Shockwave therapy for calcific shoulder tendonitis
Limited movement from calcific shoulder tendonitis can be incredibly painful, especially early in the morning.
Calcific shoulder tendonitis is caused by a small build-up of calcium deposits about 1-2 centimetres within the tendon of the rotator cuff, usually found in 30-40-year-olds and occur most in diabetic patients. Shockwave therapy for calcific shoulder tendonitis is a form of therapy which has begun to show some promising results in managing difficult to treat shoulder calcium deposits quickly and effectively.
This article examines calcific shoulder tendonitis and will help create a better understanding of the condition and some different ways of managing it to experience a pain-free life.
What is Calcific Shoulder Tendonitis/Tendinopathy?
When calcium deposits accumulate in the tendons of the shoulder muscles, this can lead to a condition called calcific shoulder tendonitis. The condition occurs around 90% of the time in the supraspinatus tendon. This means the symptoms are very specific and related to supraspinatus pathology, which can confuse things in the early clinical diagnosis.
Typically the condition occurs in women 60-77% of the time and is common around the age of 47 years old and in men it occurs later around the age of 51. It is not typically associated purely with trauma, rather the tenocyte necrosis is to blame for the resulting pathology. There is generally no systemic calcium or phosphorus abnormality in people suffering from calcific tendonitis, although - in those suffering from calcific tendonitis - there does appear to be a higher incidence of the HLA-A1 genotype.
The majority of the symptoms of calcific tendonitis are related to the pain of tendonitis. The pain of calcific tendonitis is said to increase dramatically at the start of the resorptive phase. The increased vascularisation and subsequent intratendinous pressure increase in the later stages are coupled with pain level increases.
Calcium deposits can be picked up on ultrasound scans, x-rays and MRI scans. Their appearance can be related to various stages of the disease process.
In stage 1 the calcium deposition appears as more cloudy in appearance.
Stage 2 calcium deposition is often more obvious to see as there are clearly defined margins of the calcium deposition within the tendon, and the density is also more homogenous.
In the final stages, calcium deposition is very well defined.
The resorptive phase and acute stages show a more hairy, irregular density of calcium. Tendinopathy of the supraspinatus tendon tends to occur in the critical zone, which lies between 1.25 and 2.5cm proximal to the insertion point. On the whole, this is due to changes in vascularisation in the tendon at this particular site.
This hypervascularised area tends to accumulate calcium deposits. Around 6.8% of patients with painful shoulders are actually caused by calcific shoulder tendonitis. Calcium deposits only tend to occur in degenerative tendons so the condition typically does not occur before the age of 40 years, however, it is not impossible.
There are typically 3 stages of calcific tendonitis.
Stage 1 The tenocytes are activated and result in MMP (Matrix metallo proteinase) release; this results in metaplastic changes in the tenocytes, resulting in the transformation to chondrocytes and then fibrocartilage.
Stage 2 During the calcific stage, calcium phosphate is deposited and then resorbed which leads to an increase in the regional vascularisation.
Stage 3 Usually the calcium is resorbed and the area is remodelled.
If the calcium does not go through the third stage it results in calcified deposits around the terminal end of the supraspinatus area.
The pathogenesis of historic hypoxia results in a hypoxic state and ultimately reduced circulation at the critical area.
The increased levels of calcium can result in compression of nearby structures such as the coracoacromial ligament.
Typically in about 9% of suffers, the calcific shoulder tendonitis can disappear altogether over a 3 year period.
During the acute phase, the symptoms can last between 2-3 weeks. Within the subacute phase, the symptoms can persist for around 8 weeks and in the chronic phase symptoms can go on for around 3 months.
What other treatments are available for calcific shoulder tendonitis?
90% of patients suffering from calcific shoulder tendonitis are treated conservatively. Conservative treatment includes;
Shockwave therapy
Physiotherapy
NSAID’s Needle acupuncture
Injection of local anaesthetics (corticosteroids)
Radiotherapy
Platelet-rich plasma (PRP) injections
Around 10% of clients do not respond to conservative treatment. If symptoms are progressive then surgery is recommended.
Progression normally comes in the form of the increased size of the calcium deposition and such increased pressure on surrounding structures.
Surgery is a reliable way of being able to remove large calcium deposits. Associated acromioplasty is often exercised to help with further decompression of the region.
Other treatments for calcific shoulder tendonitis include;
Shoulder surgery
How is Shockwave therapy for calcific shoulder tendonitis applied to the area?
Shockwave therapy for calcific shoulder tendonitis is applied following a set protocol.
