Extracorporeal shock wave therapy in calcific tendinitis of the shoulder

High Versus Low-Energy Extracorporeal Shockwave Therapy for Chronic Lateral Epicondylitis: A Retrospective Study

Background: Chronic lateral epicondylitis (LE), also known as tennis elbow, affects 1-3% of the population, primarily those over 40 years old. Most cases resolve with conservative treatments, but some require more advanced interventions. Extracorporeal shockwave therapy (ESWT) has emerged as a non-surgical treatment option, utilizing either low- or high-energy levels to alleviate pain and improve function. Objective: This study aimed to compare the efficacy of low-energy versus high-energy ESWT in the treatment of chronic LE, focusing on pain relief and functional improvement. Methods: A retrospective observational study was conducted including patients treated for chronic LE between 2021 and 2024. Participants were divided into two groups: low-energy ESWT (0.10 mJ/mm2) and high-energy ESWT (0.20 mJ/mm2). Both groups received 2400 pulses at a frequency of 6 Hz once a week for three weeks. Pain and functional outcomes were measured using a visual analog scale (VAS) and the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE) at the baseline, three months (T1), and six months (T2) post-treatment. Results: Forty-six patients participated, with 24 in the low-energy group and 22 in the high-energy group. Baseline demographics and clinical characteristics were similar across groups. At T1 and T2, the low-energy group showed significantly greater reductions in the VAS scores (T1: 4.45 ± 0.8 vs. 3.6 ± 1.7, p = 0.04; T2: 3.2 ± 1.2 vs. 2.1 ± 1.1, p = 0.004) and PRTEE scores (T1: 34.3 ± 6.9 vs. 26.8 ± 11.9, p = 0.03; T2: 25.3 ± 6 vs. 17.6 ± 9, p = 0.005). Significant treatment-time interactions were observed for both the VAS and PRTEE scores, indicating sustained improvements in the low-energy group. Conclusions: Low-energy ESWT was more effective than high-energy ESWT in treating chronic LE, providing greater and longer-lasting pain relief and functional improvement. These findings suggest that low-energy ESWT should be preferred in clinical practice for managing this condition. Future research should focus on larger sample sizes and randomized controlled trials to confirm these results and explore the underlying mechanisms of differential efficacy between energy levels.

Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice

OBJECTIVE

To summarise current data regarding the use of imaging in crystal-induced arthropathies (CiAs) informing a European Alliance of Associations for Rheumatology task force.

METHODS

We performed four systematic searches in Embase, Medline and Central on imaging for diagnosis, monitoring, prediction of disease severity/treatment response, guiding procedures and patient education in gout, calcium pyrophosphate dihydrate deposition (CPPD) and basic calcium phosphate deposition (BCPD). Records were screened, manuscripts reviewed and data of the included studies extracted. The risk of bias was assessed by validated instruments.

RESULTS

For gout, 88 studies were included. Diagnostic studies reported good to excellent sensitivity and specificity of dual-energy CT (DECT) and ultrasound (US), high specificity and lower sensitivity for conventional radiographs (CR) and CT. Longitudinal studies demonstrated sensitivity to change with regard to crystal deposition by US and DECT and inflammation by US and structural progression by CR and CT. For CPPD, 50 studies were included. Diagnostic studies on CR and US showed high specificity and variable sensitivity. There was a single study on monitoring, while nine assessed the prediction in CPPD. For BCPD, 56 studies were included. There were two diagnostic studies, while monitoring by CR and US was assessed in 43 studies, showing a reduction in crystal deposition. A total of 12 studies with inconsistent results assessed the prediction of treatment response. The search on patient education retrieved two studies, suggesting a potential role of DECT.

CONCLUSION

This SLR confirmed a relevant and increasing role of imaging in the field of CiAs.

Common treatment strategies for calcium hydroxyapatite deposition disease: a cost-effectiveness analysis

OBJECTIVE

To determine the cost-effectiveness of rotator cuff hydroxyapatite deposition disease (HADD) treatments.

METHOD

A 1-year time horizon decision analytic model was created from the US healthcare system perspective for a 52-year-old female with shoulder HADD failing conservative management. The model evaluated the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) of standard strategies, including conservative management, ultrasound-guided barbotage (UGB), high- and low-energy extracorporeal shock wave therapy (ECSW), and surgery. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2022 US dollars. The willingness-to-pay (WTP) threshold was $100,000.

RESULTS

For the base case, UGB was the preferred strategy (0.9725 QALY, total cost, $2199.35, NMB, $95,048.45, and ICER, $33,992.99), with conservative management (0.9670 QALY, NMB $94,688.83) a reasonable alternative. High-energy ECSW (0.9837 QALY, NMB $94,805.72), though most effective, had an ICER of $121, 558.90, surpassing the WTP threshold. Surgery (0.9532 QALY, NMB $92,092.46) and low-energy ECSW (0.9287 QALY, NMB $87,881.20) were each dominated. Sensitivity analysis demonstrated that high-energy ECSW would become the favored strategy when its cost was < $2905.66, and conservative management was favored when the cost was < $990.34. Probabilistic sensitivity analysis supported the base case results, with UGB preferred in 43% of simulations, high-energy ECSW in 36%, conservative management in 20%, and low-energy ECSW and surgery in < 1%.

CONCLUSION

UGB appears to be the most cost-effective strategy for patients with HADD, while surgery and low-energy ECSW are the least cost-effective. Conservative management may be considered a reasonable alternative treatment strategy in the appropriate clinical setting.

Extracorporeal Shockwave Therapy (ESWT) in the Management of Diabetic Foot Ulcer: A Prospective Randomized Clinical Trial

Diabetic foot ulcer (DFU) is the most common cause of prolonged hospitalization with a high cost of care due to unsatisfactory outcomes with the current mode of therapy. Extracorporeal shockwave therapy (ESWT) is a new technology in the care of nonhealing wounds. The study's main objective was to compare the healing parameters of DFUs between patients undergoing the standard of care (SOC) alone and ESWT + SOC. The secondary objective was to assess inflammatory markers in both study groups. The study was designed as a single-center, randomized trial to provide evidence on the effects of ESWT on DFU healing. Informed consent was obtained from all participants before enrolment. Forty-eight participants were recruited, enrolled, and randomly allocated into the 2 study groups. Twenty-five patients were allocated to the ESWT + SOC group, and 23 patients were allocated into the SOC-only group for a treatment period of 6 weeks. The univariate binary analysis showed more patients with healed DFU in the ESWT + SOC group than the SOC-only group at 6 weeks, though the difference did not reach statistical significance (OR = 3.2, p = .07). The adjusted multivariate binary analysis confirmed this finding; however, the effect size did not reach statistical significance at 6 weeks (OR = 3.9, p = .08). The level of circulating inflammatory markers was similar in both groups of patients. It is the author's opinion that there is a potential benefit of ESWT on diabetic wound healing with further research warranted to determine its role in treatment of DFU. A larger trial with a more extended treatment period is, however, needed to substantiate our findings.

Ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinosis. What radiologist should know

Rotator cuff calcific tendinopathy is a common condition caused by the presence of calcification into the rotator cuff or in the subacromial-subdeltoid bursa. The pathogenetic mechanism of this pathology is still debated. Calcific tendinitis frequently affects the rotator cuff and may cause shoulder pain and reduction of range of motion. It can be diagnosed with conventional radiography, ultrasound, or magnetic resonance imaging. The first therapeutic option includes conservative management based on rest, physical therapy, and oral non-steroid anti-inflammatory administration. Extracorporeal shock wave therapy is a noninvasive technique that can be useful for the fragmentation of calcific deposits. Imaging-guided percutaneous irrigation is currently considered the gold standard technique for the treatment of calcific tendinitis due to its minimal invasiveness and its success rate of about 80%.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries

ABSTRACT

Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Effectiveness of Focused Shockwave Therapy versus Radial Shockwave Therapy for Noncalcific Rotator Cuff Tendinopathies: A Randomized Clinical Trial

Background

The superiority of focused shockwave therapy (F-SWT) versus radial shockwave therapy (R-SWT) for treating noncalcific rotator cuff tendinopathies remains controversial. This study is aimed at comparing the effectiveness of F-SWT versus R-SWT for the management of noncalcific rotator cuff tendinopathies.

Methods

A total of 46 patients affected by noncalcific rotator cuff tendinopathies were randomly divided into 2 groups of 23 individuals. Patients in group A received 4 sessions of F-SWT, while patients in group B were treated by 4 sessions of R-SWT. In each session, mean energy flux density (EFD) for F-SW 3000 shots was 0.09 ± 0.018 mJ/mm² with 5.1 ± 0.5 Hz, while average pressure for R-SW 3000 shots was 4.0 ± 0.35 bar with 3.2 ± 0.0 Hz. Pain level and shoulder function were assessed with the numerical rating scale (NRS) and Constant-Murley Scale (CMS). The primary endpoint was the change in the mean NRS pain score from baseline to 24 weeks after the intervention. Secondary endpoints were changes in the mean NRS pain scores at all other follow-up points, changes in the mean CMS scores, and radiographic findings.

Results

There were no significant differences between the two groups regarding NRS pain score and CMS score within 24 weeks after intervention (all p > 0.05). However, F-SWT resulted in significantly lower NRS compared with R-SWT at 24 weeks and 48 weeks after treatment (2.7 ± 1.0 vs. 4.5 ± 1.2 and 1.4 ± 1.0 vs. 3.0 ± 0.8, respectively, all p < 0.001). Similar results were found in CMS changes and radiographic findings.

Conclusions

Both F-SWT and R-SWT are effective in patients with noncalcific rotator cuff tendinopathy. F-SWT proved to be significantly superior to R-SWT at long-term follow-up (more than 24 weeks). This trial is registered with ChiCTR1900022932.

Comparison of efficacy of corticosteroid injection versus extracorporeal shock wave therapy on inferior trigger points in the quadratus lumborum muscle: a randomized clinical trial

BACKGROUND

In this study, we aimed to compare the efficacy of corticosteroid trigger point injection (TPI) versus extracorporeal shock wave therapy (ESWT) on inferior trigger points in the quadratus lumborum (QL) muscle.

METHODS

In this single-blind randomized clinical trial, 54 low back pain patients with myofascial trigger points on QL muscle were investigated. Participants were randomly allocated into two groups with A and B pockets. Patients in group A underwent radial ESWT and received 5 treatment sessions (1 per week) and actually were not followed-up. However, patients in group B received corticosteroid TPI and received one session of corticosteroid treatment and followed-up for 4 weeks after injection. Oswestry Disability Index (ODI), visual analogue scale (VAS), pain pressure threshold (PPT) and short form (36) health survey (SF-36) were measured in both groups before, two weeks after and four weeks after intervention.

RESULTS

The between group comparison indicated that corticosteroid TPI leaded to significant higher improvements of ODI (P-value< 0.01), VAS (P value< 0.001), and PPT (P-value = 0.001) scores compared to the ESWT group at two-week follow-up time-point. ESWT group recorded significant higher improvement of ODI (P-value< 0.01) and SF-36 (P-value< 0.001) compared to the corticosteroid TPI at 4th week post treatment evaluation. At four-week follow-up time-point, the patients in the ESWT group were 1.46 times more likely to achieve 30% reduction in VAS, 2.67 times more likely to achieve 30% reduction in ODI, and 2.30 times more likely to achieve 20% improvement in SF-36 compared to the participants in corticosteroid TPI group. These results refer to large effect size for all study outcomes in ESWT group (d = 4.72, d = 1.58, d = 5.48, and d = 7.47 for ODI, PPT, SF-36, and VAS, respectively).

CONCLUSION

Corticosteroid TPI was more effective compared to ESWT in short-term controlling of pain and disability caused by myofascial pain syndrome of QL muscle. However, after 4 weeks treatment, ESWT further improved the quality of life and disability and was related with more probability of achievement the minimal clinically important difference concerning pain, disability and quality of life and large effect size for all study outcomes in treated patients compared to corticosteroid TPI.

TRIAL REGISTRATION

www.irct.ir , IRCT20100827004641N14 , retrospectively registered 2019-01-19.

Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine

Extracorporeal shockwave therapy (ESWT) is a popular non-invasive therapeutic modality in the medical field for the treatment of numerous musculoskeletal disorders. This technique first emerged around the 1980s as extracorporeal shockwave lithotripsy and has been studied since then for its application towards orthopedics and traumatology. ESWT works by the emission of acoustic waves (shockwaves) that carry energy and can propagate through tissues. Shockwaves can generate interstitial and extracellular responses, producing many beneficial effects such as: pain relief, vascularization, protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures. The combination of these effects can lead to tissue regeneration and significant alleviation of pain, improving functional outcomes in injured tissue. Considering these facts, ESWT shows great potential as a useful regenerative medicine technique for the treatment of numerous musculoskeletal injuries.

