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February 18 , 2008

Shoulder Relief — Intervening to Tame Tendonitis
By Beth W. Orenstein
For The Record
Vol. 20 No. 4 P. 28

Radiologists in Italy have developed a minimally invasive procedure for treating patients who suffer from calcific tendonitis of the shoulder. The procedure takes no more than 20 minutes and is providing many patients with long-term relief and few aftereffects at a low cost.

Calcific tendonitis causes small calcium deposit formations within the rotator cuff tendons in the shoulder. The condition is most common in adults aged 30 to 40 and seems to occur more often in women. In minor cases, physical therapy or anti-inflammatory medications may address the problem until the calcifications spontaneously break apart within a few weeks or months.

However, in many cases, the deposits become painful and can restrict shoulder mobility. Some patients have constant pain that interferes with their everyday activities, including dressing and combing their hair. Typically, the pain worsens at night.

Treatment for more severe cases has included shockwave therapy or arthroscopic surgery to remove the calcium, but both procedures have drawbacks. Approximately 50% to 70% of patients appear to benefit from two or three shockwave treatments, which stimulate blood flow in the affected area. Surgical options are expensive and require a long recovery period; shockwaves are less costly but can be extremely painful if performed when the tendonitis pain flares up.

When untreated calcifications break up, the calcium is not extracted but spreads along the tendon and lodges in the subacromial bursa, a fluid sac that helps lubricate the tendon. Calcium buildup in the tendon and bursa can cause bursitis, a painful condition with a long recovery time and a high rate of disability.

That’s why researchers from the department of radiology at A. O. Ospedale Santa Corona in Pietra Ligure and the department of experimental medicine at the University of Genoa in Italy began looking for a more effective and less costly treatment for calcific tendonitis.

Luca M. Sconfienza, MD, who presented information about the new therapy at the Radiological Society of North America (RSNA) annual meeting in November, says it builds on earlier work done in the field. In the 1960s, Charles S. Neer II, MD, described a technique where calcifications would be punctured under fluoroscopic guidance. However, Sconfienza explains that because it was difficult to center the calcification in the field of view, the technique was abandoned. Later, some researchers described other procedures, but the calcium amount they were able to retrieve was very small.

Sconfienza and his research team sought the best of all the previous procedures described in the literature and adapted them using high-resolution ultrasound guidance. “We modified it during the trial according to our experience,” he explains.

They started their trial in 1995 and, as of this past November, had treated 2,800 patients. The group continues to treat roughly 15 patients per week.

The procedure involves injecting a saline solution into the shoulder to break up the calcium deposits. Sconfienza says it is easy to perform and is completed in 10 to 20 minutes in the following four phases:

• The skin is cleaned with an iodine-based disinfectant, and a local anesthesia—mepivacaine—is injected into the skin, subcutaneous tissues, and subacromial bursa. “We take much care not to exceed 20 milliliters of mepivacaine to avoid any anesthesia-related problems,” Sconfienza says.

• The needles are then positioned. “We insert the needles in the calcification. The first needle to be inserted is the deeper one, then the other one. We take much care that the flute-beak tips are facing each other to make the water flow easier,” Sconfienza says.

• The doctor then performs the calcification rinsing, or lavage. “We connect a syringe full of saline solution to one of the needles and start to push repeatedly on the plunger,” Sconfienza says. “After a few seconds, the calcium starts to melt down and exits from the free needle. The lavage is repeated several times until the saline that comes out from the free needle is free of calcium.”

• One needle is extracted from the shoulder, and the other is retracted and inserted in the subacromial bursa, where a small amount of slow-release steroid is injected.

The procedure is relatively painless. “Patients experience not more than 10 seconds of soreness when local anaesthetic is injected,” Sconfienza says.

Generally, patients experience a complete relief from pain after 24 to 36 hours. “The complete regain of upper limb mobility is strictly related to the condition of the patient before the treatment,” Sconfienza says. “In patients whose pain and functional limitation has been present for a long time, we strongly recommend two cycles of physiokinetic therapy to favor the absorption of the small amount of calcium left and to regain complete mobility.”

