1. Calcific tendinitis of the shoulder: Whom and how to treat?
Rafic Baddoura MD, MPH
Head, Rheumatology Department
Hotel-Dieu Hospital
St Joseph University

2. What are the available treatment options?
What is the evidence these options are effective?
What prognostic factors we may use?

3. Orthop Clin N Am 34 (2003) 567– 575

4. Clinical assessment Constant and Murley score
minimum score of 0 and maximum score of 100
higher scores reflecting increased function)
Total score is obtained by adding the results of 4 subscales:
subjective pain (15 points)
function (20 points)
objective clinician assessment of range of motion (40 points)
strength (25 points)
The UCLA Shoulder Rating Scale is a 35-point shoulder scale that combines scores for
pain, from 1 to 10 points
function, from 1 to 10 points
active range of forward flexion, strength of forward flexion (manual muscle testing), scored from 0 to 5 points,
patient satisfaction scored from 0 to 5 points.
The outcome defined as follows:
34 to 35 points, excellent;
29 to 33 points, good;
21 to 28 points, mild;
20 points or less, poor.
Phys Ther Vol. 86, No. 5, May 2006, pp

5. Calcific deposit classification
Clearly circumscribed with a dense appearance (type I)
heterogeneous structure with sharp outline or homogenous structure with no defined border (type II)
Translucent and cloudy appearance without clear circumscription (type III)
Gartner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res. 1990;254:111–120

6. What are the available treatment options?
What is the evidence these options are effective?
What prognostic factors we may use?

7. Needle aspiration

8. Extracorporeal Shock Wave Therapy ESWT
ESWT classified according focal energy flux density (EFD) levels
Low : up to 0.08 mJ/mm2
Moderate: between 0.09 and 0.28 mJ/mm2
High: up to 0.6 mJ/mm2
Skeletal Radiol Sep;36(9):803-11

9. Arthroscopy, bursoscopy
Orthop Clin N Am 34 (2003) 567– 575

10. What are the available treatment options?
What is the evidence these options are effective?
What prognostic factors we may use?

11. Single-needle aspiration
Prospective study, 33 patients with calcifying tendinitis had a needling under control of an image converter. At least one year follow-up period.
Resorption of the hydroxyapatite deposits in 23 (70%);
Remission of symptoms or considerable improvement in 75%
type I: complete resorption in 33%
type II: complete resorption in 71%; only half were symptom free
type III: complete resorption in 85%
Surgical removal was necessary in 3 patients because of persisting pains
J. Gärtner Z Orthop Ihre Grenzgeb 1993; 131:

12. Two-needle us-guided aspiration
219 (86 men, 133 women) cases; mean age, 40 years +/- 11
68 (31 men, 37 women); mean age, 40 years +/- 11) refused treatment and served as controls.
Cases (n=151)
Controls (n=68)
Constant
VAS
1 month
73.2 +/- 6.2
4.8 +/- 0.6
57.5 +/- 3.9
9.1 +/- 0.5
3 months
90.2 +/- 2.6
3.3 +/- 0.4
62.6 +/- 7.2
7.3 +/- 1.8
12 months
91.7 +/- 3.1
2.7 +/- 0.5
78.4 +/- 9.5
4.5 +/- 0.9

13. Needle fragmentation irrigation versus removal under bursoscopy
102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected with corticosteroid
49 shoulders improved by >70%
The other 53 shoulders were randomized in 3 groups:
Needle Fragmentation Irrigation NFI (n = 16)
Bursoscopy BS (n = 20)
Control group CT: NSAID and analgesics on request (n = 17)
Joint Bone Spine Volume 76, July 2009, Pages

14. Needle fragmentation irrigation versus removal under bursoscopy
Joint Bone Spine Volume 76, July 2009, Pages

15. ESWT at high energy versus sham ESWT
Cases: (n = 33) ESWT in 2 sessions, 2 wks apart. Each session 1000 impulses with an energy flux density 0.55 mJ/mm
Controls: sham ESWT (n = 13)
Shoulder pain that failed to respond
to > 3 months of non-operative
treatment; NSAIDs, corticosteroid
injections, physical therapy, and
immobilization in a sling.
J Shoulder Elbow Surg Jan-Feb;17(1):55-9.

16. High versus low energy ESWT
100 patients who had had calcific tendinitis for > 12 months randomized to:
Group 1: 1500 impulses of 0.06 mJ/mm2,
group 2: 1500 impulses of 0.28 mJ/mm2, brachial plexus anesthesia.
Partial or complete disintegration of Ca deposits in
50% in group 1
64% in group 2
Constant score increased from
48 to 71 in group 1 (P < .001)
53 to 88 in group 2 (P < .001)
At 24 weeks, percent rating treatment as good or excellent,
52% in group 1
68% in group 2
(P < .01)
(P < .01)
(P < .01)
J Shoulder Elbow Surg Sep-Oct;7(5):505-9

