Download Calcific tendonitis - The Castle Practice

Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
Calcific tendonitis
Clinical features
Investigations
Management
Poor response
Good response
Refer to orthopaedic
surgery
Review as appropriate
R
Consider corticosteroid
injection
Poor response
Good response
Consider other
treatments
Review and follow-up
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 1 of 6
Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
1 Calcific tendonitis
Quick info:
Calcific tendonitis:
• occurs in adults age 30-50 years
• is caused by the deposition of calcium phosphate crystals onto the supraspinatus tendon of the rotator cuff
• may be mild, chronic pain interspersed with episodes of acute, severe shoulder pain and inflammation, associated with sporadic
pain down the arm or up into the neck
• pain increases in severity with movement and at night
• other symptoms include stiffness and weakness of the shoulder joint
• during the acute phase, the joint is usually too painful to allow examination
• X-rays may show calcium deposits in soft tissue
Reference:
New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders.
Wellington: NZGG; 2004.
2 Clinical features
Quick info:
Calcific tendonitis:
• occurs in patients age 30-50 years
• is caused by the deposition of calcium phosphate crystals onto the supraspinatus tendon of the rotator cuff
• may be mild, chronic pain interspersed with episodes of acute, severe shoulder pain and inflammation, associated with sporadic
pain down the arm or up into the neck
• pain increases in severity with movement and at night
• other symptoms include stiffness and weakness of the shoulder joint
• during the acute phase, the joint is usually too painful to allow examination
3 Investigations
Quick info:
X-rays may show calcium deposits in soft tissue.
4 Management
Quick info:
Management may involve:
• patient education
• ice packs applied to the painful area
• rest or immobilisation is beneficial
• physical therapy to stretch and strengthen the tendon and associated muscles
• simple analgesia or non-steroidal anti-inflammatory drugs (NSAIDs; eg ibuprofen), unless contra-indicated
• NSAIDs:
• provide short-term symptomatic relief, but are associated with adverse effects
• contra-indications include:
• patients with severe renal disease
• pregnancy
• patients with aspirin allergy
• prescribe with caution in patients with:
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 2 of 6
Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
• hypertension
• gastrointestinal complaints
• mild liver or kidney disease – use lowest effective dose and monitor renal function
• asthma
• monitor adverse effects
• early referral may be considered necessary if the patient has severe pain or dysfunction
References:
New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders.
Wellington: NZGG; 2004.
Speed C. Shoulder pain. Clin Evid 2008; 1: 1107-31.
5 Poor response
Quick info:
Poor response:
• some or all of the patient's symptoms, including pain, persist
• treatment does not fully restore the patient's ability to perform normal daily activities, including work, sleep, recreational and
other activities
6 Good response
Quick info:
Good response:
• symptoms, including pain, improve
• treatment restores the patient's ability to perform normal daily activities, including work, sleep, recreational and other activities
9 Consider corticosteroid injection
Quick info:
Consider corticosteroid and local anaesthetic injection:
• may improve pain in the short-term
• procedure may be carried out with or without fluoroscopic or ultrasound guidance
• monitor blood sugar levels following intra-articular injection in patients with diabetes
References:
New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders.
Wellington: NZGG; 2004.
Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and Medical Research Council;
2003.
Speed C. Shoulder pain. Clin Evid 2005; 1543-60.
10 Poor response
Quick info:
Poor response:
• some or all of the patient's symptoms, including pain, persist
• treatment does not fully restore the patient's ability to perform normal daily activities, including work, sleep, recreational and
other activities
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 3 of 6
Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
11 Good response
Quick info:
Good response:
• symptoms, including pain, improve
• treatment restores the patient's ability to perform normal daily activities, including work, sleep, recreational and other activities
12 Consider other treatments
Quick info:
In patients who remain refractory to first-line treatment and corticosteroid injection, consider:
• extracorporeal shock wave therapy (ESWT):
• is a non-invasive alternative to open or arthroscopic surgical procedures
• has been found to reduce pain and improve shoulder function
• involves short duration sonic pulses aimed at the affected area to break down the calcium phosphate crystals in the tendon
and joint
• high energy ESWT may be more effective than low energy ESWT
• therapeutic ultrasound may reduce pain in the short-term but evidence is limited
• arthroscopic removal of the calcium deposits followed by debridement may be beneficial
• limited evidence suggests electrical stimulation may be beneficial
References:
National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave lithotripsy for calcific tendonitis (tendinopathy)
of the shoulder. Interventional Procedure Guidance 21. London: NICE; 2003.
New Zealand Guidelines Group (NZGG). The diagnosis and management of soft tissue shoulder injuries and related disorders.
