Ultrasound therapy for calcific tendinitis of the shoulder

Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy

HYPOTHESIS

Ultrasound (US)-guided needling with subacromial corticosteroid injection is more effective than extracorporeal shock wave therapy (ESWT) for function restoration and pain relief in patients with calcific tendinitis of the shoulder.

METHODS

Fifty-four patients diagnosed with unilateral painful calcific tendinitis were randomly allocated to a US needling or ESWT group. The US needling group underwent US-guided needling and received a subacromial corticosteroid injection. The ESWT group received ESWT 3 times a week. All patients were prospectively evaluated; American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale for pain scores were recorded before the procedure and at 6 weeks, 12 weeks, 6 months, 12 months, and the last follow-up. The size and morphology of the deposits were evaluated by radiography.

RESULTS

The average follow-up period was 23.0 months. At last follow-up, the mean size of the deposits was significantly different between the 2 groups (P = .001); it decreased to 0.5 mm from 14.8 mm in the US needling group and to 5.6 mm from 11.0 mm in the ESWT group. There were also significant improvements in clinical outcomes in both groups after treatment (P < .05). At 1-year follow-up, the US needling group had significantly better scores than the ESWT group with regard to the American Shoulder and Elbow Surgeons assessment (90.3 and 74.6, respectively; P = .001), Simple Shoulder Test (83.3 and 70.8, respectively; P = .015), and visual analog scale for pain (1.4 and 3.3, respectively; P = .003).The initial calcium deposit sizes and clinical outcomes were weakly correlated in both groups (P > .05).

CONCLUSION

Both treatment modalities for calcific tendinitis improved clinical outcomes and eliminated calcium deposits. US-guided needling treatment, however, was more effective in function restoration and pain relief in the short term.

Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis

BACKGROUND

This meta-analysis assessed the short-term to midterm effectiveness of minimally invasive treatments in the management of calcifying tendinopathy of the shoulder cuff, a common source of chronic shoulder pain that leads to pain, a decreased active range of motion, and loss of muscular strength. When conservative therapies fail, minimally invasive treatment options can be considered before resulting to surgery.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this review. A systematic literature search was conducted in May 2013 to identify all studies that examined the short-term to midterm effectiveness of minimally invasive treatments for chronic calcifying tendinopathy. The primary end points were identified as function, pain, and total resorption rates. Grades of Recommendation Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence.

RESULTS

Included were 20 studies (1544 participants). Common methodological flaws were related to randomization. In general, there is moderate-quality GRADE evidence that high-energy extracorporeal shockwave therapy has a significant effect on pain relief and functional status compared with other interventions. There is variable-quality GRADE evidence on the efficiency of other interventions.

CONCLUSION

High-energy extracorporeal shockwave therapy is the most thoroughly investigated minimally invasive treatment option in the short-term to midterm and has proven to be a safe and effective treatment. Ultrasound-guided needling is safe but has not been proven to be more effective than an ultrasound-guided subacromial corticosteroid injection in recent level I research, and further research will have to prove its effectiveness.

Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Treatment of nongout joint deposition diseases: an update

This update develops the actual therapeutic options in the management of the joint involvement of calcium pyrophosphate deposition disease (CPPD), basic calcium phosphate (BCP) deposition disease, hemochromatosis (HH), ochronosis, oxalosis, and Wilson's disease. Conventional pharmaceutical treatment provides benefits for most diseases. Anti-interleukine-1 (IL-1) treatment could provide similar results in CPPD than in gout flares. There is only limited evidence about the efficacy of preventive long-term colchicine intake, methotrexate, and hydroxychloroquine in chronic CPPD. Needle aspiration and lavage have satisfactory short and midterm results in BCP. Extracorporeal shockwave therapy has also proved its efficacy for high-doses regimes. Phlebotomy does not seem to have shown real efficacy on joint involvement in HH so far. Iron chelators' effects have not been assessed on joint involvement either, while IL-1 blockade may prove useful. NSAIDs have limited efficacy on joint involvement of oxalosis, while colchicine and steroids have not been assessed either. The use of nitisinone for ochronotic arthropathy is still much debated, but it could provide beneficial effects on joint involvement. The effects of copper chelators have not been assessed either in the joint involvement of Wilson's disease. NSAIDs should be avoided because of the liver affection they may worsen.

The intraoperative use of ultrasound facilitates significantly the arthroscopic debridement of calcific rotator cuff tendinitis

INTRODUCTION

During arthroscopy, the localization of calcific deposit in patients suffering from calcifying tendinitis can be demanding and time consuming, frequently using ionizing radiation. Intraoperative ultrasound has been recently promoted, facilitating deposit localization and reducing radiation dose.