Shock wave therapy for rotator cuff disease with or without calcification

BACKGROUND

Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains equivocal.

OBJECTIVES

To determine the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcification, and to establish its usefulness in the context of other available treatment options.

SEARCH METHODS

We searched Ovid MEDLINE, Ovid Embase, CENTRAL, ClinicalTrials.gov and the WHO ICTRP up to November 2019, with no restrictions on language. We reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that used quasi-randomised methods to allocate participants, investigating participants with rotator cuff disease with or without calcific deposits. We included trials of comparisons of extracorporeal or radial shock wave therapy versus any other intervention. Major outcomes were pain relief greater than 30%, mean pain score, function, patient-reported global assessment of treatment success, quality of life, number of participants experiencing adverse events and number of withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed the certainty of evidence using GRADE. The primary comparison was shock wave therapy compared to placebo.

MAIN RESULTS

Thirty-two trials (2281 participants) met our inclusion criteria. Most trials (25) included participants with rotator cuff disease and calcific deposits, five trials included participants with rotator cuff disease and no calcific deposits, and two trials included a mixed population of participants with and without calcific deposits. Twelve trials compared shock wave therapy to placebo, 11 trials compared high-dose shock wave therapy (0.2 mJ/mm² to 0.4 mJ/mm² and above) to low-dose shock wave therapy. Single trials compared shock wave therapy to ultrasound-guided glucocorticoid needling, ultrasound-guided hyaluronic acid injection, transcutaneous electric nerve stimulation (TENS), no treatment or exercise; dual session shock wave therapy to single session therapy; and different delivery methods of shock wave therapy. Our main comparison was shock wave therapy versus placebo and results are reported for the 3 month follow up. All trials were susceptible to bias; including selection (74%), performance (62%), detection (62%), and selective reporting (45%) biases. No trial measured participant-reported pain relief of 30%. However, in one trial (74 participants), at 3 months follow up, 14/34 participants reported pain relief of 50% or greater with shock wave therapy compared with 15/40 with placebo (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.62 to 1.94); low-quality evidence (downgraded for bias and imprecision). Mean pain (0 to 10 scale, higher scores indicate more pain) was 3.02 points in the placebo group and 0.78 points better (0.17 better to 1.4 better; clinically important change was 1.5 points) with shock wave therapy (9 trials, 608 participants), moderate-quality evidence (downgraded for bias). Mean function (scale 0 to 100, higher scores indicate better function) was 66 points with placebo and 7.9 points better (1.6 better to 14 better, clinically important difference 10 points) with shock wave therapy (9 trials, 612 participants), moderate-quality evidence (downgraded for bias). Participant-reported success was reported by 58/150 people in shock wave therapy group compared with 35/137 people in placebo group (RR 1.59, 95% CI 0.87 to 2.91; 6 trials, 287 participants), low-quality evidence (downgraded for bias and imprecision). None of the trials measured quality of life. Withdrawal rate or adverse event rates may not differ between extracorporeal shock wave therapy and placebo, but we are uncertain due to the small number of events. There were 11/34 withdrawals in the extracorporeal shock wave therapy group compared with 13/40 withdrawals in the placebo group (RR 0.75, 95% CI 0.43 to 1.31; 7 trials, 581 participants) low-quality evidence (downgraded for bias and imprecision); and 41/156 adverse events with extracorporeal shock wave therapy compared with 10/139 adverse events in the placebo group (RR 3.61, 95% CI 2.00 to 6.52; 5 trials, 295 participants) low-quality evidence (downgraded for bias and imprecision). Subgroup analyses indicated that there were no between-group differences in pain and function outcomes in participants who did or did not have calcific deposits in the rotator cuff.

AUTHORS' CONCLUSIONS

Based upon the currently available low- to moderate-certainty evidence, there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. Wide clinical diversity and varying treatment protocols means that we do not know whether or not some trials tested subtherapeutic doses, possibly underestimating any potential benefits. Further trials of extracorporeal shock wave therapy for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review. A standard dose and treatment protocol should be decided upon before further research is conducted. Development of a core set of outcomes for trials of rotator cuff disease and other shoulder disorders would also facilitate our ability to synthesise the evidence.

Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies

OBJECTIVE

Calcium hydroxyapatite depositional disease (HADD) is usually asymptomatic and self-limiting; however, when there is an associated inflammatory process or HADD occurs in an unusual location, it may mimic trauma, infection, or neoplasm. The purpose of this article is to review the imaging features of HADD and how to distinguish it from more worrisome entities that can have similar appearances.

CONCLUSION

An understanding of the presentations of HADD is important to allow early and confident diagnosis. In particular, familiarity with presentations that resemble more ominous pathologies is essential to avoid costly and time-consuming workup or intervention.

Efficacy of Extracorporeal Shockwave Therapy on Calcified and Noncalcified Shoulder Tendinosis: A Propensity Score Matched Analysis

Background

Extracorporeal shock wave therapy (ESWT) had been proved to be beneficial in calcific tendinosis; however, the treatment efficacy in noncalcific tendinosis of rotator cuff still remains controversial. The present study was to compare the outcomes ESWT among the noncalcific rotator cuff tendinosis and different types of calcific tendinosis on the basis of similar shoulder functional status.

Methods

A retrospective, comparative study was conducted with the enrollment of 20 patients in each group through propensity score matching in a 1:1:1 ratio from 291 patients who underwent single ESWT for painful shoulder tendinosis. The patients were divided into three groups which included noncalcified tendinosis (NCTS), type I dense calcified tendinosis of shoulder (DCTS), and type II and type III translucent calcified tendinosis of shoulder (TCTS) according to Gartner and Heyer classification. The clinical evaluation included the subjective pain score with visual analog scale (VAS) and functional outcome with Constant and Murley score (CMS).

Results

Twelve months after ESWT, the VAS in TCTS (1.5 ± 2.48) was statistically significant lower than NCTS (2.9 ± 2.86) and DCTS (3.8 ± 2.46) (p=.011). For the functional outcome, the overall CMS was superior in TCTS than the NCTS and DCTS (86.9 ± 19.7 versus 78.7 ± 18.3 and 71.1 ± 17.8, p=.014). Besides, the subscales of pain score, strength, and range of motion in TCTS improved significantly better than NCTS and DCTS. 70% of patients were complaint-free in TCTS group, which was higher than the NCTS group (15%) and DCTS group (25%) (p<0.05).

