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Ultrasound Therapy

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Therapeutic ultrasound as a treatment modality that has been used by therapists over the last 50 years to treat soft tissue injuries.

Ultrasonic waves (sound waves of a high frequency) are produced by means of mechanical vibration of the metal treatment head of the ultrasound machine. The treatment head is then moved over the surface of the skin in the region of the injury. When sound waves come into contact with air it causes a dissipation of the waves, and so a special ultrasound gel is placed on the skin to ensure maximal contact between the treatment head and the surface of the skin.

What are the Effects of Therapeutic Ultrasound?


The effects of therapeutic ultrasound are still being disputed. To date, there is still very little evidence to explain how ultrasound causes a therapeutic effect in injured tissue. Nevertheless practitioners world wide continue to use this treatment modality relying on personal experience rather than scientific evidence. Below are a number of the theories by which ultrasound is proposed to cause a therapeutic effect. Thermal Effect: As the ultrasound waves pass from the treatment head into the skin they cause the vibration of the surrounding tissues, particularly those that contain collagen. This increased vibration leads to the production of heat within the tissue. In most cases this cannot be felt by the patient themselves. This increase in temperature may cause an increase in the extensibility of structures such as ligaments, tendons, scar tissue and fibrous joint capsules. In addition, heating may also help to reduce pain and muscle spasm and promote the healing process. Effects on the Inflammatory and Repair Processes: One of the greatest proposed benefits of ultrasound therapy is that it is thought to reduce the healing time of certain soft tissue injuries. Ultrasound is thought to accelerate the normal resolution time of the inflammatory process by attracting more mast cells to the site of injury. This may cause an increase in blood flow which can be beneficial in the sub-acute phase of tissue injury. As blood flow may be increased it is not advised to use ultrasound immediately after injury. Ultrasound may also stimulate the production of more collagen- the main protein component in soft tissue such as tendons and ligaments. Hence ultrasound may accelerate the the proliferative phase of tissue healing. Ultrasound is thought to improve the extensibility of mature collagen and so can have a positive effect to on fibrous scar tissue which may form after an injury.

Application of Ultrasound:

Ultrasound is normally applied by use of a small metal treatment head which emits the ultrasonic beam. This is moved continuously over the skin for approximately 3-5 mins. Treatments may be repeated 1-2 times daily in more acute injuries and less frequently in chronic cases. Ultrasound dosage can be varied either in intensity or frequency of the ultrasound beam. Simply speaking lower frequency application provides a greater depth of penetration and so is used in cases where the injured tissue is suspected to be deeply situated. Conversely, higher frequency doses are used for structures that are closer to the surface of skin.

Contraindications For Use:


As ultrasound is thought to affect the tissue repair process and so it is also highly possible that it may affect diseased tissue tissue in an abnormal fashion. In addition the proposed increase in blood may also function in spreading malignancies around the body. Therefore a number of contraindications should be followed when using therapeutic ultrasound: Do not use if the patient suffers from: Malignant or cancerous tissue Acute infections Risk of haemorrhage Severely ischeamic tissue Recent history if venous thrombosis Exposed neural tissue Suspicion of a bone fracture If the patient is pregnant Do not use in the region of the gonads (sex organs), the active bone growth plates of children, or the eye.

Ultrasound in Physiotherapy
Ultrasound is high frequency sound waves, greater than 20,000 Hz. Therapeutic ultrasound is in the frequency range of 0.9 - 3 MHz. The utilization of ultrasound has been a 20th century phenomenon. In addition to its use by the military to detect submarines, it was also used in the 1930's for emulsification, and atomization of particles in a gas. Since then, ultrasound has been used therapeutically for its effects of cavitation, stable and unstable bubble formation, and a phenomenon called acoustic streaming or microstreaming. Ultrasound is used to:

break up scar tissue and adhesions reduce inflammation, swelling and calcium deposits create a deep heat to a localized area to ease muscle spasms (much deeper than can be achieved with a hot pack - up to 5 cm) increase soft tissue extensibility prior to stretching and exercise facilitate healing at the cellular level speeds metabolism and improves blood flow reduces nerve root irritation at low intensities can speed bone healing enhance transcutaneous drug delivery by phonophoresis

The main piece of equipment is a high-frequency generator, which provides an electrical current through a cable to a transducer which contains a piezoelectric crystal. This crystal when exposed to the current will vibrate at a given frequency, expanding and contracting, which produces the necessary compression wave. By using a different frequency the therapist can target tissues at different depths for either healing or destruction, or simply use the device to reduce pain. Although simple in principle, the use of ultrasound as a therapeutic modality requires a comprehensive understanding of its effects on the body tissues and of the physical mechanisms by which its effects are produced. The lower the frequency used, the deeper is the penetration of the waves into the body. By varying the frequency from continuous to intermittent, the amount of heat applied can likewise be controlled by the physiotherapist.

