Shockwave therapy for calcific shoulder tendonitis

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 with 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 the 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 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 histic hypoxia results in a hypoxic state and ultimately reduced circulation at the critical area.  The increased levels of calcium can results 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 with calcific shoulder tendonitis are treated conservatively.  Conservative treatment includes;
  1. Shockwave therapy
  2. Physiotherapy
  3. NASID’s
  4. Needle acupuncture
  5. Injection of local anaesthetics (corticosteroids)
  6. Radiotherapy
  7. 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 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;
  1. Shoulder surgery

How is shockwave therapy 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 a 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 reduction in the original pain felt.

 

How long will shockwave therapy 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 with 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 with 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 shockwave therapy for this condition?

One is able to get shockwave therapy 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 high level in research papers.
At Pefect 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 treatment last for?

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.

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