Conclusion

The present study indicated that the high-dose ESWT posed superior clinical efficacy in type II/III calcification tendinosis rather than type I calcification and noncalcific shoulder tendinosis.

Comparison of Radial Extracorporeal Shock Wave Therapy and Traditional Physiotherapy in Rotator Cuff Calcific Tendinitis Treatment

Objectives

This study aims to investigate the efficacy of radial extracorporeal shock wave therapy (rESWT) in relieving pain and improving range of motion (ROM) and functionality besides conventional physiotherapy methods in the treatment of chronic rotator cuff calcific tendinitis (RCCT).

Patients and methods

We studied 80 patients (35 males, 45 females; mean age 53.3±9.6 years; range, 40 to 70 years) with chronic RCCT. Patients were randomly divided into two groups: rESWT group (n=40) treated with conventional physiotherapy and rESWT, and control group (n=40) treated only with a conventional physiotherapy program. The traditional physiotherapy program included ultrasound, transcutaneous electrical nerve stimulation, shoulder joint ROM and stretching exercises, and ice applications. All patients received a total of 20 treatments, five days a week for four weeks. rESWT was applied once a week for four weeks in total. Before and after treatment, all patients were evaluated for age, height, weight, Body Mass Index (BMI), pain intensity with a Visual Analog Scale, shoulder ROM, and functional disability status with the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH).

Results

Mean BMI value of the participants was 26.1±3.0 kg/m2. Although all parameters of the patients in both groups improved significantly, patients in the rESWT group had a statistically significant improvement in pain, ROM and QuickDash scores (p<0.001, p<0.001, and p<0.001, respectively).

Conclusion

We assume that rESWT is an effective and noninvasive method of reducing pain and increasing ROM and functional status without the need for surgery.

Long-term outcome of low-energy extracorporeal shockwave therapy on gluteal tendinopathy documented by magnetic resonance imaging

Background

Previous outcome studies for extracorporeal shock wave therapy (ESWT) have included clinically diagnosed greater trochanteric pain syndrome (GTPS). The purpose of this study is to investigate outcome of ESWT on GTPS with gluteal tendinopathy documented by magnetic resonance imaging (MRI).

Methods

Medical records of 38 consecutive patients were retrospectively reviewed, who underwent ESWT for GTPS with MRI-documented gluteal tendinopathy (> 6 months). ESWT was conducted (1/week) when the Roles-Maudsley score (RMS) showed “Poor” or “Fair” grade after conservative treatment until RMS had reached “Good” or “Excellent” grade (treatment success) or until 12 treatments had been applied. Numeric rating scale (NRS) and RMS were evaluated before, 1 week after (immediate follow-up) and mean 27 months after ESWT program (long-term follow-up). Success rate was calculated at each follow-up point.

Results

Initial NRS (5.9 ± 1.6) significantly decreased at immediate (2.5 ± 1.5, p< 0.01) and long-term follow-up (3.3 ± 3.0, p< 0.01), respectively. Success rates were 83.3% (immediate) and 55.6% (long-term), respectively. There was no correlation among age, symptom duration and NRS.

Conclusion

Low-energy ESWT can be an effective treatment for pain relief in chronic GTPS with MRI-documented gluteal tendinopathy. However, its long-term effect appears to decrease with time.

Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions: A Narrative Review

Extracorporeal shockwave therapy (ESWT) is a technology that was first introduced into clinical practice in 1982 for urologic conditions. Subsequent clinical applications in musculoskeletal conditions have been described in treatment of plantar fasciopathy, both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, management of nonunion fractures, and joint disease including avascular necrosis. The aim of this review is to summarize the current understanding of treatment of musculoskeletal conditions with ESWT, accounting for differences in treatment protocol and energy levels. Complications from ESWT are rare but include 2 reported cases of injury to bone and Achilles tendon rupture in older adults using focused shockwave. Collectively, studies suggest ESWT is generally well-tolerated treatment strategy for multiple musculoskeletal conditions commonly seen in clinical practice. LEVEL OF EVIDENCE: III.

A review of the cellular and molecular effects of extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is a novel therapeutic modality and its use in promoting connective tissue repair and analgesic effect has been advocated in the literature. It is convenient, cost-effective, and has negligible complications; it therefore bypasses many of the problems associated with surgical interventions. This paper reviews the proposed mechanisms of action in promoting tissue repair and regeneration as well as analysing its efficacy providing an analgesic effect in clinical applications. Further research will be required to not only identify the underlying mechanisms more precisely, but will also be critical for ensuring consistency across the literature so that the most beneficial treatment protocol can be developed. Extracorporeal shockwave therapy stands as a promising alternative modality in promoting tissue repair.

Low-energy versus middle-energy extracorporeal shockwave therapy for the treatment of snapping scapula bursitis

OBJECTIVE

Extracorporeal shockwave therapy (ESWT) has been used successfully in treatment of musculoskeletal disorders. Our objective was to assess the effectiveness of low versus middle-energy ESWT on snapping scapula bursitis.

METHODS

Thirty-five patients, divided into two groups, group (L), received low-energy ESWT, group (M) received middle-energy ESWT. Groups were evaluated at 1,3,6 and 12 months using the Visual Analogue Scale (VAS), the Constant-Murley scoring (CMS) and the Roles and Maudsley criteria.

RESULTS

In groups (L) and (M), VAS average values after 1,3,6 months and one year were (43±5.17, 38±4.33, 28±4.18 and 19±3.39) and (37±4.85, 26±4.74, 21±4.45 and 7±3.42) respectively. At six and twelve months, statistical difference was detected, P (0.034, 0.026) respectively. After one year of completing the treatment, the average values of CMS were (83.5±6.44 and 91±5.33) respectively, P=0.046. Roles and Maudsley criteria demonstrated that, patients in group (L), 6 (35%) excellent, 5 (29%) good, 4 (24%) acceptable and 2 (12%) had poor results. Whereas, patients in group (M), 11 (61%) excellent, 3 (17%) good, 3 (17%) acceptable and 1 (5%) had poor results.

CONCLUSION

Although low-energy ESWT showed good early-term results, but middle-energy ESWT protocol demonstrated better early-term, Mid-term, and late-term results.