MATERIAL AND METHODS

In this prospective, randomized, controlled and clinical observer-blinded pilot trial, 20 patients with calcific tendinitis were operated. In group I, the deposit was localized conventionally. In group II, the deposit was localized using intraoperative ultrasound. The needle punctures to detect the deposit and operation times were noted. Patients were postoperatively evaluated after 2 and 6 weeks and 9 months.

RESULTS

In group II, the needle punctures to detect the deposit were significantly lower than in group I (p < 0.0001). Operation time to localize the deposit was also significantly less in group II (p < 0.033). In both groups, patients improved significantly with increased shoulder function (p < 0.0001) and decreased pain (p < 0.0001) 2 weeks and 9 months (p < 0.001) after surgery. The difference between the groups was not significant. Excellent radiological findings were obtained in both groups after 9 months.

CONCLUSIONS

Intraoperative US significantly facilitates the detection of calcific deposits during arthroscopic debridement by speeding up surgery and reducing the number of needle punctures. Hence, we have changed our method of detecting calcific deposits intraoperatively from fluoroscopy to ultrasound.

Arthroscopic Removal of Chronic Symptomatic Calcifications of the Supraspinatus Tendon Without Acromioplasty: Analysis of Postoperative Recovery and Outcome Factors

BACKGROUND

Little knowledge exists on postoperative recovery of pain and shoulder function following arthroscopic removal of calcific deposits of the supraspinatus tendon (ACDSSP). Certain factors may influence outcome, including acromial morphology.

PURPOSE

To examine postoperative recovery following ACDSSP without acromioplasty and to analyze influential outcome factors.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This prospective study evaluated 82 patients (105 shoulders) after ACDSSP without acromioplasty. Time periods for postoperative recovery of pain and subjective shoulder function were recorded. The absolute and normalized Constant scores (CSabs and CSnorm, respectively), Oxford Shoulder Score (OSS), DASH score (DS), and subjective shoulder value (SSV) were measured after a mean follow-up of 33.9 months. Analyzed outcome factors included localization of the calcific deposit (CD), acromial morphology, radiographic extent of CD removal, type of nonoperative treatment, and preoperative duration of symptoms.

RESULTS

Mean duration of postoperative pain was 2.2 weeks. Recovery of subjective shoulder function required 11.1 weeks on average. Mean ± standard deviation follow-up values were 91.1 ± 8.3 for CSabs, 104.2% ± 8.2% for CSnorm, 13.1 ± 2.6 for OSS, 1.81 ± 4.59 for DS, and 93.8% ± 10.7% for SSV. Abduction was significantly (P = .008) lower in patients with type III (170° ± 17.5°) compared with type I (174° ± 20.7°) and type II (179° ± 4.5°) acromions. Also, abduction was significantly (P = .001) lower in patients with long-standing symptoms (>72 months). Minor calcific remnants were found in 19 of 105 shoulders (18.1%), but affected neither postoperative recovery nor outcome.

CONCLUSION

ACDSSP without acromioplasty yielded favorable outcomes and effected fast remission of pain regardless of acromial morphology. However, recovery of subjective shoulder function required almost 3 months on average. Minimal restriction of abduction occurred in patients with hook-shaped acromions and long-standing preoperative symptoms. The present data do not support routine performance of acromioplasty.

Nonpharmacologic and pharmacologic management of CPP crystal arthritis and BCP arthropathy and periarticular syndromes

Calcium crystal arthritis is often unrecognized, poorly managed, and few effective therapies are available. The most common types of calcium crystals causing musculoskeletal syndromes are calcium pyrophosphate (CPP) and basic calcium phosphate (BCP). Associated syndromes have different clinical presentations and divergent management strategies. Acute CPP arthritis is treated similarly to acute gouty arthritis, whereas chronic CPP and BCP arthropathy may respond to strategies used for osteoarthritis. Calcific tendonitis is treated with a variety of interventions designed to dissolve BCP crystals. A better understanding of the causes and larger well-planned trials of current therapies will lead to improved care.

Comparision of ultrasound therapy of various durations in the treatment of subacromial impingement syndrome

[Purpose] A prospective, randomized, single-blind study was performed in order to compare the efficacy of ultrasound treatments of various durations for patients with subacromial impingement syndrome. [Subjects and Methods] One hundred patients who had been diagnosed with subacromial impingement syndrome by clinical examination and magnetic resonance imaging were included in this study. Patients were randomly divided into two groups of fifty patients per group. The first group received 15 sessions of therapeutic ultrasound (4 minutes), superficial heat and transcutaneous electrical stimulation therapy combined with exercise. The second group received the same treatment except that each of the 15 ultrasound sessions were eight minutes in length. The patients were evaluated before and after the treatment. A visual analog scale (VAS) was used to assess pain, the University of California at Los Angeles (UCLA) and Constant Scale were used to assess shoulder function and the Beck Depression Inventory (BDI) was used to quantify depressive symptoms. [Results] There were no statistically significant differences between the groups in age, time since the onset of pain, sex, education and depression levels prior to the treatment. The post-treatment evaluation of patients VAS, UCLA, Constant, and BDI scores showed statistically significant within group improvements. When the two groups were compared, we found no statistically significant differences in the Constant activities of daily living, Constant external rotation, Constant force and BDI scores. However, the second group scored better than the first group in all the remaining parameters. [Conclusion] Ultrasound therapy was found to have beneficial effects on pain and functional status in the treatment of subacromial impingement syndrome. Eight minutes of ultrasound treatment was shown to be more effective than 4 minutes of ultrasound treatment.

Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids

BACKGROUND

Calcific tendinitis of the rotator cuff (RCCT) is frequently diagnosed in patients with shoulder pain, but there is no consensus on its treatment.

PURPOSE

To compare 2 regularly applied RCCT treatments: ultrasound (US)-guided needling and lavage (barbotage) combined with a US-guided corticosteroid injection in the subacromial bursa (subacromial bursa injection [SAI]) (group 1) versus an isolated SAI (group 2).

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients were randomly assigned to the 2 groups. Shoulder function was assessed before treatment and at regular follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant shoulder score (CS, primary outcome), the Western Ontario Rotator Cuff Index (WORC), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Additionally, calcification location, size, and Gärtner classification were assessed on radiographs. Results were analyzed using the t test, linear regression, and a mixed model for repeated measures.

RESULTS

This study included 48 patients (25 female, 52.1%; mean age, 52.0 ± 7.3 years; 23 patients in group 1) with a mean baseline CS of 68.7 ± 11.9. No patients were lost to follow-up. Four patients in group 1 and 11 in group 2 (P = .06) had an additional barbotage procedure or surgery during the follow-up period because of persisting symptoms and no resorption. At 1-year follow-up, the mean CS in group 1 was 86.0 (95% CI, 80.3-91.6) versus 73.9 (95% CI, 67.7-80.1) in group 2 (P = .005). The mean calcification size decreased by 11.6 ± 6.4 mm in group 1 and 5.1 ± 5.7 mm in group 2 (P = .001). There was total resorption in 13 patients in group 1 and 6 patients in group 2 (P = .07). With regression analyses, correcting for baseline CS and Gärtner type, the mean treatment effect was 20.5 points (P = .05) in favor of barbotage. Follow-up scores were significantly influenced by baseline scores. Results for the DASH and WORC were similar.

CONCLUSION

On average, there was improvement at 1-year follow-up in both treatment groups, but clinical and radiographic results were significantly better in the barbotage group.

Rotator cuff preservation in arthroscopic treatment of calcific tendinitis

PURPOSE

We sought to evaluate (1) clinical and radiologic results after arthroscopic calcific deposit (CD) removal and (2) the relevance of remnant calcifications (RCs).

METHODS

The study included 102 patients undergoing arthroscopic CD removal, preserving integrity of the rotator cuff. Postoperatively, we divided patients into 2 groups according to the extent of CD removal achieved. Group 1 consisted of patients with complete CD removal. Group 2 included patients showing minor RCs. Ninety-three patients (99 shoulders) completed follow-up. The mean patient age was 50.6 years (31 to 68 years), and the mean follow-up period was 37.3 months (24 to 83 months). We obtained anteroposterior (AP) and outlet radiographs before surgery, postoperatively, and at follow-up. We used the absolute and age- and sex-related Constant scores (CSabs, CSrel) as outcome measures. We compared both groups statistically (Mann-Whitney U test; P < .05).

RESULTS

Complete CD removal was achieved in 82 of 99 (82.8%) shoulders (group 1). Postoperatively, minor RCs were found in 17 of 99 (17.2%) shoulders (group 2), an average of 58.6% (± 26.2) of the mean preoperative size. All RCs showed complete (14 of 17) or virtually complete (3 of 17) resolution at follow-up. Overall mean CSabs and CSrel were 88.8 points (± 10.4) and 99.0% (± 3.7), respectively. Mean values of CSabs and CSrel in group 1 (89.5 points ± 9.5 and 99.1% ± 3.7, respectively) and group 2 (86.1 points ± 12.9 and 98.7% ± 4.2, respectively) did not differ.

CONCLUSIONS

Arthroscopic CD removal, preserving integrity of the rotator cuff yielded good to excellent results in 90% of patients and avoided iatrogenic tendon defects in all patients. Minor RCs did not impair clinical outcome and spontaneously resolved at follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in the general population

OBJECTIVE

To determine the incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in a general urban adult population.

STUDY DESIGN

Observational study in a municipal medical center.

SETTING

Single tertiary referral center.

METHODS

All symptomatic patients with a differential diagnosis of retropharyngeal calcific tendinitis underwent fiber-optic assessment, laboratory studies, and imaging studies. The main outcome measure was the incidence of retropharyngeal calcific tendinitis.