For instance, contusions are one of the most frequent and debilitating injuries encountered in sports medicine. Although contusions may be caused by shearing and tension between over-stressed body parts, the most common cause is compression of soft tissue, usually when it is crushed between bone and some hard surface. This almost invariably involves capillary rupture and infiltrative bleeding, followed by edema and inflammation. This usually involves hematoma or "pooling" of blood, and occasionally myositis ossificans can result as a complication if not treated. This is a syndrome in which the body starts laying down painful calcium deposits within the muscle. Quick and effective treatment is crucial in sports injuries. Proper and efficient healing is essential to the health and career of any athlete, regardless of how minor or major the injury. Basic treatment involves the application of ice to contain the immediate inflammation, followed by timely applications of ultrasound to reduce the subsequent edema and further stimulate the healing process.

Ultrasound is effective in treating wounds in both the inflammatory and the proliferative stages. Ultrasound causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These and other events appear to accelerate the acute inflammatory phase and promote healing.

In the proliferative phase of healing, ultrasound effects fibroblasts and stimulates them to secrete collagen. This accelerates the process of wound contraction and increases the tensile strength of the healing tissue. Connective tissues will elongate better if both heat and stretch are applied. Continuous ultrasound at higher therapeutic intensities provides an effective means of heating deeper tissues prior to stretching them. Its effectiveness has been enhanced over the years by studies which help determine optimum techniques and patterns of application, and a wide range of injuries have shown to be responsive to this noninvasive therapy.

What is Supraspinatus tendinitis? Supraspinatus tendinitis or painful arc syndrome occurs in the shoulder. The shoulder joint owes its stability to the 'rotator cuff' muscles - which are four small muscles located around the shoulder joint which help with movement, but importantly their tendons stabilise the head of the humerus within the joint capsule. The tendon of one of these muscles - the supraspinatus commonly impinges on the acromion (the bone forming the tip of the shoulder) as it passes between the acromion and the humeral head. The supraspinatus muscles helps abduct (lift up sideways) the arm. Any friction between the tendon and the acromion is normally reduced by the subacromial bursa - a fluid filled sac between the supraspinatus tendon and the acromion.Sometimes, with wear and tear supraspinatus tendinitis results, which is commonly associated with inflammation of the bursa - subacromial bursitis. There may even be little tears in the tendon fibres - partial tears or sometimes even complete tears. Tendinitis and partial tears in the supraspinatus tendon causes a 'painful arc' since as the person elevates his arm sideways, the tendon begins to impinge under the acromion throught the middle part of the arc, and this is usually relieved as the arm reaches 180 degrees (vertical).There may be other causes of a painful arc. Arthritis of the acromio-clavicular joint (at the tip of the shoulder) may also cause pain- but that is typically at the end of the arc - when the arm is almost vertical. Statistics on Supraspinatus tendinitis Supraspinatus tendinitis is very common, it the most common inflammatory problem encountered around the shoulder joint. It is typically seen in people aged 25-60. Risk Factors for Supraspinatus tendinitis The tendinitis results usually from chronic wear and tear of the supraspinatus tendon as it passes under the acromion - this may be in sports-people and people that do a lot of overhead work though it may occur in any person. Anatomical factors such as the shape of the acromion or a tight subacromial space due to a thickened ligament may be predisposing factors.