Long-Term Outcome and Factors Affecting Prognosis of Extracorporeal Shockwave Therapy for Chronic Refractory Achilles Tendinopathy

Objective

To investigate the factors affecting prognosis of extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy (AT).

Methods

Thirty-six patients (48 consecutive feet) with chronic AT (>6 months) and who underwent ESWT for ‘poor’ or ‘fair’ grade in Roles-Maudsley Score (RMS) after unsuccessful conservative treatment were included in the present study. A maximum of 12 sessions of ESWT were conducted until treatment success: RMS reached ‘good’ or ‘excellent’. Termination of ESWT for no response, or ‘poor’ or ‘fair’ grade was regarded as treatment failure. Immediate outcome, long-term outcome (telephone interview after mean 26 months), and factors affecting treatment success were analyzed.

Results

Numeric Rating Scale was significantly decreased at immediate and long-term follow-up. Success rate was 71.1% and 90.3%, respectively. Univariate logistic regression identified that immediate treatment success was associated with retrocalcaneal enthesophyte on X-ray (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01–0.28), pretreatment abnormal ultrasonography echogenicity within Achilles tendon (OR, 18.89; 95% CI, 2.08–171.96), mean duration of ‘post-treatment soreness’ (OR, 0.55; 95% CI, 0.33–0.94), and duration of ‘post-treatment soreness after first ESWT’ (OR, 0.06; 95% CI, 0.01–0.34). The duration of ‘post-treatment soreness after first ESWT’ was found to be the only factor associated with long-term success (OR, 0.32; 95% CI, 0.10–0.99).

Conclusion

ESWT appears to be effective in achieving long-term success in chronic refractory AT. Immediate success was associated with absence of retrocalcaneal enthesophyte on X-ray, presence of pretreatment abnormal ultrasonography echogenicity, shorter mean duration of ‘post-treatment soreness’, and shorter duration of ‘post-treatment soreness after first ESWT’. The shorter duration of ‘post-treatment soreness after first ESWT’ was identified as the only positive prognostic parameter in achieving long-term success.

Comparison of Therapeutic Effect of Extracorporeal Shock Wave in Calcific Versus Noncalcific Lateral Epicondylopathy

Objective

To assess the therapeutic effect of extracorporeal shock wave therapy (ESWT) in lateral epicondylopathy with calcification, and compare it to the effect of ESWT in lateral epicondylopathy without calcification.

Methods

A retrospective study was conducted. Forty-three patients (19 with calcific and 24 with noncalcific lateral epicondylopathy in ultrasound imaging) were included. Clinical evaluations included the 100-point score, Nirschl Pain Phase scale before and after ESWT, and Roles and Maudsley (R&M) scores after ESWT. ESWT (2,000 impulses and 0.06–0.12 mJ/mm²) was performed once a week for 4 weeks.

Results

The 100-point score and Nirschl Pain Phase scale changed significantly over time (p<0.001), but there was no significant difference between groups (p=0.555). The R&M scores at 3 and 6 months after ESWT were not significantly different between groups. In the presence of a tendon tear, those in the calcific lateral epicondylopathy group showed poor improvement of 100-point scores compared to the noncalcific group (p=0.004).

Conclusion

This study demonstrated that the therapeutic effect of ESWT in calcific lateral epicondylopathy was not significantly different from that in noncalcific lateral epicondylopathy. When a tendon tear is present, patients with calcific lateral epicondylopathy might show poor prognosis after ESWT relative to patients with noncalcific lateral epicondylopathy.

Radiological and clinical predictors of long-term outcome in rotator cuff calcific tendinitis

OBJECTIVES

Knowledge on the epidemiology and long-term course of rotator cuff calcific tendinitis (RCCT) is scarce. We assessed demographics, radiological characteristics, and their association with long-term outcomes in a large patient group.

METHODS

Baseline demographics, radiological characteristics and treatment were recorded in 342 patients. Interobserver agreement of radiological measures was analyzed. Long-term outcome was evaluated with questionnaires (WORC, DASH). The association of baseline characteristics with outcome was assessed.

RESULTS

Mean age was 49.0 (SD = 10.0), and 59.5 % were female. The dominant arm was affected in 66.0 %, and 21.3 % had bilateral disease. Calcifications were on average 18.7 mm (SD = 10.1, ICC = 0.84 (p < 0.001)) and located 10.1 mm (SD = 11.8) medially to the acromion (ICC = 0.77 (p < 0.001)). Gärtner type I calcifications were found in 32.1 % (Kappa = 0.47 (p < 0.001)). After 14 years (SD = 7.1) of follow-up, median WORC was 72.5 (range, 3.0-100.0; WORC < 60 in 42 %) and median DASH 17.0 (range, 0.0-82.0). Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior WORC. DASH results were similar.

CONCLUSIONS

Many subjects have persisting shoulder complaints years after diagnosis, regardless of treatment. Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior outcome. Radiological measures had moderate-to-good reliability and no prognostic value.

KEY POINTS

• Most RCCT studies report on short-term outcome and/or small patients groups. • In this large, long-term observational study, RCCT appeared to not be self-limiting in many subjects. • Negative prognostic factors included female gender, more calcifications, dominant arm affected, and longer duration of symptoms. • Interobserver agreement of general radiological RCCT measures is moderate to good. • More rigorous diagnostics and treatment might be needed in specific RCCT cases.

The Effects of Extracorporeal Shock Wave Therapy in Patients with Coccydynia: A Randomized Controlled Trial

Coccydynia is pain in the coccygeal region, and usually treated conservatively. Extracorporeal shock wave therapy (ESWT) was incorporated as non-invasive treatment of many musculoskeletal conditions. However, the effects of ESWT on coccydynia are less discussed. The purpose of this study is to evaluate the effects of ESWT on the outcomes of coccydynia. Patients were allocated to ESWT (n = 20) or physical modality (SIT) group (n = 21) randomly, and received total treatment duration of 4 weeks. The visual analog scale (VAS), Oswestry disability index (ODI), and self-reported satisfaction score were used to assess treatment effects. The VAS and ODI scores were significantly decreased after treatment in both groups, and the decrease in the VAS score was significantly greater in the ESWT group. The mean proportional changes in the ODI scores were greater in the ESWT group than in the SIT group, but the between-group difference was not statistically significant. The patients in the ESWT group had significantly higher subjective satisfaction scores than SIT group. We concluded that ESWT is more effective and satisfactory in reducing discomfort and disability caused by coccydynia than the use of physical modalities. Thus, ESWT is recommended as an alternative treatment option for patients with coccydynia.