Sconfienza says his team has found no disadvantages, contraindications, or complications after having treated approximately 2,800 patients. In the past, he says that some authors have avoided the use of two needles, thinking that this practice could lead to tendon tears. “Actually, we have reported no tendon tears in any patients after 10 years of follow-up,” he explains.

The therapy can be used to treat multiple calcifications at the same time in selected cases. “We try to treat all calcifications when they are in the same shoulder and, if they are not too big, to avoid crystal bursitis for the big amount of calcium that is mobilized,” Sconfienza says.

The only limit in treating one or both shoulders and one or many calcifications is the maximum amount of local anesthetic that can be injected. Currently, the limit is fixed at 20 milliliters for a single session in healthy patients, Sconfienza says.

“The treatment can be repeated, especially in cases of multiple calcifications that we prefer not to treat during a single session,” he says. In addition, the researchers have performed repeat procedures on a few patients who experienced reactive bursitis after the initial treatment, typically two months later.

Sconfienza says they found that this procedure is particularly suitable for patients with shoulder pain and upper limb functional limitation caused by tendon calcifications, and there is no age or gender limitation. “We do not treat asymptomatic patients,” he says. The best candidate is a patient in the middle of a hyperalgic pain crisis. “In these subjects, we get the best outcome.”

An ultrasound is also required to diagnose the problem, and plain film x-rays could be used as well, Sconfienza says. However, in some cases, x-rays tend to underestimate the dimensions of the calcification.

Low-Cost Treatment
Sconfienza says the treatment has many advantages because it does not require pretreatment, stitches, a hospital stay, or convalescence. “Practically speaking, the procedure ends in the exact moment that patients exit our ward,” he says. Recovery time is at most one hour. Calcifications that are completely treated do not return.

Another important advantage of this treatment is its low cost—approximately $100 per treatment. That’s much lower than the $460 for a complete cycle of shockwaves and the roughly $5,100 surgery would cost, Sconfienza says. The procedure requires an ultrasound system equipped with a high-frequency probe. The researchers used an iU22 Ultrasound System by Philips.

A. O. Ospedale Santa Corona and the University of Genoa are among several institutions currently offering this new therapy. “Their staff trained at our hospital,” Sconfienza says. But theoretically, Sconfienza says the procedure could be performed in any hospital or clinic that has ultrasound equipment with a superficial probe. “We think that almost every sonographer could perform it after a brief training,” he says. “We currently organize short and inexpensive teaching courses at our department or abroad to make this procedure available to other colleagues.”

Calcium buildups such as the ones found in the shoulder are quite rare in other parts of the body, but the researchers have treated calcifications successfully in the patellar ligament, Achilles’ tendon, and elbow. “Generally speaking, this procedure is suitable to treat calcifications with metaplastic origin,” Sconfienza says.

He believes that the procedure has the potential to become the gold standard for calcific tendonitis unresponsive to medical treatment. “In our hospital, orthopedic surgeons do not perform surgery on a calcific shoulder anymore, and this way of thinking is quickly spreading,” he says.

Study Results
At RSNA 2007, Sconfienza reported that he and his colleagues used ultrasound-guided percutaneous therapy to treat 2,543 shoulders in 1,607 women and 938 men (with a mean age of 42) with calcific tendonitis. All the patients had shoulder pain that was unresponsive to previous medical treatment.

One-year follow-up was reported for 2,018 of the patients in the study. The results showed that in 71.7% of the patients, the calcification was fully aspirated in one treatment with a considerable reduction in pain and significant improvement to mobility of the affected limb. In 23.6% of patients, a second procedure was performed due to the presence of more than one calcification. In 3.8% of patients, the calcification had dissolved or moved before treatment could take place. In 0.9% of patients, no resolution of symptoms occurred because of the presence of a tendon tear.

The researchers are working to eliminate those cases where they are unable to retrieve all calcium. They also are experimenting with new methods to eliminate the steroid in the bursa. “Generally speaking, we are making every effort to make the procedure more accessible for patients in terms of waiting lists,” Sconfienza says.

“As people age, many complain of pain in the shoulders. This pain is commonly caused by calcium buildup,” Sconfienza says. “This procedure can allow them to feel better immediately with little cost.”

— Beth W. Orenstein is a freelance medical writer from Northampton, Pa.