Tears in the tendon of the supraspinatus or other rotator cuff muscles (commonly occur together) often result from a fall on the shoulder, usually in older people. They can also result from attrition - gradual degeneration with wear and tear, or other inflammatory disorders such as rheumatoid arthritis. Progression of Supraspinatus tendinitis The tendinitis results from trauma (e.g. a fall, dog on leash) in around 30% of cases. 5% of cases are bilateral (involving both shoulders). The pain will severely limit shoulder movement and may cause secondary muscular neck pains. How is Supraspinatus tendinitis Diagnosed? An x-ray may show calcification in calcific tendinitis. X-rays can be useful in determining the acromial anatomy though they will not help with diagnosing soft tissue problems such as tendon tears or bursitis. Prognosis of Supraspinatus tendinitis Around 70% of patients with tendinitis will improve over 5-20 days and mobilize the joint themselves, though treatment with physiotherapy and steroid injections will help. Further tendinitis and even partial or complete tears may occur in the future. Complete tears are treated surgically in young people, though this may be harder in older people or patients with other causes such as rheumatoid arthritis. Chronic trauma and impingement may lead to osteoarthritis of the shoulder in the long term. How is Supraspinatus tendinitis Treated? Rest is important during the initial phase of tendinitis to allow the inflammation to settle. Analgesics such as NSAIDs - naprosyn 250mg three times daily with food. Injection of corticosteroid (e.g. triamcinolone acetate 40mg) with local anesthetic into the subacromial bursa or the supraspinatus tendon itself will help (though there may be an increase in discomfort in the first 48 hours). Calcific tendinitis may require aspiration and injection of steroid into the joint or even surgical removal of the calcium crystals. A surgical arthroscopic (inserting a tiny camera into the shoulder joint through a small cut under anesthetic) acromioplasty - i.e. re-shaping the acromion or dividing the coracoacromial ligament is required often to prevent further episodes. At the same time the rotator cuff tendons can be repaired - though this may be difficult if left too late and the tendon retracts. Supraspinatus tendinitis References 1. Collier, J., Longmore M., Brown TD., Oxford Handbook of Clinical Specialties 5th Ed.

2. Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002; 3. Murtagh, J. General Practice. Second Ed. McGraw-Hill, 1998. Treatments Used in This Disease:
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Corticosteroids for Pain Relief

Drugs/Products Used in the Treatment of This Disease:


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Kenacort-A (Triamcinolone acetonide) Naprosyn (Naproxen) Nurofen (Ibuprofen) Voltaren Rapid 12.5/ 25/ 50 (Diclofenac potassium)

Rotator Cuff Calcific Tendonitis Injury Explained


Rotator Cuff Calcific Tendonitis is a fairly common cause of shoulder pain, which is difficult to distinguish from rotator cuff tendonitis or a torn rotator cuff. The cause of this relatively common shoulder problem is not fully understood. As the name suggests, Rotator Cuff Calcific Tendonitis is characterised by calcific deposits in the rotator cuff tendons of the shoulder. The rotator cuff consists of the Supraspinatus, Infraspinatus, Teres minor and Subscapularis muscles and tendons. The Supraspinatus tendon is most commonly affected although some people can suffer calcific deposits in several tendons.

The pathology of this condition is divided into three phases:

1. The first phase is the 'Pre-calcific' stage, which consists of thinning of tendon fibres, with a change in this tissue to fibrocartilage. This is thought to be due to repeated damage to the tendon due to overuse. 2. This is followed by the 'Calcific' stage. Here, calcium crystals are deposited within the tendon, which has a chalk like appearance. These calcium crystals are derived from calcium circulating within the blood. This calcific material is usually spontaneously re-absorbed as a material which resembles toothpaste. 3. Once fully re-absorbed, there follows a 'Post calcific' stage, where scar tissue is laid down in the space that the calcific material had occupied. Top of Page

Rotator Cuff Calcific Tendonitis Signs & Symptoms


An acute rotator cuff Rotator Cuff Calcific Tendonitis can cause exquisite shoulder pain that can radiate to the neck and down the arm. During the acute phase, this is irritated by all shoulder movements. In more chronic Rotator Cuff Calcific Tendonitis, the most common finding is shoulder pain at night. This pain is difficult to localise and covers a diffuse area over the shoulder region. Clinically this condition can't be differentiated from Shoulder bursitis (Impingement Syndrome). Indeed, the formation of calcific deposits in the rotator cuff may not be painful in itself - the pain may emanate from other structures, such as the Sub acromial bursa which may become impinged' and inflamed. Large calcific deposits will be visible on x-ray, but ultrasound scans may be more effective at determining the exact location.