Mechanical Stimulation (Pulsed Electromagnetic Fields "PEMF" and Extracorporeal Shock Wave Therapy "ESWT") and Tendon Regeneration: A Possible Alternative

The pathogenesis of tendon degeneration and tendinopathy is still partially unclear. However, an active role of metalloproteinases (MMP), growth factors, such as vascular endothelial growth factor (VEGF) and a crucial role of inflammatory elements and cytokines was demonstrated. Mechanical stimulation may play a role in regulation of inflammation. In vitro studies demonstrated that both pulsed electromagnetic fields (PEMF) and extracorporeal shock wave therapy (ESWT) increased the expression of pro-inflammatory cytokine such as interleukin (IL-6 and IL-10). Moreover, ESWT increases the expression of growth factors, such as transforming growth factor β(TGF-β), (VEGF), and insulin-like growth factor 1 (IGF1), as well as the synthesis of collagen I fibers. These pre-clinical results, in association with several clinical studies, suggest a potential effectiveness of ESWT for tendinopathy treatment. Recently PEMF gained popularity as adjuvant for fracture healing and bone regeneration. Similarly to ESWT, the mechanical stimulation obtained using PEMFs may play a role for treatment of tendinopathy and for tendon regeneration, increasing in vitro TGF-β production, as well as scleraxis and collagen I gene expression. In this manuscript the rational of mechanical stimulations and the clinical studies on the efficacy of extracorporeal shock wave (ESW) and PEMF will be discussed. However, no clear evidence of a clinical value of ESW and PEMF has been found in literature with regards to the treatment of tendinopathy in human, so further clinical trials are needed to confirm the promising hypotheses concerning the effectiveness of ESWT and PEMF mechanical stimulation.

Effectiveness of passive physical modalities for shoulder pain: systematic review by the Ontario protocol for traffic injury management collaboration

BACKGROUND

Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities are commonly used to treat shoulder pain. However, previous systematic reviews reported conflicting results.

PURPOSE

The aim of this study was to evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the shoulder.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1990, to April 18, 2013.

STUDY SELECTION

Randomized controlled trials (RCTs) and cohort and case-control studies were eligible. Random pairs of independent reviewers screened 1,470 of 1,760 retrieved articles after removing 290 duplicates. Twenty-two articles were eligible for critical appraisal. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Of those, 11 studies had a low risk of bias.

DATA EXTRACTION

The lead author extracted data from low risk of bias studies and built evidence tables. A second reviewer independently checked the extracted data.

DATA SYNTHESIS

The findings of studies with a low risk of bias were synthesized according to principles of best evidence synthesis. Pretensioned tape, ultrasound, and interferential current were found to be noneffective for managing shoulder pain. However, diathermy and corticosteroid injections led to similar outcomes. Low-level laser therapy provided short-term pain reduction for subacromial impingement syndrome. Extracorporeal shock-wave therapy was not effective for subacromial impingement syndrome but provided benefits for persistent shoulder calcific tendinitis.

LIMITATIONS

Non-English studies were excluded.

CONCLUSIONS

Most passive physical modalities do not benefit patients with subacromial impingement syndrome. However, low-level laser therapy is more effective than placebo or ultrasound for subacromial impingement syndrome. Similarly, shock-wave therapy is more effective than sham therapy for persistent shoulder calcific tendinitis.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Calcific tendinitis of the rotator cuff: management options

Calcific tendinitis of the rotator cuff tendons is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. It is thought to be an active, cell-mediated process, although the exact pathophysiology remains unclear. Nonsurgical management continues to be the mainstay of treatment; most patients improve with modalities such as oral anti-inflammatory medication, physical therapy, and corticosteroid injections. Several options are available for patients who fail nonsurgical treatment, including extracorporeal shock wave therapy, ultrasound-guided needle lavage, and surgical débridement. These modalities alleviate pain by eliminating the calcific deposit, and several recent studies have demonstrated success with the use of these treatment options. Surgical management options include arthroscopic procedures to remove calcific deposits and subacromial decompression; however, the role of subacromial decompression and repair of rotator cuff defects created by removing these deposits remains controversial.

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.

Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis

The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively).

It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.

Cite this article: Bone Joint J 2013;95-B:1521–6.

Mid-term results following arthroscopic capsular release in patients with primary and secondary adhesive shoulder capsulitis

PURPOSE

The purpose of this study was to assess the effectiveness of arthroscopic capsular release carried out for refractory cases of both primary and secondary adhesive shoulder capsulitis that were not responsive to at least 6 months of prior conservative therapy.

METHODS

Arthroscopic 360-degree capsular release was performed on 167 patients (173 shoulders) with adhesive shoulder capsulitis. Ninety-one shoulders (52.6%) had primary and 82 shoulders (47.4%) secondary adhesive capsulitis. The median follow-up period was 36 months (range 14-67 months).

RESULTS

All patients were evaluated according to the constant score. Both groups (primary and secondary adhesive capsulitis) experienced a significant improvement for all ranges of motion immediately postoperative, as well as at the time of follow-up. The median preoperative constant score was 41 (range 18-61) points and increased significantly to a median of 83 (range 27-100) at the time of follow-up. In the group of primary adhesive capsulitis, median preoperative score was 42 points (range 19-58) and increased to 85 points (range 36-100) at follow-up. In the group of secondary adhesive capsulitis, the preoperative mean increased from 41 points (range 18-61) to 74 points (range 27-100) at the time of the follow-up. The constant score component for pain and the visual analogue scale (VAS) score were also significantly increased.

CONCLUSION

Arthroscopic capsular release in patients with primary and secondary adhesive shoulder capsulitis represents a valuable therapeutic choice with minimal complications, to effectively reduce pain and improve movement in all planes of motion.

LEVEL OF EVIDENCE

Therapeutic retrospective case series study, Level IV.

Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of shock wave therapy (SWT) for functional improvement and the reduction of pain in patients with calcific tendinitis of the shoulder, and to determine the rate of disappearance of calcifications after therapy at 6 months' follow-up.

DATA SOURCES

Articles were searched from the Cochrane Library, MEDLINE, Embase, CINAHL, and Ovid database.

STUDY SELECTION

We included randomized controlled trials from 1992 to 2011, and their quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

DATA EXTRACTION

Studies were evaluated by 2 independent reviewers for their methodologic quality. Disagreements were settled by a third reviewer. Data were then extracted and cross-checked for accuracy. The reviewers were not blinded to the authors of the articles.

