AJCC April 2001


April 2001
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Chiropractic Treatment of Calcific Tendonitis


by Gregg Carb, D.C.	Al Ueda, D.C.

INTRODUCTION

Shoulder pain is a very common complaint among the general patient population, especially those over age 30. Some of these patients will be found (through x-ray evaluation) to have deposits of calcium within the tendons of the rotator cuff muscles. The tendon of the supraspinatus muscle is most frequently involved. In a significant number of cases the calcium deposits are found bilaterally. As with intervertebral disc bulges, however, studies show that only a percentage of those with detectable calcific deposits are actually symptomatic, meaning concurrent or overlapping causes may also be present for those expressing shoulder pain.

The deposits of calcium are thought to occur as the result of a degenerative process, secondary to mechanical irritation such as subacromial impingement or simple overuse (impingement and overuse suggest strain from shoulder abduction). Another theory of pathogenesis is that blood flow to the supraspinatus tendon is diminished through pressure exerted by the head of the humerus against the supraspinatus tendon when the arm is held in a position adduction. Interestingly, the two theories combined suggest that both abduction and adduction stresses of the arm can be problematic for patients with calcific tendinitis.

Fortunately, calcific tendinitis is usually a self-limiting disorder that eventually undergoes a resorptive phase in most cases. Initially, the symptomatic onset is characterized by an acute stage of inflammation (of the supraspinatus tendon and/or subacromial bursa). During this phase, patients complain of pain on active and/or passive motion, and pain at night while trying to find a comfortable sleeping position. Treatment consists of limiting painful positions and movements but allowing motion to occur within pain-free ranges. Ice and/or pulsed ultrasound can be helpful to reduce swelling. Soft-tissue work can be performed to the supraspinatus muscle and related structures. The joint structures of the axial (cervical/ thoracic spine) and appendicular (sternoclavicular/acromioclavicular/ scapulothoracic) skeleton should be assessed and adjusted as necessary. Postural faults should be evaluated and corrected.

In the sub-acute and chronic stages, soft tissue release can be performed directly on the supraspinatus tendon and coraco-acromial ligament. A strengthening and stretching program should target both the rotators cuff muscles (supraspinatus/infraspinatus/teres minor/subscapularis) and the scapular stabilizers (trapezius/ rhomboids/levator scapulae/serratus anterior/pectoralis minor). Activities of daily living, postural habits, and ergonomic issues will have to be considered to identify any aggravating factors and to avoid recurrent episodes. Patients in the late chronic phase of calcific tendinitis that fail conservative care measures are candidates for medical referral, which will most likely consist of steroid injection and/or arthroscopic surgery (advise against routine acromioplasty).

CASE HISTORY

A healthy-appearing 40 year-old Asian female presented for chiropractic evaluation of right shoulder pain in October 2000. She was employed as a color printer technician. Her occupation required her to flex and abduct her right shoulder/arm repeatedly throughout the day. She had been working at her current employment for over 16 years.

Her symptoms started one week before presenting for examination. She first became aware of the pain when reaching for some print paper that weighed approximately 11 1/2 pounds. Her secondary complaint was neck pain. The shoulder pain was described as moderate in severity and occurring on a constant basis. The pain was dull and achy in the resting position and became sharp and stabbing when moving the arm in certain positions, such as when getting dressed.

On examination, motor strength of the right upper extremity was substantially reduced due to pain in the following planes of motion: shoulder abduction and adduction, wrist extension and flexion. Reflexes were normal with the exception of right triceps, which was too painful to be tested. Right shoulder active range of motion was markedly diminished in flexion, extension, abduction, and adduction compared to the uninjured left side. Palpation revealed pain at the supraspinatus insertion, subacromial bursa, and teres minor with trigger points. There was right sternoclavicular joint tenderness. Superior to inferior glide of both shoulders revealed some crepitus and joint laxity with increased pain on the right side compared to the left. Shoulder orthopedic tests showed Cross-Over test positive on right side for right anterior shoulder pain and ApleyÕs I & II tests positive for pain at right shoulder.

X-rays were obtained in the AP, AP internal and AP external views. All views revealed calcific tendinitis of the supraspinatus tendon of the right shoulder (Figure One).

The patient was treated 3-4 times a week for six weeks. The first two weeks of treatment consisted of ice application to the painful area, manipulation of the cervical spine, thoracic spine, and right sternoclavicular joint with myofascial release to the rotator cuff muscles, most notably the supraspinatus, infraspinatus, and teres minor. From the third to sixth week of treatment rotator cuff exercises were started using Theracisor tubing (15 reps/day). The patient was instructed to go just below the painful range of motion. Additionally, Russian stimulation was applied with dynamic (changing 0- 250) frequency and amplitude of 12 mA for 15 min.

Upon re-examination in December 2000, the patient reported being able to dress again without pain. The severity of pain was reduced to slight and occasional, with the character of pain dull and achy without any sharp and stabbing pains. Full passive ROM was without pain. Full active ROM was without pain. Active range of motion with 5 pounds was only difficult in abduction near the end-range of motion. All reflexes could be tested and all were 2+. Follow-up X-ray of the right shoulder revealed no remaining calcific deposits in the right supraspinatous tendon (Figure Two). Treatment emphasizing strengthening and flexibility was continued for a few additional weeks and, at this time, the patient has reported no flare-ups and continues to improve in strength and stability of the right shoulder.

References

1. PA Gimblett et al. A Conservative Management Protocol for Calcific Tendinitis of the Shoulder. JMPT 1999 22:622-7.

2. GR Ebenbichler et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999 May 20;340(20):1533-8.

3. J Jerosch, JM Strauss, S Schmiel. Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 1998 Jan-Feb;7(1):30-7.