, often slightly uncomfortable massage. Sometimes massage therapy and a bit of stretching is all that is required. The massage therapist and physiotherapist will assess and help you to overcome the pain. However, if the muscle has been overloaded for a long time or if the tendon of the muscle has become pinched or impinged within the shoulder joint then a broader set of interventions will be necessary. There must be precise therapy to the muscles that cross the joint as well as to the joint itself.

Once any impingement issues within the shoulder joint are resolved it is often necessary to strengthen the muscles of the shoulder joint. This is done through static and dynamic movements in which your hand or arm pushes in certain directions to create strength in the rotator cuff muscles. It is also common for rounded shoulder posture to set the stage for shoulder impingement and tendinitis. If this is the case you will have to stretch and strengthen certain muscles and become proactive at changing how you hold your body and how you use it for work and/or creation. Ask your physiotherapy department for brochure and stretching techniques to help your frozen shoulder, shoulder pain relief, impingement and joint loosening technique.

At the first 6 months there was no change in the shoulder pain level as the patient still working from 8 am to 5 pm and that might be a contributing factor to the pain.

The diameter of the calcification in the right shoulder did not change but the length of the calcification started to reduce in size by 2 mm for the first 3 months then the diameter of the calcification started to reduce by rate of 1 to 2 mm a month. At the 8th month the pain was moderate and the range of shoulder motion improved, by the 11th month the pain was mild and almost full range of the shoulder was possible. By the 12th month the calcification reduced from 28 x 8 mm to 8 x 3 mm and by 16th month the calcification was 0.2 -0.4 in length x0.1 mm in width.

The medication was reduced to 1 Diclofenac 75 mg pill a day and 200 mg ibuprofen a day. The physiotherapy stopped for the first 8 months, the stretching and home exercise continued. The author emphasis that you must check with your physician and the pharmacist regarding the adverse reaction of these medication on your stomach. If you have ulcer or allergic reaction you must find out before taking these drugs. The patient also was taken Robax (55 mg demothocarbomal) one pill a day in the first 6 months to help the lower back pain.

Conclusion

It is possible to eliminate most of calcified tendinitis of the shoulder by combination of treatments that include physiotherapy, massage therapy, anti-inflammatory medication and regular exercise (stretching) of shoulder muscles and tendons. It is difficult to completely eliminate the central part of the calcification as this part is the chronic calcified tendinitis that scared the tissue. In patients with symptomatic calcified tendinitis of the shoulder, ultrasound treatment helps resolve calcification and is associated with short-term clinical improvement.

References

1. Gartner J, and Simons B. “Analysis of calcific deposits in calcifying tendinitis.” Clin Orthop Relat Res (May 1990): 254: 111-20.

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Thank you for reading

Steve Ramsey, MSc -Medical Ultrasound, PhD- Public Health.

Calgary- Alberta.