INJECTION THERAPY FOR CALCIFIC TENDINOPATHY

What is calcific tendinopathy (also known as calcific tendinitis)?

Calcific tendinopathy, commonly known as calcific tendinitis, is characterised by rapid onset, intense shoulder pain that can radiate down the arm and keep you awake at night. It usually begins without warning and causes severe movement restrictions in all directions. The supraspinatus tendon is the most prevalent site of calcific tendinopathy. An ultrasound scan is used to diagnose it. An MRI or x-ray are not required. Rest and anti-inflammatories are the best treatments for calcific tendinopathy. If the pain persists, an ultrasound-guided steroid injection and/or barbotage and lavage operation are quite beneficial.

What are the symptoms of calcific tendinopathy?

The symptoms of calcific tendinopathy are:

  • Severe discomfort in the shoulder and arm that appears out of nowhere.
  • Pain that restricts movement and makes it impossible to move the arm.
  • Pain that is more intense in the mornings and keeps you up at night.

What conditions can be mistaken for calcific tendinopathy?

If this does not seem like your problem, there are a number of different disorders that can cause discomfort similar to calcific tendonopathy, including:

  1. acromio-clavicular (AC) joint osteoarthritis
  2. frozen shoulder
  3. shoulder impingement
  4. rotator cuff pain
  5. sub-acromial bursitis
  6. shoulder joint osteoarthritis

Calcific tendinopathy vs frozen shoulder

Calcific tendinopathy is more common in younger age groups, often 20–40 years old, whereas frozen shoulder affects people in their 40s and 60s virtually entirely. Calcific tendonopathy and frozen shoulder can produce acute pain, especially at night, as well as a restriction in arm movement. The development of calcific tendinopathy is abrupt and acute, whereas the onset of frozen shoulder is gradual. acromioclavicular (AC) joint pain is exacerbated by movement across the midline of the body, such as moving your arm across your neck.

Anatomy

Shoulder issues are a very prevalent source of discomfort in people of all ages. According to studies, up to one-third of people will experience shoulder pain at some point in their lives (Dong et al., 2015).

Shoulder impingement syndrome, which accounts for more than 65 percent of shoulder pathologies, is the most common cause of shoulder pain (Dong et al., 2015).

Shoulder calcific tendinopathy is a prevalent and excruciating disorder. According to Chianca et al., (2018), calcific tendinopathy affects 2.5 percent to 7.5 percent of healthy adult shoulders, with 20% of cases being asymptomatic. According to studies, up to 20% of patients with calcific tendinopathy had bilateral (both sides) calcifications. Calcific tendinopathy can affect any part of the rotator cuff, with the supraspinatus tendon accounting for 80% of cases, the infraspinatus tendon for 15%, and the subscapularis tendon for 5%. (see below image). Calcific tendinopathy of the shoulder is most common in people in their fourth and fifth decades of life, with women accounting for 70% of cases.

Medical experts frequently use the phrase shoulder impingement to describe pain caused by the rotator cuff tendons or the surrounding bursa (small fluid filled sacs used to reduce friction during movement).

Shoulder impingement symptoms can be caused by a variety of conditions. These are some of them:

  • Calcific tendinopathy – the focus of this article
  • Rotator cuff tendinitis/tendinopathy
  • Rotator cuff tears (partial or full)
  • Subacromial bursitis
  • Long head of bicep tendinitis/tendinopathy
ultrasound-guided_injection_shoulder_rotator-cuff

The following are some of the symptoms of calcific tendinopathy of the shoulder:

  • Acute or severe discomfort on the side of your shoulder that may radiate down to your elbow.
  • Pain that appears out of nowhere.
  • When you lift your arm, especially overhead or away from your body, the pain gets greater.
  • The pain is more intense at night. This may interfere with your ability to sleep or wake up.
  • Feelings of heaviness in your arm
  • Objects such as shopping bags can be uncomfortable to lift and carry.

What causes calcific tendinopathy?