RESULTS

Thirteen patients with symptoms suggestive of retropharyngeal calcific tendinitis were evaluated in our institution between January 2008 and December 2011. Final diagnosis was made by means of a computed tomographic scan: 8 patients had retropharyngeal calcific tendinitis, 1 had retropharyngeal abscess, and the remaining 4 had other deep neck infections. The mean annual crude retropharyngeal calcific tendinitis incidence was 0.50 cases per 100,000 person-years, and the standardized incidence was 1.31 for the age-matched population.

CONCLUSIONS

Retropharyngeal calcific tendinitis is not a rare disease and is probably underdiagnosed because symptoms are nonspecific, treating physicians are often unfamiliar with this entity, and it is a self-limiting pathology.

Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review

OBJECTIVE

To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge.

DATA SOURCES

The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases.

STUDY SELECTION

Two reviewers independently selected relevant reviews and randomized clinical trials.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included. Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were more effective (moderate evidence) than was placebo treatment in the short- and long-term.

CONCLUSIONS

This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Atraumatic quadriceps tendon tear associated with calcific tendonitis

Calcific tendonitis of the quadriceps tendon is an uncommon condition. We present the first case of a quadriceps tendon tear associated with calcific tendonitis. In this case, the patient presented with symptoms mimicking a rupture of the quadriceps tendon. This case illustrates that although calcific tendonitis of the quadriceps is a rare condition it is not benign and should be considered when investigating acute symptoms associated with the extensor mechanism of the knee.

The role of MRI in musculoskeletal practice: a clinical perspective

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.

Tendinopathy in sport

CONTEXT

Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited.

EVIDENCE ACQUISITION

The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature.

RESULTS

Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies.

CONCLUSIONS

Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.

O ultrassom é efetivo no tratamento da tendinite calcárea do ombro?

Introdução: A tendinite calcária do ombro é uma calcificação caracterizada pela deposição de sais de cálcio nos tendões do manguito rotador, provocando dor no ombro e perda de amplitude de movimento (ADM). O ultrassom é sugerido como alternativa promissora para facilitar a reabsorção dos depósitos de cálcio. Os mecanismos que fundamentam esse efeito são, entretanto, ainda controversos na literatura, e a utilização clínica do ultrassom na tendinite calcária tem sido baseada mais em evidências empíricas do que científicas. Objetivos: Realizar uma revisão bibliográfica sobre os efeitos biológicos e terapêuticos do ultrassom, a fim de identificar o real papel desse recurso no tratamento da tendinite calcária do ombro. Materiais e métodos: Para sua elaboração, foi feita uma busca bibliográfica em bases de dados eletrônicas e uma pesquisa manual. Resultados: Dentre os estudos selecionados, dois demonstraram redução da dor e do tamanho da calcificação e dois não apresentaram resultados positivos. Discussão: Os benefícios promovidos pelo ultrassom são dependentes dos parâmetros utilizados. Variáveis como o tamanho da área a ser tratada, diferenças teciduais, duração da aplicação e o objetivo da conduta terapêutica também devem ser considerados. Conclusão: Com base nesta revisão, pode-se afirmar que o ultrassom terapêutico é um recurso efetivo no tratamento da tendinite calcária do ombro.

Therapeutic modalities--an updated review for the hand surgeon

The number of therapeutic modalities available to the hand surgeon has greatly increased over the past several decades. A field once predicated only on heat, massage, and cold therapy now uses electrical stimulators, ultrasound, biofeedback, iontophoresis, phonophoresis, mirror therapy, lasers, and a number of other modalities. With this expansion in choices, there has been a concurrent effort to better define which modalities are truly effective. In this review, we aim to characterize the commonly used modalities and provide the evidence available that supports their continued use.

Therapeutic ultrasound affects IGF-1 splice variant expression in human skeletal muscle

BACKGROUND

Animal models of skeletal muscle damage and repair demonstrate that therapeutic ultrasound (TUS) enhances muscle force recovery after damage, increases satellite cell proliferation, and decreases insulin-like growth factor (IGF)-1 splice variant (mechano growth factor) gene expression. However, these effects have not been verified in humans.

PURPOSE

This study was undertaken to examine the 3 known splice variants of the IGF-1 gene in human skeletal muscle after damage and TUS treatment.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixteen healthy men (18-29 years of age), physically active, were randomized to either a control (CON) or experimental group (EXP). The EXP group underwent 200 lengthening contractions (muscle damage) of the quadriceps of both legs, 48 hours before TUS. Both groups received TUS, delivered for 10 minutes on a standardized area of the vastus lateralis of only 1 leg (1.0 MHz, 1.5 W/cm(2)). Bilateral muscle biopsy samples were taken from all participants, 6 hours after TUS. Total RNA was extracted, and quantitative real-time polymerase chain reaction conducted for each IGF-1 splice variant.