DATA SYNTHESIS

In 4 of the 6 studies included for review, the resorption of calcifications was evaluated using meta-analysis because the studies had 2 treatment groups, while the other 2 studies were analyzed descriptively because they had 3 treatment groups. Fixed- and random-effects models were used to meta-analyze total and partial resorption ratios, and I(2) statistics were calculated to assess heterogeneity.

CONCLUSIONS

We found a clinical improvement with a pooled total resorption ratio of 27.19 (95% confidence interval [CI], 7.20-102.67) and a pooled partial resorption ratio of 16.22 (95% CI, 3.33-79.01). SWT increases shoulder function, reduces pain, and is effective in dissolving calcifications. These results were maintained over the following 6 months.

ESWT for tendinopathy: technology and clinical implications

PURPOSE

The general consensus that tendinopathy, at least in the chronic stage, is mainly a degenerative condition and inflammation plays a minor role has led to a shift from treatments that target inflammation towards treatment options that promote regeneration. One of these treatments is extracorporeal shockwave therapy (ESWT), a physical therapy modality that uses pressure waves to treat tendinopathy. This review was undertaken to give an overview of the literature concerning this treatment, and special attention is given to the differences between focused and radial ESWT.

METHODS

A narrative description of wave characteristics, generation methods and in vitro effects of ESWT is given. The literature on ESWT as a treatment for one common tendinopathy, patellar tendinopathy, was systematically reviewed.

RESULTS

Waves that are generated for focused and radial ESWT have very different physical characteristics. It is unclear how these characteristics are related to clinical effectiveness. Studies into the biological effects of ESWT have mainly used focused shockwave therapy, showing a number of effects of shockwaves on biological tissue. The systematic review of studies into the clinical effects of ESWT for patellar tendinopathy showed conflicting evidence for its effectiveness.

CONCLUSION

Physical characteristics of focused and radial waves differ substantially, but effect on clinical effectiveness is unclear. Whereas in vitro studies often show the effects of ESWT on tendon tissue, results of clinical studies are inconsistent. Based on the review of the literature, suggestions are given for the use of ESWT in clinical practice regarding timing and treatment parameters.

Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis: a randomized clinical trial comparing two different energy levels

BACKGROUND

Extracorporeal shock-wave therapy (ESWT) represents a valid intervention in the treatment of people with supraspinatus calcifying tendinitis (SCT), but there is limited evidence for the useful range of ESWT doses.

OBJECTIVE

The aim of this study was to compare 2 different ranges of energy flux density in treatment of SCT with ESWT.

DESIGN

This study was designed as a single-blind randomized clinical trial.

SETTING

This study was performed in a university hospital.

PATIENTS

Forty-six patients with SCT were randomly assigned to 2 groups that received different therapeutic energy doses of ESWT: (1) group A received ESWT at an energy level of 0.20 mJ/mm², and (2) group B received ESWT at an energy level of 0.10 mJ/mm².

INTERVENTION

The treatment protocol consisted of 4 sessions performed once a week.

MEASUREMENTS

The change in mean Constant Murley Scale (CMS) scores at 3 and 6 months was the primary endpoint. The change in the mean visual analog scale (VAS) scores from baseline to 3 and 6 months after the intervention and radiographic change in size of calcium deposits were evaluated as secondary endpoints. At 12 months, pain relief was assessed using a numeric rating scale.

RESULTS

Significant clinical improvement based on mean CMS scores was observed after 6 months in group A (X=79.43, SD=10.33) compared with group B (X=57.91, SD=6.53). Likewise, after 6 months, a significant decrease in VAS scores was found in group A (X=2.09, SD=1.54) compared with group B (X=5.36, SD=0.78). Calcific deposits disappeared in the same percentage of patients in both groups.

LIMITATIONS

The small sample size and lack of a control group were limitations of the study.

CONCLUSIONS

In ESWT for SCT, an energy level of 0.20 mJ/mm² appears to be more effective than an energy level of 0.10 mJ/mm² in pain relief and functional improvement.

Focused extracorporeal shock wave therapy in calcifying tendinitis of the shoulder: a meta-analysis

Background:

The objective of this study is to assess the effectiveness of extracorporeal shock wave therapy in the management of calcifying tendinitis of the shoulder. Furthermore, a dose-response relationship was sought as a secondary confirmation of effectiveness.

Hypothesis:

Focused extracorporeal shock wave therapy has a high, dose-responsive effectiveness in the management of calcifying tendinitis of the shoulder.

Study Design:

Meta-analysis.

Methods:

Studies were identified from online databases (MEDLINE, EMBASE, and Cochrane Controlled Trials Register), manual searches, and personal communication with experts in the field. After assessment of heterogeneity, a random effects model was generated. The primary end points were identified as pain and function by using the visual analog scale and the Constant-Murley Score, respectively. These end points were pooled and the weighted mean differences and 95% confidence intervals were estimated. Odds ratios of the secondary end point deposit resorption were pooled.

Results:

In 14 studies, shock wave therapy led to a significantly higher reduction of pain (weighted mean difference, −2.8 points; 95% confidence interval, −4.2 to −1.5 points) and improvement of function (weighted mean difference, 19.8 points; 95% confidence interval, 13.4-26.3 points), compared to other treatments and placebo. High-energy treatment produced significantly better results than low-energy treatment for pain reduction (weighted mean difference, 1.7 points; 95% confidence interval, 0.7-2.6 points) and improvement of function (weighted mean difference, 10.7 points; 95% confidence interval, 7.2-14.1 points). These results are consistent with a dose-response relationship supporting the effectiveness of shock wave therapy.

Conclusion:

Shock wave therapy for calcifying tendinitis of the shoulder is effective in pain relief, function restoration, and deposit resorption; however, these conclusions are susceptible to bias arising from the limitations of the included studies.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Calcific tendinopathy of the rotator cuff tendons

Calcific tendinopathy (CT) of the tendons of the rotator cuff is common in white populations, with a reported prevalence varying from 2.7% to 22%, mostly affecting women between 30 and 50 years. Although CT shows a strong tendency toward self-healing by spontaneous resorption of the deposits, it does not always follow this typical pattern. The etiopathogenesis of CT is still unknown. Many pathogenetic theories have been proposed, and clinical associations between CT and diabetes and thyroid disorders have been reported. The choice of therapeutic approach should depend on the evolution of the condition.

Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder

PURPOSE

Strategies for extracorporeal shockwave therapy in calcifying tendinitis of the rotator cuff vary concerning quantity of sessions and doses. The purpose of this prospective pilot study was to determine the difference between the outcome of a single high-dosage extracorporeal shockwave therapy and two sessions of low-dosage extracorporeal shockwave therapy.

METHODS

This study compared a single high-level middle-energetic extracorporeal shockwave therapy (0.3 mJ/mm(2)) with a low-level middle-energetic extracorporeal shockwave therapy applied twice in a weekly interval (0.2 mJ/mm(2)). Thirty patients that suffered from calcifying tendinitis for at least 6 months received navigated, fluoroscopy-guided extracorporeal shockwave therapy. The gain of Constant Murley Score, Visual Analogue Scale during state of rest and weight-bearing situations ("stress") and radiographic progress was documented 6 and 12 weeks after therapy.

RESULTS

In both groups, a significant reduction in pain during stress and improvement of function was observed. In contrast, no significant reduction in pain during rest was observed. No significant difference between both groups concerning reduction in the calcific deposit after 6 weeks was detected. Group B showed minor advantages in radiographical improvement after 12 weeks. In 36% of the patients, the calcific deposit completely dissoluted after 12 weeks.

CONCLUSIONS

This pilot study indicates that a single high-level extracorporeal shockwave therapy may be as effective as two applications of a lower-dosed extracorporeal shockwave therapy for calcifying tendinitis. An effective single-session strategy could reduce treatment time, material costs and healthcare expenses and ionizing radiation in case of fluoroscopy guidance.

The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis

BACKGROUND

This systematic review explored the midterm effectiveness of extracorporeal shockwave therapy (ESWT) in reducing pain and improving shoulder function. Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. ESWT is an alternative to surgery when conservative treatments such as nonsteroidal antiinflammatory drugs, steroidal injections, and physiotherapy fail to relieve symptoms. It is hypothesised that ESWT is effective in the midterm for reducing pain and improving function for patients with chronic calcific tendinitis and that a dose-response relationship exists in the treatment parameters for effectiveness.

MATERIALS AND METHODS

Articles were electronically searched from the Cochrane Controlled Trials Register, MEDLINE, CINAHL, PUBMED, EMBASE, SPORTSDiscus and PEDro using a comprehensive search strategy. Studies were included if they were randomized controlled trials testing the midterm effectiveness of ESWT for chronic calcific tendonitis. Methodologic quality was assessed by PEDro (total score = 10). The strength of the evidence was reported using the National Health and Medical Research Council body of evidence framework.

RESULTS

Six of the nine included studies scored 7 or more for methodologic quality. All studies had follow-up periods of at least 6 months. Common methodologic flaws were insufficient blinding of clinicians and assessors. There was consistent evidence of midterm effectiveness of ESWT in reducing pain and improving shoulder function for patients with chronic calcified tendinitis.

DISCUSSION

ESWT is a potential alternative to surgery with good mid-term effectiveness and minimal side effects. This review noted several limitations with the current body of evidence. Studies were mainly from a few European countries involving medical doctors, with a lack of diverse perspectives and effectiveness evaluation from other health professionals who might use this treatment option for patients with chronic calcific tendinitis. Further, the different outcome measures used and inadequate reporting details in the included studies did not permit a quantitative synthesis of the effectiveness of this treatment. A lack of follow up period beyond one year in the studies also precluded conclusion to be made on the longer term effectiveness of ESWT.

CONCLUSION

Due to variable treatment parameters (eg dosage), this review was unable to provide clear guidance of the dose-effect of the midterm effectiveness of ESWT. Studies of better methodologic design using standardized treatment protocols and studies with longer follow-up are required.

Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: a randomized study

Objective: To generate data on optimal shoulder position comparing two ultrasound-guided extracorporeal shock wave therapy techniques for the treatment of calcifying tendinitis of the shoulder.

Design: Random assignment to two groups of treatment with three months follow-up.

Setting: The data were collected in outpatients.

Subjects: Thirty-five subjects affected by calcifying tendinitis of the shoulder were examined.

Interventions: Each subject received three sessions of ultrasound-guided extracorporeal shock wave therapy (performed weekly). Neutral position technique was used in group A (n = 17, mean age 53 ± 9.2 years) and the hyperextended internal rotation technique was used in group B (n = 18, mean age 52.2 ± 10.8 years).

Main outcome measures: The Constant and Murley method and radiographs were used to evaluate each subject before the treatment and at three months follow-up.

Results: There were no significant differences between changes in Constant total score and pain, activity of daily living and range of motion subscales of the two groups. Only the pain subscale showed a significant difference in favour of group B. Significant differences in the radiographic outcome were observed between the two groups: the percentage of total or subtotal resorption of the calcified deposits was 35.3% in group A (neutral position technique) versus 66.6% in group B (hyperextended internal rotation technique). The resorption of the calcific deposit positively influenced the clinical outcome.

Conclusions: Positioning the shoulder in hyperextension and internal rotation during extracorporeal shock wave therapy seems to be a useful technique to achieve resorption of calcific deposits.

Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis--a systematic review

Extracorporeal shock-wave therapy (ESWT) is suggested as a treatment alternative for calcific and non-calcific rotator cuff tendinosis (RC-tendinosis), which may decrease the need for surgery. In this study we assessed the evidence for effectiveness of ESWT for these disorders. The Cochrane Library, PubMed, Embase, Pedro, and Cinahl were searched for relevant systematic reviews and RCTs. Two reviewers independently extracted data and assessed the methodological quality. Seventeen RCTs (11 calcific, 6 non-calcific) were included. For calcific RC-tendinosis, strong evidence was found for effectiveness in favour of high-ESWT versus low-ESWT in short-term. Moderate evidence was found in favour of high-ESWT versus placebo in short-, mid- and long-term and versus low-ESWT in mid- and long-term. Moreover, high-ESWT was more effective (moderate evidence) with focus on calcific deposit versus focus on tuberculum major in short- and long-term. RSWT was more effective (moderate evidence) than placebo in mid-term. For non-calcific RC-tendinosis, no strong or moderate evidence was found in favour of low-, mid- or high-ESWT versus placebo, each other, or other treatments. This review shows that only high-ESWT is effective for treating calcific RC-tendinosis. No evidence was found for the effectiveness of ESWT to treat non-calcific RC-tendinosis.

New options in the management of tendinopathy

Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.