17. High versus low energy ESWT
Shoulder pain for at least 12 months
Resistant to regular physiotherapy and subacromial injections of steroids.
An area of radiological calcification at least 1 cm in diameter with no signs of disintegration (type I or II)
Cloudy and transparent calcifications (type III) were excluded.
Rotator cuff lesions were excluded by means of sonography and in some cases by magnetic resonance imaging
Additional reasons for exclusion were evidence of subacromial impingement of the rotator cuff independent of calcareous deposits
Cases (n=40): 2000 impulses, twice, with an energy flux density of 0.42 mJ/mm2
Controls (n=40): 2000 impulses, twice, with an energy flux density of 0.23 mJ/mm2
J Orthop Sci (2003) 8:777–783

18. High versus low energy ESWT
Constant score
Clinical versus radiographic
X-ray regression:
Cases: 22 patients (55%)
Controls: 15 patients (38%)
J Orthop Sci (2003) 8:777–783

19. High versus low energy RSWT
Cases: 4 sessions at 1-week intervals, with 2,500 impulses per session (500 impulses with a pressure of 1.5 bar and a frequency of 4.5 Hz and 2,000 impulses with a pressure of 2.5 bar and a frequency of 10 Hz), and a fixed impulse time of 2 milliseconds. EFD/impulse = 0.10 mJ/mm2.
Controls: 4 sessions at 1-week intervals, with 25 impulses per session (5 impulses with a pressure of 1.5 bar and a frequency of 4.5 Hz and impulses with a pressure of 2.5 bar and a frequency of 10 Hz).
Cases (n=45)
Controls (n=45)
UCLA
X-ray regression
After treatment
At 6 months
39 patients (87%)
0 patient
Phys Ther May;86(5):

20. High versus low energy ESWT
High-energy group received 1500 shock waves of 0.32 mJ/mm2 / treatment, 120 impulses /min
Low-energy group received 6000 shock waves of 0.08 mJ/mm2 /treatment, 120 impulses /min
Adequate IV analgesia and sedation. Local anesthetics were prohibited.
All patients received a second ESWT treatment at 12 to 16 days
Each treatment session lasted as long as 1 hour.
In each group patients received a cumulative energy dose of J/mm2.
Sham treatment: an air-chambered polyethylene foil with coupling gel was placed against the patient's skin, but no coupling gel was applied to the site of the shock wave head.
Calcific deposits > 5 mm in diameter, and symptoms for > 6 months.
Rotator cuff tears and subacromial bursitis were ruled out in all patients by clinical and sonographic examination, and when in doubt, by MRI prior to randomization and at all follow-up visits.
Type III Gärtner deposits were excluded
All participants had previous conservative treatments, including both physiotherapy (active and passive exercise, mobilization, manual therapy and massage, muscle strengthening) and local anesthetic or corticosteroid injections.
Gerdesmeyer JAMA Vol. 290 No. 19, November 19, 2003

21. High versus low energy ESWT
Pain and Constant score
Gerdesmeyer JAMA Vol. 290 No. 19, November 19, 2003

22. High versus low energy ESWT
Calcium deposits
Gerdesmeyer JAMA Vol. 290 No. 19, November 19, 2003

23. ESWT with or without localization
3 sessions of low-energy focused shock wave therapy was administered in weekly intervals in both groups.
Cases: calcium deposit was localized using a radiographically guided, 3-D, computer-assisted device.
Controls: calcium deposit was localized using the point of maximum tenderness through palpation with feedback from the patient.
Cases (n=25)
Controls (n=25)
Constant
X-ray regression
At 12 weeks
6 patients (24%)
1 patient (4%)

24. High versus low energy fluoroscopy-guided ESWT
High-energy ESWT, low-energy ESWT, or placebo (sham therapy).
The 2 ESWT groups received the same cumulative energy dose.
Patients in all 3 groups received 2 treatment sessions approximately 2 weeks apart, followed by physical therapy.
Cases
(n=40)
Controls (n=40)
Constant
High Energy
Low Energy
Sham
At 6 months
31.0 [ ]
15.0 [ ]
6.6 [ ]
P<0.001
P<0.001

25. ESWT versus conventional surgery in calcifying tendinitis of the shoulder
A prospective quasirandomized chronic calcifying tendinitis
surgical extirpation (Group I, 29 patients)
high-energy ESWT (Group II, 50 patients) 3,000 impulses, EFD 0.6 mJ/mm2
University of California Los Angeles Rating
12 months
Group I 30 points with 75% good or excellent results
Group II 28 points with 60% good or excellent results
24 months
32 points with 90% good or excellent results after.
29 points with 64% good or excellent results
Radiologically, at 12 months
Group I no calcific deposit in 85% of the patients
Group II no calcific deposit in in 47% of the patients
homogenous deposit: surgery superior to high-energy ESWT
inhomogenous deposit: high-energy ESWT equivalent to surgery