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Rotator Cuff Calcific Tendonitis Treatment


What you can do Consult a sports injury expert Apply cold or hot packs/therapy to help relieve pain Use anti-infammatory gel for pain relief Wear a shoulder support for reassurance
Because calcific deposits are usually spontaneously re-absorbed, physiotherapy treatment is usually very effective. The doctor may prescribe analgesics for pain relief during an acute episode of Rotator Cuff Calcific Tendonitis. Anti-Inflammatory Gel may be more appropriate where tablets are not well tolerated.

For those who want to continue with sports and work activities a Neoprene Shoulder Support can provide support and reassurance. The first priority of physiotherapy treatment is to reduce the pain and inflammation using ice therapy. Ice Packs can be applied for periods of twenty minutes every couple of hours (never apply ice directly to the skin as it can cause an ice burn). The Ice Packs relieve pain and reduce inflammation in the tissue. The Aircast Cryo/Cuff is the most effective method of providing ice therapy and can be used for the home treatment of shoulder injuries and shoulder pain. It can provide continuous ice cold water and compression for 6 hours and significantly reduce pain and inflammation. In more chronic cases, which don't settle with physiotherapy treatment, then a referral to a consultant radiologist may be useful. The radiologist can sight the lesion using an Ultrasound scan, and can deliver an injection of Corticosteroid using a needle. Apart from relieving pain and reducing the associated inflammation, this is thought to assist re-absorption of calcific material. On occasions radiologists have reported being able to 'suck up' the toothpaste like calcium material (if the deposits are in the re-absorption stage). This has been reported to give patients instant relief. Surgery is generally not considered for this condition, unless there is persistent severe pain of a chronic nature. In these cases, the surgeon can remove the calcific deposits using an arthroscope. This is so long as the deposits have been identified on previous investigations and the surgeon is sure that this is the cause of the shoulder pain.

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Rotator Cuff Calcific Tendonitis Prevention


What you can do Use resistance bands for strengthening exercises
The key to preventing rotator cuff problems is to address the problems of overuse and impingement of the Rotator Cuff. Because of their position the Rotator Cuff can become irritated and inflamed during repeated overhead shoulder movements as a result of being squashed or 'impinged' within the tight space they operate in. Where impingement is occurring, the space for the Rotator Cuff is reduced. This space can be optimised by practicing shoulder stability exercises with a physiotherapist, using Resistance Bands. These exercises concentrate on controlling the movement of the shoulder blade, by ensuring that muscle contract in the correct sequence during shoulder movements, to ensure that the ball of the upper arm remains stable in the shoulder socket during work, sport and functional activities. Resistance Bands are ideal for progressing shoulder strength and stability.

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Recommended Products for Rotator Cuff Calcific Tendonitis


Shoulder Supports & Braces Pain Relief Home Rehabilitation Kit Ice Packs & Cold Therapy

Background
Painter described calcification in the shoulder in 1907. Codman established that the calcification was within the tendons of the rotator cuff. Calcifying tendinitis of the shoulder is characterized by the presence of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff.[1] This article addresses only calcifying tendinitis as it occurs in the shoulder. (See also the eMedicine article Rotator Cuff Disease.)

Recent studies
Rebuzzi et al performed a retrospective study comparing arthroscopic surgery (22 cases) with low extracorporeal shockwave therapy (ESWT) (24 cases) in patients with calcific deposits in the supraspinatus tendon. The patients who underwent ESWT received an average of 3 treatment sessions with 1,500 impulses/session of 0.10-0.13 mJ/mm2. According to the UCLA rating system, the mean score for the arthroscopy group improved from 9.36 (5.2) to 30.3 (7.62) points after 24 months, with 81.81% reporting good or excellent results. In the ESWT group, the mean score after 24 months rose from 12.38 (6.5) to 28.13 (9.34) points, with 70.83% reporting good or excellent results. After 2 years of follow-up, no calcific deposits were present in 86.35% of the arthroscopy patients and in 58.33 % of the ESWT patients.[2] Lorbach et al evaluated preoperative deposit stage, postoperative deposit elimination, and preoperative ESWT on the treatment of tendinosis calcarea. Of 45 patients studied, the 24 patients who underwent ESWT before surgery did not show better results than those who did not receive ESWT. The authors concluded that arthroscopic removal of calcific deposits provides good clinical results for pain reduction, shoulder function, and patient satisfaction but that the type of calcific deposit and preoperative treatment with ESWT did not have any significant impact on the postoperative results. [3] Adamietz et al studied 102 patients with 115 painful shoulder joints who underwent low-dose radiotherapy. Radiotherapy consisted of 2 series, with a total dose of 6.0 Gy. According to the authors, pain relief was achieved in 94 of 115 joints (82%) at a follow-up of a median of 18 months. They noted that low-dose radiotherapy showed the greatest benefit in patients with Farin type III calcification.[4]