Unfortunately, the aetiology of calcific tendinopathy is unknown, but it is thought to be induced by the change of tenocytes (tendon-producing cells) into chondrocytes (cells used to produce cartilage). Calcium is deposited within the tendon as a result of this (Chianca et al., 2018).

Chianca et al., (2018) disused the synthesis of calcium within a tendon, dividing its pathophysiology into three separate stages:

  1. Stage before calcification. Tenocyte cells are transformed into a fibrocartilage substance before being transformed into a calcific deposit at this stage.
  2. Stage of calcification. Increased pressure within the tendon causes inflammation and severe, acute pain during this phase. Conservative treatment, such as non-steroidal medications, is frequently ineffective during this stage.
  3. Stage after calcification. The calcific deposits within the tendon are reabsorbed during the post-calcific phase through a process known as remodelling. It may take several months to finish this task.

How is calcific tendinopathy diagnosed?

Although a physiotherapist can make a clinical diagnosis of shoulder impingement syndrome, a clinical examination alone cannot accurately detect calcific tendinopathy.

To get a complete and thorough diagnosis of the reason of your shoulder pain, you’ll need a diagnostic ultrasound scan. It is critical to have a precise diagnosis so that the most appropriate and effective treatment strategy may be implemented.

frozen-shoulder-treatment

Diagnostic musculoskeletal ultrasound

In the diagnosis of calcific tendinopathy, diagnostic ultrasound imaging is superior to magnetic resonance imaging (MRI) (Ardic et al., 2006, Chianca et al., 2018). Ultrasound imaging of the musculoskeletal system has also been shown to be effective in detecting inflammation associated with tendon and bursal disorders. It also has the unique capability of dynamically assessing tendon mobility in real-time, which is not feasible with x-ray or MRI.

How do we treat Calcific tendinopathy pain?

The majority of cases with calcific tendinopathy are self-limited and can be treated with rest, physiotherapy, and a short course of non-steroidal medicine (Louwerens et al., 2016).

What if therapeutic approaches don’t work?

There are alternative therapy choices accessible to you if your pain persists and conservative management measures have failed to relieve it. Shockwave therapy and ultrasound-guided steroid injections have been shown to be beneficial in lowering pain and recovering shoulder function in studies (Chianca et al., 2018). Each treatment’s success is inextricably connected to continuing involvement in a physiotherapy programme.

Shockwave treatment

Tendon recovery is aided with shockwave therapy. It emits intense sound waves that generate a controlled microtrauma environment in the area. This has a direct effect on the calcium in the tendon. Shockwave therapy has been shown to be effective in the following ways:

  • stimulates a healing response
  • causes fragmentation of calcium deposits within a tendon
  • encourages reabsorption of the calcium by the body
  • reduces pain by desensitising local nerve endings

(Chianca et al., 2018).

A treatment course of three to six sessions is required. For best outcomes, this should be used with a course of physiotherapy.

Injection therapy

Ultrasound guided injectable therapy is a precise and effective therapeutic method for pain relief and improved mobility. With ultrasound guided injections, current research has found increased accuracy rates (Daniels et al, 2018, Aly et al., 2015), a considerable reduction in discomfort, and fewer post-injection problems.

Calcific tendonopathy necessitates a barbotage & lavage operation, which is a sophisticated injection technique. Barbotage and lavage is a procedure that uses both a local anaesthetic and a corticosteroid. The calcium deposit will be broken up and aspirated (drawn up in the syringe) as much as possible during the process. This surgery relieves discomfort while also removing the calcific region in the tendon.

The patient’s pain problems are typically dramatically reduced as a result of this surgery. In the days following the injection surgery, we also provide a graded exercise programme to assist the shoulder return to normal strength and function.

Our practitioners are completely qualified musculoskeletal sonographers, independent medical prescribers, and highly skilled injection physiotherapists. For £250, we offer a complete one-stop service that includes a clinical evaluation, ultrasound scan, and an ultrasound guided barbotage and lavage process.