The clinician will carry out a thorough case history taking which isolates the area that is painful and begins to understand the clinical history behind the condition.
It is important to make sure that the condition being treated is actually calcific shoulder tendonitis and is therefore treatable with shockwave therapy.
Around 75% of those treated with calcific shoulder tendonitis and shockwave therapy resolve in less than 6 months.
During the examination period, a tender point where the pain is maximal will be located, upon which a water-based medium will be applied.
This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your calcific shoulder tendonitis will begin.
At first, the clinician will ensure the discomfort is kept to a minimum.
After a while, as the impulses increase, and little pain is felt. However, more often than not, there is some pain felt over the area of application. After treatment, you should feel very little pain and this may last for a few days.
After this, an aching sensation can occur. After subsequent treatments, there will be a definite improvement in symptoms leading to a reduction in the original pain felt.
How long will Shockwave therapy for calcific shoulder tendonitis take to work?
Generally, most applications of shockwave for calcific shoulder tendonitis and most conditions will resolve within 3-4 sessions of 30 minutes (roughly).
This obviously can depend on the exact presentation of the condition. Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.
It is vital that you continue to work with a physical therapist to maintain the exercise regime you should already be carrying out for calcific shoulder tendonitis, prior to consulting for shockwave treatment.
This will involve balancing exercises, strength exercises and a good eccentric loading programme depending on your stage of calcific shoulder tendonitis.
What is the evidence for shockwave therapy and this condition?
Shockwave therapy for calcific shoulder tendonitis is a well-researched area with new research coming out all the time it clearly shows that there is a huge benefit to those suffering from calcific tendonitis.
Lee et al 2011 assessed the mid-term effectiveness of shockwave therapy in the management of chronic calcific shoulder tendonitis and realised its effectiveness in reducing pain and improving function in calcific shoulder tendonitis for up to a year after its application.
They concluded that shockwave therapy has minimal side effects and is less expensive than surgery.
For those suffering from conservative resistant tendonitis shockwave therapy was recommended before considering surgery.
Harniman et al (2004) concluded in a systematic review there was moderate evidence of high energy shockwave therapy in the management of calcific tendonitis.
Although, this and a study by Vavken et al (2009) did not look at the long term effects of shockwave therapy.
Other studies by Rompe have highlighted the benefits of shockwave therapy in the management of conservative therapy-resistant tendinopathy.
Where can I get some shockwave therapy for calcific shoulder tendonitis?
One is able to get Shockwave therapy for calcific shoulder tendonitis at a few specialist clinics in the UK. There are a growing number of clinics providing this specialist form of treatment.
It is beneficial to make certain the type of machine they use is a swiss dolor clast machine as this is the only one that has been tested to a high level in research papers.
At Perfect Balance Clinic, we often see people with different types of Tendinopathy who have tried other forms of treatment.
Shockwave for us has been the one form of treatment that has consistently delivered results for Tendinopathy.
How long will the Shockwave therapy for calcific shoulder tendonitis?
If everything goes to plan with your shockwave therapy for calcific shoulder tendonitis then the treatment should make a significant contribution to reducing the pain and improving the function of your calcific shoulder tendonitis.
In most cases, the shockwave will get rid of the calcific shoulder tendonitis. With some tendon surgery, there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result.
Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.
Conclusion
Shockwave therapy is an effective form of treatment for calcific shoulder tendonitis. It has very high success rates with very low risk of complication so is far more advantageous than surgery as a treatment modality in the management of persistent shoulder calcific tendonitis.
With a 90% chance of success (10% being still resistant and needing surgery), it is certainly a useful modality to consider.
For more information about Shockwave therapy for calcific shoulder tendonitis, book a consultation today
This article was written by our team of specialist therapists at Perfect Balance Clinic. If you would like more specific advice about how our team can help you with this condition or symptoms you may be having, please complete the contact form below and one of the team will get back to you shortly.
For more information on how Shockwave therapy can benefit your tendonitis please use the links below...