RESULTS

Muscle damage was confirmed by a decrease in the isometric peak torque and increase in creatine kinase activity levels 48 hours after damage (P < .01). After muscle damage, gene expression of total IGF-1 and 2 IGF-1 splice variants increased. Therapeutic ultrasound induced significant increase in IGF-1Eb gene expression in undamaged muscle (1.4 ± 0.2-fold, P < 0.01). In damaged skeletal muscle, no significant change in gene expression attributable to TUS was determined.

CONCLUSION

Insulin-like growth factor-1 splice variants are differentially regulated in human skeletal muscle in response to exercise-induced muscle damage and TUS treatment. A single treatment of TUS in damaged muscle induces no change in the gene expression of the 3 IGF-1 splice variants in humans. In contrast, in undamaged skeletal muscle, TUS significantly increased IGF-1Eb splice variant gene expression.

CLINICAL RELEVANCE

These findings suggest that TUS may have additional therapeutic uses beyond its current common practice but may not be effective for muscle injury treatment in a young, healthy population.

Calcific tendonitis of the shoulder: is subacromial decompression in combination with removal of the calcific deposit beneficial?

HYPOTHESIS

We postulated that treatment of patients with calcific tendonitis of the supraspinatus tendon by debridement of the calcific deposit alone was comparable to treatment by debridement and concomitant subacromial decompression.

MATERIALS AND METHODS

During a 10-year period, 50 consecutive patients with calcific tendonitis refractory to nonoperative measures were surgically treated by debridement (D) as an isolated procedure (25 patients) or by debridement and concomitant subacromial decompression (D+SAD; 25 patients), and the surgical groups were retrospectively compared. The main outcome of interest was the time to resumption of unrestricted activity without pain. An abbreviated version of disabilities of the Disabilities of Arm, Shoulder and Hand (QuickDASH) score and University of California-Los Angeles (UCLA) shoulder summary scores were compiled at a mean follow-up of 5 years (range, 2-10 years).

RESULTS

Average time to return to activity without pain was significantly shorter for the D group compared with the D+SAD group (11 vs 18 weeks; P < .006). At the final evaluation, QuickDASH scores were equally low (group D, 6; group D + SAD, 11; P = .191), indicating that both treatment groups had high levels of function. The mean UCLA shoulder scores at final evaluation were 33 for both groups (P = .678).

DISCUSSION

Patients treated by debridement of the calcific deposit and concomitant subacromial decompression required a longer time to return to unrestricted activity without pain.

CONCLUSIONS

Debridement of a calcific deposit alone is a better surgical option to treat calcific tendonitis.

Mechanical means to improve bone strength: ultrasound and vibration

Not all fractures heal well. One method that has been used to improve fracture healing is low-intensity pulsed ultrasound (LIPUS). LIPUS has been US Food and Drug Administration approved for several years, and some preclinical and clinical evidence indicates that fracture healing can be improved by this technique, which appears to be generally safe. There are several suggested mechanisms of action of LIPUS. Clinical studies generally support its usefulness in accelerating fracture healing. A less-established modality is whole body vibration (WBV), which appears to stimulate bone and muscle growth while suppressing adipogenesis in animal studies. Early studies in humans, including some in children with disabilities, suggest that WBV holds promise as a technique for reducing fracture risk. The exact place of WBV in preventing fracture remains to be established.

Local injection/induction of osteoclasts for the treatment of calcified tendinitis

Calcified tendinitis is characterized by calcification in the rotary cuff tendon of the shoulder. The rationale of therapeutic methods is mainly removal of the calcification. Osteoclasts are the principle cells capable of resorbing bone and calcified tissues. Therefore, we hypothesized local injection of cultured human osteoclasts or induction of osteoclasts by recombinant RANKL in vivo may be effective for the treatment of calcified tendonitis. Human osteoclasts cultured in vitro is technically feasible and the osteoclasts are capable of active bone resorption. Thus, injection of osteoclasts may help remove the calcified tendonitis. In addition, human RANKL is commercially available. Therefore, local RANKL injection can recruit peripheral monocytes and macrophages. In the presence of RANKL, these monocytes and macrophages can subsequently differentiate into osteoclasts that can directly resorb calcification via their bone resorbing machinery. Different from the other treatments, the advantage of this therapeutic method includes: (1) less invasive because only local injection/induction of osteoclasts into the calcified lesion is conducted; (2) more efficient by direct osteoclasts injection or using RANKL to recruit osteoclasts to efficiently resorb calcification. Therefore, we proposed local injection/induction of osteoclasts as a potential biological method for clinical treatment of calcified tendinitis.