Wellington: NZGG; 2004.
Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and Medical Research Council;
2003.
Speed C. Shoulder pain. Clin Evid 2008; 1: 1107-31.
13 Review and follow-up
Quick info:
• review:
• pain control
• functional ability
• response to treatment
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 4 of 6
Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
Key Dates
Due for review: 31-May-2011
Last reviewed: 30-Oct-2009, by International
Updated: 30-Oct-2009
Accreditations
The editorial process used to create this pathway is accredited by:
NHS Institute for Innovation and Improvement:
Accreditation attained: 30-Oct-2009
Due for review: 31-May-2011
Disclaimer
Certifications
The evidence for this pathway is certified by:
BMJ Publishing Group Ltd:
Disclaimer
Evidence summary for Calcific tendonitis
The pathway is based on our interpretation of the following guidelines (9, 2, 6). All of these guidelines have been graded for
quality and prioritised for inclusion based on their methodological quality. All intervention nodes (ie. those concerning therapy
and therapeutic advice) have been graded for the quality of the evidence underlying them. Key non-interventional nodes are also
referenced.
Search date: May-2006
Evidence grades:
Intervention node supported by level 1 guidelines or systematic reviews
Intervention node supported by level 2 guidelines
Intervention node based on expert clinical opinion
Non-intervention node, not graded
Evidence grading:
Graded node titles that appear on this page
Calcific tendonitis
Evidence grade
Reference IDs
9
Management
9, 10
Consider corticosteroid injection
9, 2, 10
Consider other treatments
8, 9, 2, 10
References
This is a list of all the references that have passed critical appraisal for use in the pathway Shoulder pain
ID Reference
1 American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 2001.
2 Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and
Medical Research Council; 2003.
3 Brigham and Women's Hospital. Upper extremity musculoskeletal disorders. A guide to prevention,
diagnosis and treatment. Boston, MA: Brigham and Women's Hospital; 2006.
4 Clinical Knowledge Summaries (CKS). Shoulder pain. Newcastle upon Tyne: CKS; 2008.
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 5 of 6
Calcific tendonitis
Surgery > Orthopaedics > Shoulder pain
ID Reference
5 Clinical Knowledge Summaries (CKS). Osteoarthritis. Newcastle upon Tyne: CKS; 2009.
6 Dinnes J, Loveman E, McIntyre L et al. The effectiveness of diagnostic tests for the assessment of shoulder
pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7: 1-185.
http://www.ncchta.org/fullmono/mon729.pdf
7 Gotzsche P. Non-steroidal anti-inflammatory drugs. Clin Evid 2002; 1203-1211.
8 National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave lithotripsy for calcific
tendonitis (tendinopathy) of the shoulder. Interventional Procedure Guidance 21. London: NICE; 2003.
http://www.nice.org.uk/nicemedia/pdf/ip/IPG021guidance.pdf
9 New Zealand Guidelines Group. The diagnosis and management of soft tissue shoulder injuries and related
disorders. Wellington: New Zealand Guidelines Group; 2004.
http://www.nzgg.org.nz/guidelines/0083/040715_FINAL_Full_Shoulder_GL.pdf_1.pdf
10 Speed C. Shoulder pain. Clin Evid 2008; 1107-31.
Disclaimers
NHS Institute for Innovation and Improvement
It is not the function of the NHS Institute for Innovation and Improvement to substitute for the role of the clinician, but to support
the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own
professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made
to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness or
completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date.
BMJ Publishing Group Ltd
The updates supplied by the BMJ Group Ltd for the Evidence Summary are prepared by systematically reviewing certain published
medical research and guidelines relevant to the topics covered, as agreed with Map of Medicine Ltd. Readers should be aware
that professionals in the field may have different opinions and not all studies are covered. Because of this fact and also because
of regular advances in medical research, we strongly recommend that readers independently verify any information they choose
to rely on. Ultimately it is the readers' responsibility to make their own professional judgements. The BMJ Group Ltd does not
independently verify the accuracy of the published research or guidelines and is not responsible for changes being made within
the Map of Medicine as a result of the evidence. The updates to the Evidence Summaries are supplied on an "as is" basis without
warranty of any kind express or implied and to the fullest extent permitted by law, accepts no liability for losses, injury or damage
caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct
or indirect, special, incidental or consequential, resulting from the application of the information, errors or omissions in the updates
supplied for the Evidence Summary, the Pathways covered by it or the research referred to in it.
Last reviewed: 30-Oct-2009
Due for review: 31-May-2011
Printed on: 20-Jan-2010
© Map of Medicine Ltd
IMPORTANT NOTE
Last reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.
Page 6 of 6