Calcific tendonitis supraspinatus tendon

by Nathan Wei, MD, FACP, FACR Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores. Click here: Second Opinion Arthritis Treatment Kit

Calcifying tendinitis is a diagnosis made from imaging studies or from direct inspection of the affected tendon.

Therefore, it is a description of a morphologic status. Calcifying tendinitis may be an incidental finding in an asymptomatic shoulder, or it may be the cause of shoulder pain. However, calcification may be found in a painful shoulder yet not be the cause of pain. Indeed, considering that calcific deposits are found in 3-20% of painless shoulders and 7% of painful shoulders, the calcific deposit may not be the cause of shoulder pain in many cases. The incidence of calcification of the rotator cuff in the general population without shoulder symptoms is 3-20% according to different reports. The highest incidence is in adults aged 30-50 years. Among Europeans and Americans, no examples of patients older than 71 years were found, but a study of Taiwanese shoulders disclosed that most subjects were older than 60 years. American surgeons believe that the incidence of symptomatic calcifying tendinitis has declined in the last 20 years.
The supraspinatus tendon is affected most often. Calcification is observed with decreasing frequency in the infraspinatus, teres minor, and subscapularis tendons. More than one tendon may be involved. Women are affected slightly more frequently than are men, and the right shoulder is affected slightly more often than is the left. Both shoulders had or developed calcific deposits in 13-47% of subjects. Housewives and clerical workers account for most cases. The calcific deposit usually is described as being approximately 1-2 cm proximal to the tendon insertion on the greater tuberosity. The cause of calcifying tendinitis is not known. It generally is agreed that it is not caused by trauma, and it rarely is part of a systemic disease. The pathophysiology of calcifying tendinitis is controversial. The early hypothesis of Codman and others was that calcification is a consequence of age-related tendon degeneration; however, this is not supported by the following observations: The peak incidence of calcifying tendinitis occurs at an earlier age than that of degeneration (at least outside of Taiwan). Calcifying tendinitis, in contrast to degenerative tendinopathy, may resolve, and the tendon heals spontaneously.