Enhancement of vancomycin activity against biofilms by using ultrasound-targeted microbubble destruction

Treating biofilm infections on implanted medical devices is formidable, even with extensive antibiotic therapy. The aim of this study was to investigate whether ultrasound (US)-targeted microbubble (MB) destruction (UTMD) could enhance vancomycin activity against Staphylococcus epidermidis RP62A biofilms. Twelve-hour biofilms were treated with vancomycin combined with UTMD. The vancomycin and MB (SonoVue) were used at concentrations of 100 μg/ml and 30% (vol/vol), respectively, in studies in vitro. After US exposure (0.08 MHz, 1.0 W/cm(2), 50% duty cycle, and 10-min duration), the biofilms were cultured at 37 °C for another 12 h. The results showed that many micropores were found in biofilms treated with vancomycin combined with UTMD. Biofilm densities (A(570) values) and the viable counts of S. epidermidis recovered from the biofilm were significantly decreased compared with those of any other groups. Furthermore, the highest percentage of dead cells was found, using confocal laser scanning microscopy, in the biofilm treated with vancomycin combined with UTMD. The viable counts of bacteria in biofilms in an in vivo rabbit model also confirmed the enhanced effect of vancomycin combined with UTMD. UTMD may have great potential for improving antibiotic activity against biofilm infections.

[Basic calcium phosphate crystal deposition disease]

Hydroxyapatite crystals are a common cause of periarticular disease. Virtually, any joint can be involved, but the shoulder is by far most commonly involved. These calcifications, often asymptomatic, can lead to an acute microcrystalline tendinitis or bursitis, which may simulate infection. The diagnosis of periarticular calcifications relies on imaging techniques using X-rays or ultrasounds. Treatment of acute tendinitis or bursitis includes icing, rest, analgesics or non steroidal anti-inflammatory drug and oral steroids or local steroids injection. Removal of the deposit can be considered in patients with chronic pain, particularly at the shoulder.

Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach

Calcific tendinopathy of the rotator cuff is a chronic disease that mostly in the acute phase compromises the articular function. The aim of this study is to estimate the effectiveness of the ultrasonic-guided percutaneous treatment (UGPT) in association with the rehabilitative treatment. We evaluated 106 patients with calcific tendinopathy, treated by UGPT. They underwent clinical evaluation by a physiatrist at T0 (the same day of UGPT), and were reassessed at follow-up 1 month (T1) after treatment. The assessment at T0 and T1 was done by the Constant-Murley scale. Analyzing the results, we found that at T0, the average Constant score was 43.5 out of 100; at T1 it was 83.2 out of 100. The improvement was statistically significant (P < 0.0005). We found that UGPT and rehabilitation associated with the multidisciplinary management of the patient (orthopedic surgeon-radiologist-physiatrist) was able to prevent adhesive bursitis, and to achieve clinical cure in most of the treated cases.

Calcified plaque resorptive status as determined by high-resolution ultrasound is predictive of successful conservative management of calcific tendinosis

OBJECTIVE

In patients with calcific tendinosis, the morphology of calcified plaques is associated with response to conservative management. We aimed to determine changes in pain and morphology of plaques in patients with calcific tendinosis and non-arc-shaped plaques identified by high-resolution ultrasonography who received only conservative treatment.

METHODS

A total of 33 patients with a mean age of 63.3±10.3 years were included. Pain scores at the time of first and follow-up ultrasound were recorded, and the degree of plaque resolution was calculated.

RESULTS

At follow-up, 90.9% (30 of 33) of patients reported improvement in pain, and 84.8% (28 of 33) patient had more than 50% elimination of plaques. Most of increased vascularity observed in color Doppler ultrasonography during 1st visit disappeared at follow-up.

CONCLUSIONS

In patients with calcific tendinosis, non-arc-shaped plaques determined by high-resolution ultrasonography are likely to resolve and conservative management is warranted.

Osteoporosis: nonpharmacologic management

Osteoporosis is a chronic disorder of the skeleton causing increased bone fragility and fractures. In the second of our 3-part series, we discuss the beneficial effects of nonpharmacologic agents in the management of osteoporosis. We review the evidence supporting the use of exercise, whole-body vibration, hip protectors, low-intensity pulsed ultrasound, bracing, and vertebral augmentation procedures. The mechanism of action, precautions, and expected outcomes are discussed. Nonpharmacologic management of osteoporosis blends in very well with an overall exercise prescription. The nonpharmacologic interventions discussed are readily available and easy to implement. The use of such techniques demonstrates the important role of the physiatrist in the management of osteoporosis.

Focal bone abnormality as a complication of ultrasound diathermy: a report of eight cases

PURPOSE

To review the magnetic resonance (MR) imaging findings in eight patients who developed marrow lesions after undergoing physiotherapy with use of ultrasound diathermy.