Shockwave therapy for Achilles Shockwave therapy for Plantar Fasciitis Shockwave therapy for Patellar Tendonitis Shockwave therapy for Greater trochanteric pain syndrome Shockwave therapy for Hamstring Tendinopathy Shockwave therapy for Calcific Shoulder Tendonitis Shockwave therapy for Tennis Elbow
References for Shockwave therapy for calcific shoulder tendonitis
Aina R, Cardinal E, Bureau NJ, Aubin B, Brassard P. Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique. Radiology 2001;221:455?61. Anitua E, Andia I, Ardanza B, Nurden P, Nurden AT. Autologous platelets as a source of proteins for healing and tissue regeneration. Thromb Haemost 2004;91:4?15. Anitua E, Sanchez M, Nurden AT, Nurden P, Orive G, And?a I. New insights into and novel applications for platelet-rich fibrin therapies. Trends Biotechnol 2006;24:227?34. Anitua E, Sanchez M, Orive G, Andia I. The potential impact of the preparation rich in growth factors (PRGF) in different medical fields. Biomaterials 2007;28:4551?60. Bateman JE. The neck and shoulder. Philadelphia: WB Saunders; 1978. Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12,122 shoulders. JAMA 1941;116:2477?82. Bosworth BM. Examination of the shoulder for calcium deposits. J Bone Joint Surg 1941;23:567?77. Brooks CH, Revell WJ, Heatley FW. A quantitative histological study of the vascularity of the rotator cuff tendon. J Bone Joint Surg Br 1992;74;151?3. Carlson ER. Bone grafting the jaws in the 21st century: the use of platelet-rich plasma and bone morphogenetic protein. Alpha Omegan 2000;93:26?30. De Morton NA. The PEDro scale is a valid measure of the method- ological quality of clinical trials: a demographic study. Aust J Physi- other 2009;55:129-33. De Palma AF, Kruper JS. Long-term study of shoulder joints afflicted with and treated for calcific tendinitis. Clin Orthop 1961;20:61?72. Farin PU, Rasanen H, Jaroma H, Harju A. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavege. Skeletal Radiol 1996;25:551?4. Faure G, Daculsi G. Calcific tendonitis: a review. Ann Rheum Dis 1983;42:49-53. Gartner J, Heyer A. Calcific tendinitis of the shoulder [in German]. Orthopade 1995;24:284?302. Gerdesmeyer L, Wagenpfeil S, Haake M, Maier M, Loew M, Wortler K, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA 2003;290:2573-80. Gschwend N, Scherer M, Lohr J. Tendinitis calcarea of shoulder joint [in German]. Orthopade 1981;10:196?205. Haake M, Deike B, Thon A, Schmitt J. Exact focusing of extracor- poreal shock wave therapy for calcifying tendinopathy. Clin Orthop Relat REs 2002;397:323-31. Haake M, Rautmann M, Wirth T. Assessment of the treatment costs of extracorporeal shock wave therapy versus surgical treat- ment for shoulder diseases. Int J Technol Assess Health Care 2001;17:612-7. Harmon PH. Methods and results in the treatment of 2,580 painful shoulders, with special reference to calcific tendinitis and the frozen shoulder. Am J Surg 1958;95:527?44. Hartig A, Huth F. Neue aspekte zur morphologie und therapie der tendinosis calcarea der schultergelenke. Arthoskopie 1995;8:117?22. Harvie P, Pollard TCB, Carr A. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg 2007;16: 169-73. doi:10.1016/j.jse.2006.06.007 Hearnden A, Desai A, Karmegam A, Flannery M. Extracorporeal shock wave therapy in chronic calcific tendonitis of the shoulderdis it effective? Acta Orthop Belgica 2009;75:25-31. Hsu CJ, Wang DY, Tseng KF, Fong YC, Hsu HC, Jim YF. Extracor- poreal shock wave therapy for calcifying tendinitis of the shoulder. J Shoulder Elbow Surg 2008;17:55-9. doi:10.1016/j.jse.2007.03.023 Hurt G, Baker CL Jr. Calcific tendinitis of the shoulder. Orthop Clin North Am 2003;34:567?75. Jerosch J, Strauss JM, Schmiel S. Arthroscopic therapy of tendinitis calcarea?acromioplasty or removal of calcium? [in German]. Unfallchirurg 1996;99:946?52. Kevy SV, Jacobson MS. Comparison of methods for point of care preparation of autologous platelet gel. J Extra Corpor Technol 2004;36:28?35. Lam F, Bhatia D, Rooyen KV, Beer JF. Modern management of calcifying tendonitis of the shoulder. Curr Orthop 2006;20:446-52. doi:10.1016/j.cuor.2006.09.005 Lippmann RK. Observations concerning the calcific cuff deposit. Clin Orthop 1961;20;49?60. Macnab I. Rotator cuff tendinitis. Ann R Coll Surg Engl 1973;53;271?87. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003;83:713-21. Maniscalco P, Gambera D, Lunati A, Vox G, Fossombroni V, Beretta R, et al. The ?Cascade? membrane: a new PRP device for tendon ruptures. Description and case report on rotator cuff tendon. Acta Biomed 2008;79:223?6. McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder. III. Observations on the pathology, course and treatment of calcific deposits. Ann Surg 1946;124:354?62. Merlin T, Weston A, Tooher R. Extending an evidence hierarchy to include topics other than treatment: revising the Australian ?levels of evidence.?. BMC Med Res Methodol 2009;9:34. doi:10.1186/1471- 2288-9-34 Milone FP, Copeland MM. Calcific tendinitis of the shoulder joint. Presentatin of 136 cases treated by irradiation. Am J Roentgenol Radium Ther Nucl Med 1961;85:901?13. Moseley HF. Shoulder lesions. 3rd ed. Edinburgh: Churchill Livingstone; 1960. Moseley HF. The results of nonoperative and operative treatment of calcified deposits. Surg Clin North Am 1963;43:1505? 6. Mouzopoulos G, Stamatakos M, Mouzopoulos D, Tzurbakis M. Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review. Skeletal Radiol 2007;36:803-11. doi:10.1007/ s00256-007-0297-3 Patterson RL, Darrach W. Treatment of acute bursitis by needle irrigation. J Bone Joint Surg 1937;19:993. Pfister J, Gerber H. Chronic calcifying tendinitis of the shoulder-therapy by percutaneous needle aspiration and lavage: a prospective open study of 62 shoulders. Clin Rheumatol 1997;16:269?74. Plenk HP. Calcifying tendinitis of the shoulder; a critical study of the value of x-ray therapy. Radiology 1952;59:384?9. Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disabil Rehabil 2008;30:1584?9. Rizzello G, Franceschi F, Longo UG, Ruzzini L, Meloni MC, Spiezia F, et al. Arthroscopic management of calcific tendinopathy of the shoulder: do we need to remove all the deposit? Bull NYU Hosp Jt Dis 2009;67:330?3. Rochwerger A, Franceschi JP, Viton JM, Roux H, Mattei JP. Surgical management of calcific tendinitis of the shoulder: an analysis of 26 cases. Clin Rheumatol 1999;18:313?6. Rompe JD, Rumler F, Hopf C, Nafe B, Heine J. Extracorporal shock wave therapy for calcifying tendinitis of the shoulder. Clin Orthop Relat Res 1995;321:196?201. Sanchez M, Anitua E, Cugat R, Azofra J, Guadilla J, Seijas R, et al. Nonunions treated with autologous preparation rich in growth factors. J Orthop Trauma 2009;23:52?9. Siegal DS, Wu JS, Newman JS, Del Cura JL, Hochman MG. Calcific tendinitis: a pictorial review. Can Assoc Radiol J 2009;60:263?72. Uhthoff HK, Dervin GF, Loehr JF. Tendinitis calcificante. In: The shoulder, 3rd Ed. Rockwood C Jr, Matsen FA III, Wirt MA, Lippitt SB, editors. New York: Elsevier; 2006. Uhthoff HK, Sarkar K, Hammond I. Significance of density and demarcation of calcifications in calcifying tendinitis [in German]. Radiologe 1982;22:170?4. Uhthoff HK. Calcifying tendinitis, an active cell-mediated calcification. Virchows Arch A Pathol Anat Histol 1975;366:51? 8. Weibrich G, Kleis WK, Hafner G, Hitzler WE. Growth factor levels in platelet-rich plasma and correlations with donor age, sex, and platelet count. J Craniomaxillofac Surg 2002;30:97?102. Weibrich G, Kleis WK. Curasan PRP kit vs. PCCS PRP system. Collection efficiency and platelet counts of two different methods for the preparation of platelet-rich plasma. Clin Oral Implants Res 2002;13:437?43. Welfling J, Kahn MF, Desroy M, Paolaggi JB, de Seze S. Calcifications of the shoulder. II. The disease of multiple tendinous calcifications [in French]. Rev Rheum Mal Osteoartic 1965;32:325?34. Whitman DH, Berry RL, Green DM. Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg 1997;55:1294?9. Wildemann B, Schmidmaier G, Ordel S, Stange R, Haas NP, Raschke M. Cell proliferation and differentiation during fracture healing are influenced by locally applied IGF-I and TGF-beta1: comparison of two proliferation markers, PCNA and BrdU. J Biomed Mater Res B Appl Biomater 2003;65:150?6. Yoo JC, Koh Kh, Park WH, Park JC, Kim SM, Yoon YC. The outcome of ultrasound-guided needle decompression and steroid injection in calcific tendinitis. J Shoulder Elbow Surg 2010;19:596?600.