Calcifying tendinitis rarely is associated with tears of the rotator cuff. Treatment includes anti-inflammatory drugs, percutaneous needle aspiration and surgery. Ultrasound therapy is frequently used for a number of painful musculoskeletal disorders, but clinical efficacy for most applications has not been evaluated. Ebenbichler and colleagues conducted a sham-controlled study to evaluate the efficacy of pulse ultrasound therapy for calcific tendonitis. The randomized, double-blind study was conducted in Vienna, Austria, and included 54 patients (61 shoulders). The diagnosis of calcific tendonitis was based on radiographic and ultrasonographic evidence of calcific tendonitis. The diameter of the calcification had to exceed 5 mm, and all patients had to have pain or restricted range of motion in the affected shoulder for at least four weeks. Exclusion criteria were a prior history of shoulder surgery, a corticosteroid injection within the past three months or the regular use of analgesics or anti-inflammatory drugs. Ultrasound therapy was administered five times per week for three weeks, followed by three times weekly for three weeks, for a total of 24 treatments. Each session lasted 15 minutes. The primary outcome of the study was a radiographic change in the calcium deposits at the end of the 24 treatments and at a nine-month follow-up visit. Secondary outcomes included an assessment of pain in the shoulder, active range of motion, strength of the shoulder and the patient's ability to perform activities of daily living. A pain score was also used to evaluate outcome. The ultrasound therapy group included 32 shoulders, and the sham treatment group included 29 shoulders. The mean age of patients in the ultrasound group was 49 years and the mean age of those in the sham group was 54 years. Radiologic evaluation of the ultrasound group revealed that the calcium deposits had resolved in six shoulders (19 percent) and had decreased by at least 50 percent in nine shoulders (28 percent). In the sham treatment group, calcium deposits did not resolve in any patient and decreased by at least 50 percent in three (10 percent) of the shoulders. At the nine-month follow-up evaluation, calcium deposits had resolved in 13 (42 percent) of the shoulders in the ultrasound treatment group. An additional seven shoulders (23 percent) were found to demonstrate improvement. In contrast, in the sham treatment group resolution occurred in two shoulders (8 percent) and improvement was noted in three shoulders (12 percent). Clinical improvement was significantly more common in the ultrasound therapy group than in the sham treatment group. Twenty-nine shoulders (91 percent) in the ultrasound group demonstrated improvement, compared with 15 shoulders (52 percent) in the sham treatment group. The ultrasound group had a greater decrease in pain and more improvement in quality of life. The authors conclude that ultrasound therapy is of definite benefit in patients with symptomatic calcific tendonitis. It helps eliminate the calcifications and provides at least short-term symptomatic relief. These findings are consistent with several other studies. The authors note that the way in which ultrasound stimulates resorption of calcium deposits is not known. It may increase blood flow and metabolism in the affected area, thus facilitating disintegration of calcium deposits. Your doctor's first goal will be to control your pain and inflammation. Initial treatment is likely to be rest and anti-inflammatory medication, such as ibuprofen. The anti-inflammatory medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone can be very effective at temporarily easing inflammation and swelling. When the calcium deposits are being reabsorbed, the pain can be especially bad. Your doctor may suggest trying to remove the calcium deposit by inserting two large needles into the area and rinsing with sterile saline. (Saline is simply a saltwater solution.) This procedure is called lavage. Sometimes lavage breaks the calcium particles loose. Then they can be removed with the needles. Getting rid of the calcium deposits can help speed up the healing. Even when lavage fails to remove calcium deposits, it reduces pressure in the tendon, leading to less pain.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, therapy focuses on easing your pain and inflammation. Treatments may include heat or ice. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder. Later, strengthening exercises will help you improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities. You may need therapy treatments for up to six or eight weeks. Most patients are able to get back to their activities with full use of their arm within this time. the pain and loss of movement continue to get worse or interfere with your daily life, you may need surgery. Surgery for calcific tendonitis does not require patients to stay in the hospital overnight. It does require anesthesia. Most surgeries to correct calcific tendonitis of the shoulder are arthroscopic surgeries. The arthroscope is a special TV camera that can be inserted into the shoulder joint through a small incision in the skin. Other small incisions allow the surgeon to insert small surgical instruments into the joint as well. The surgeon uses the arthroscope to locate the calcium deposit in the rotator cuff tendon. Once the deposit is found, the surgeon uses the small instruments to remove the calcium deposits and rinse the area. Loose calcium crystals must be removed. They can be very irritating to the surrounding tissues. Extracorporeal shock wave lithotripsy (ESWT) may be an alternative to surgery. ESWT allows controlled sonic pulses of short duration to produce transient pressure disturbances in the shoulder with the aim of fragmenting deposits. The procedure aims to improve shoulder function and reduce pain. The mechanism of ESWT on calcifying tendonitis is unknown. ESWT is an established technique for the treatment of renal calculi and has since been used in orthopaedics. FLASH A truly effective treatment for tendonitis is available in the form of percutaneous needle tenotomy with autologous tissue grafting. This is a minimally invasive procedure using a small needle with ultrasound guidance. Blood is drawn from a patient and spun in a special centrifuge in order to harvest the platelet rich plasma component. Platelets are cells that contain multiple growth and healing factors. The patient then has the skin over the inflamed bursa anesthetized with local lidocaine. A small needle is introduced into the bursa and multiple tiny holes are made. The platelet rich plasma is then injected. Healing then occurs.

In rare instances, open surgery is necessary. In open surgery, the doctor gets to the calcium deposit by cutting through muscles and other surrounding tissues. The tendon itself is then cut to allow removal of the calcium deposits. The doctor then rinses the area to get rid of calcium crystals and stitches the muscles and skin together.