MATERIALS AND METHODS

The authors retrospectively reviewed the medical charts and MR images of eight patients (six women and two men aged 22-69 years) who received ultrasound diathermy treatment for a variety of soft tissue injuries involving primarily the knee, shoulder, and wrist. All patients underwent MR imaging without the use of intravenous gadolinium-based contrast material. The institutional review board approved the study, and the requirement to obtain informed consent was waived.

RESULTS

MR imaging of all patients revealed subcortical rim or arc lesions with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, without involvement of the deeper aspect of the bone marrow. The imaging features of the lesions were similar to those of focal osteonecrosis. Follow-up MR imaging performed in three patients approximately 2-3 months after cessation of ultrasound therapy revealed resolution of the bone lesions. Symptoms resolved in all patients.

CONCLUSION

This study demonstrated that ultrasound diathermy may produce an osseous injury. The abnormality itself was usually mild and transient, with apparent full recovery after termination of therapy.

Deciphering the pathogenesis of tendinopathy: a three-stages process

Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.

Chronic shoulder pain of myofascial origin: a randomized clinical trial using ischemic compression therapy

OBJECTIVE

The aim of this clinical trial was to evaluate the effect of 15 myofascial therapy treatments using ischemic compression on shoulder trigger points in patients with chronic shoulder pain.

METHODS

Forty-one patients received 15 experimental treatments, which consisted of ischemic compressions on trigger points located in the supraspinatus muscle, the infraspinatus muscle, the deltoid muscle, and the biceps tendon. Eighteen patients received the control treatment involving 15 ischemic compression treatments of trigger points located in cervical and upper thoracic areas. Of the 18 patients forming the control group, 16 went on to receive 15 experimental treatments after having received their initial control treatments. Outcome measures included a validated 13-question questionnaire measuring shoulder pain and functional impairment. A second questionnaire was used to assess patients' perceived amelioration, using a scale from 0% to 100%. Outcome measure evaluation was completed for both groups at baseline after 15 treatments, 30 days after the last treatment, and finally for the experimental group only, 6 months later.

RESULTS

A significant group x time interval interaction was observed after the first 15 treatments, indicating that the experimental group had a significant reduction in their Shoulder Pain and Disability Index (SPADI) score compared with the control group (62% vs 18% amelioration). Moreover, the patients perceived percentages of amelioration were higher in the experimental group after 15 treatments (75% vs 29%). Finally, the control group subjects significantly reduced their SPADI scores after crossover (55%).

CONCLUSION

The results of this study suggest that myofascial therapy using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.

Percutaneous ultrasound-guided treatment of shoulder tendon calcifications: Clinical and radiological follow-up at 6 months()

INTRODUCTION

Calcific tendinitis of the shoulder is a common condition characterized by chronic pain and/or very painful acute episodes. Different treatments are used during painful flare-up, but they are often ineffective. US-guided percutaneous needle aspiration/lavage is proving to be an effective means for eliminating these calcifications.

MATERIALS AND METHODS

We treated 123 consecutive patients (mean age 48 years) with calcific tendinitis of the shoulder. Fifty-five patients had persistent symptoms requiring 2 or more treatments with lavage and intrabursal steroid infiltration. Before and after treatment, US studies were done independently by 2 radiologists with experience in musculoskeletal ultrasound. Results were concordant in over 90% of the cases. Constant Shoulder Scores were calculated before and 6 months after treatment. At 6 months, MRI was performed to identify impingement and/or bursitis.

RESULTS

Post-treatment Constant scores were significantly improved in all 68 patients treated once (Group 1: mean scores 28.6 vs. 81.4) and in 52 of the 55 treated twice or more (Group 2: mean scores 34.1 vs. 71.1) (p < 0.0001 in both cases). Pretreatment Constant scores were similar in patients with and without shoulder impingement on MRI (31.2 vs. 30.9, respectively), but after treatment the impingement group's scores were significantly higher (82.2 vs. 73.3, respectively; p < 0.001).

CONCLUSIONS

US-guided percutaneous needle aspiration/lavage is an effective and economic treatment for calcific tendinitis of the shoulder. Pretreatment MRI should be done to check for impingement since it is often associated with an incomplete response to the first treatment.

[Bilateral calcifying tendinitis of the long tendon of the biceps associated with a SLAP lesion]

Calcifying tendinitis is a common disorder related to deposition of hidroxyapatite crystals, which is most common around the shoulder joint, involving the supraespinosus tendon. It can however, affect almost any tendon at its insertion. Clinical features are variable and include pain and inflammation that often resolves spontaneously. We present a case of bilateral calcifying tendinitis of the long head of the biceps tendon at its insertion on the superior glenoid rim associated with superior labrum antero-posterior tears (SLAP) confirmed by arthroscopy. Calcium deposits were surgically removed and the SLAP lesions were repaired.

Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions

PURPOSE OF REVIEW

To evaluate recent trials and reviews of physical modalities and conservative treatments for selected upper extremity musculoskeletal conditions for evidence supporting their use.