26. J Orthop Traumatol. 2008 Dec;9(4):179-85.
Arthroscopy surgery versus ESWT for chronic calcifying tendinitis of the shoulder
Retrospective study in patients with chronic calcific deposit
Arthroscopic extirpation (group I, 22 cases)
Low ESWT: 3 treatment sessions with 1,500 impulses/session of mJ/mm2. (group II, 24 cases).
Patients included in the study had
unsuccessful conservative therapy for six months
no evidence of subacromial impingement of the rotator cuff detected by sonography or magnetic resonance imaging.
Ca deposits had to be types I and II / Gärtner classification.
(UCLA) rating system after 24 months,
group I: mean score rose from 9.36 (+/-5.2) to 30.3 (+/-7.62), with 81.81% reporting good or excellent results (P < 0.001).
group II mean score rose from (+/-6.5) to (+/-9.34), with 70.83% reporting good or excellent results (P < 0.001).
Radiologically, after 24 months,
No calcific deposit in 86.35% (P < 0.001) of group I
No calcific deposit in % (P < 0.001) of group II.
(P =0.38)
J Orthop Traumatol Dec;9(4):

27. What are the available treatment options?
What is the evidence these options are effective?
What prognostic factors we may use?

28. Effect of Ca deposit radiographic shape on ESWT outcome
Cases: (n = 33) ESWT in 2 sessions, 2 wks apart. Each session 1000 impulses with an energy flux density 0.55 mJ/mm
Controls: sham ESWT (n = 13)
No significant difference in Constant score between type I and type II Gartner Classification
J Shoulder Elbow Surg Jan-Feb;17(1):55-9.

29. Effect of Ca deposit radiographic shape on ESWT outcome
Case-series of 80 subjects
ESWT: one to five sessions at an interval of 4-6 weeks. Each patient received 1800 impulses in each session. EFD mJ/mm2
Cases
(n=80)
No Controls
Constant
X-ray regression
After treatment
57 (71%)
X-ray regression by calcium deposit shape:
Amorphous: 100% Mixed: % Homogeneous: 44.4%

30. Effect of MRI negative contrast reaction around Ca deposit on ESWT outcome
Case-series 62 patients with chronic courses of calcifying tendinitis
Clinical assessment before and after low-energy ESWT
Size (p = 0.61) and morphology (p = 0.7) of the deposits before ESWT not associated with the clinical outcome
MRI negative contrast reaction around
Constant > 75
Ca deposit
Synovia
Bursae Se
0.38
0.49
0.44 Sp
0.95
0.82
0.86
PPV
0.94
0.84
P<
P<0.0049
P<0.01
Archives of Orthopaedic and Trauma Surgery 2000

31. Effect of subacromial decompression on calcific tendinitis
50 patients reviewed after arthroscopic subacromial decompression.
Cases: 25, had calcific deposits in the rotator cuff visible on x-rays. Calcific deposits were left untouched in all cases.
Controls: 25, without calcification, similar state of the rotator cuff, date of surgery, age, and sex.
No significant difference in postoperative Constant score
Calcification
Before surgery
2 yrs after surgery
> 5 mm
18 (72%)
4 (17%)
< 5 mm
7 (28%)
20 (83%)
p < 0.001

32. Effect of Ca deposit resection and acromioplasty in rotator cuff tendinopathy
Multi-center study (112 patients) / French Society of Arthroscopy
Several arthroscopic procedures on
the calcification (respect or removal),
The coracoacromial arch (respect, ACL release or acromioplasty)
Cases (n=112)
No Controls
Constant
X-ray regression
At follow-up
(82%) improved
(88%)
Results were better when the calcification had been removed
Acromioplasty gave no better results: necessary only when no calcification is found (12 %)

33. Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):516-21.
Influence of deposit stage and failed ESWT on the results of arthroscopic resection of calcific tendonitis
45 (17 men, 28 women)
mean age of 49 +/- 8 years
mean follow-up 36 months (14-89)
24 patients (53.3%) underwent preoperative ESWT.
For the clinical evaluation the
Constant and Murley Score
Simple Shoulder Test (SST)
Western Ontario Rotator Cuff Index (WORC)
visual analog scales for pain, function and satisfaction
For the radiological evaluation, the classifications according to Gartner and Bosworth were used.
P value
Constant
63.5 +/- 11.4
93.9 +/- 9.9
< .0001
SST
1.7 +/- 2
9.9 +/- 2.8
<.0001
WORC
1, /
/- 392 points
Ca deposits
37 type I
6 type II
2 type III
37 Absent
6 type I
No significant correlation of the clinical results with the pre- or post-op findings
Patients who underwent ESWT before surgery (n=24) did not show significantly better results than patients without ESWT
Knee Surg Sports Traumatol Arthrosc May;16(5):

34. Take home message
Type III Ca deposits are likely to resolve spontaneously
Needling is a simple low-cost straight forward procedure in type II Ca deposits with persistent pain despite conservative therapy
No significant difference in terms of pain and function between high energy ESWT and arthroscopic removal in type II Ca deposits
Type I Ca deposits are associated with lower rate of radiographic regression with ESWT
No significant correlation between radiographic and clinical outcomes