RECENT FINDINGS

Recent evidence suggests that many localized tendinopathies are related more to degenerative than inflammatory processes. With this realization, there is increased emphasis on finding new modalities to treat tendinopathies and other localized musculoskeletal conditions that rely on other than anti-inflammatory mechanisms. Although there is good evidence to support the short-term benefits of corticosteroid injections, convincing evidence in support of other conservative treatments and modalities is generally lacking. Extracorpal shock wave therapy may have significant clinical benefit for calcific tendinitis; however, it requires intravenous sedation in most cases and does not appear to be effective in lateral epicondylitis. The most consistent positive treatment effects for rotator cuff tendinitis were achieved by ultrasound-guided subacromial corticosteroid injection as well as manual therapy in conjunction with therapeutic exercise.

SUMMARY

Although there is evidence supporting the use of several different physical modalities and conservative treatments for upper extremity musculoskeletal conditions, there is a strong need for larger, higher quality randomized controlled trials. Although most studies are able to demonstrate short-term benefits, there is a lack of high-quality data demonstrating that these conservative treatments have long-term benefits, particularly, with regard to functional outcomes.

Calcific tendinitis: a pictorial review

Calcific tendinitis is caused by the pathologic deposition of calcium hydroxyapatite crystals in tendons and is a common cause of joint pain. The disease typically affects the shoulder and hip, with characteristic imaging findings; however, any joint can be involved. Occasionally, calcific tendinitis can mimic aggressive disorders, such as infection and neoplasm, especially on magnetic resonance imaging. Radiologists should be familiar with the imaging findings to distinguish calcific tendinitis from more aggressive processes. Image-guided percutaneous needle aspiration and steroid injection of calcific tendinitis are useful techniques performed by the radiologist for the treatment of symptomatic cases. Familiarity with these procedures and their imaging appearance is an important aspect in the management of this common disease.

Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review

BACKGROUND

Although therapeutic ultrasound is commonly used to treat shoulder injuries, research to date on the ability of ultrasound to improve outcomes for shoulder pathologies is conflicting.

OBJECTIVE

This study aimed to systematically and critically review available literature to ascertain whether beneficial effects of ultrasound were associated with certain shoulder pathologies or particular ultrasound treatment protocols.

METHODS

Five electronic databases were searched, and the included studies, identified through pair consensus, were randomized controlled trials (RCTs) that utilized ultrasound for soft tissue shoulder injury or pain.

STUDY SELECTION AND DATA EXTRACTION

Eight studies included in this review (n=586 patients, median PEDro score=8.0/10) evaluated various parameters, including the duration of patients' symptoms (0-12 months), duty cycle (20% and 100%), intensity (0.1-2.0 W/cm2), treatment time per session (4.5-15.8 minutes), number of treatments (6-39), and total energy applied per treatment (181-8,152 J).

DATA SYNTHESIS

Inconsistent outcome measures among studies precluded meta-analysis; however, 3 RCTs showed statistically significant benefits of ultrasound, 2 of which examined calcific tendinitis. Studies that showed beneficial effects of ultrasound typically had 4 times longer total exposure times and applied much greater ultrasound energy per session (average of 4,228 J) compared with studies that showed no benefit of ultrasound (average of 2,019 J). No studies that delivered < or = 720 J per session showed improvement in treatment groups.

LIMITATIONS

Current research involving ultrasound treatment protocols that delivered low levels of ultrasound energy do not adequately address whether ultrasound can improve outcomes for shoulder disorders.

CONCLUSION

Determining whether therapeutic ultrasound can affect soft tissue shoulder pathologies will require further research and systematic reviews that involve appropriate ultrasound treatment protocols.

Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial

BACKGROUND

Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus.

OBJECTIVE

The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS.

DESIGN

The study was designed as a randomized clinical trial.

SETTING

The study was conducted in a university hospital.

PATIENTS

Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group.

INTERVENTION

Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks.

MEASUREMENTS

Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST).

RESULTS

For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool.

LIMITATIONS

This study was limited by sample size, lack of a control or placebo group, and follow-up period.

CONCLUSIONS

Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.

Calcifying tendinitis of the shoulder: advances in imaging and management

Calcifying tendonitis of the shoulder is a common, acute or chronic, painful disorder characterized by calcifications in the rotator cuff tendons. A natural cycle exists during which the tendon repairs itself. In chronic calcific tendonitis, however, this cycle is blocked at one of the healing stages. Because chronic presentation with exacerbations is usual, initial treatment should be conservative, including rest, physical therapy, nonsteroidal anti-inflammatory drugs, and, in later stages, subacromial infiltration with corticosteroids. Surgery is recommended when conservative treatment fails. This article discusses advances in imaging and medical, physical, and surgical management, as well as current evidence for the treatment of calcifying tendonitis of the shoulder.