Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder

Effect of extracorporeal shock wave therapy and ultrasound-guided percutaneous lavage in reducing the pain of rotator cuff calcific tendinopathy; an updated systematic review and meta-analysis

Background

Extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous lavage (UGPL or barbotage) are among those used to treat the pain of rotator cuff calcific tendinopathy (RCCT). This meta-analysis was done to review the effect ESWT and UGPL in reducing the pain of RCCT.

Methods

A comprehensive search was done based on the PRISMA. PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar were reviewed for articles published by Feb 1, 2024, on ESWT vs. UGPL. The main keywords searched are as follows: "rotator cuff calcific tendinopathy", "tendinitis", " ESWT", " ultrasound-guided percutaneous lavage", " RCCT ″, " UGPL", " extracorporeal shock wave therapy" and titles or abstracts may contain one or a mix of these elements. This study was registered at PROSPERO with code" CRD42022385068". STATA version 13 was applied to analyze.

Results

In general, 779 patients from 22 studies were analyzed. The mean age was 51.85 ± 3.41 years. The patients were referred after 18.69 months of suffering from tendinopathy symptoms. Right-sided and supraspinatus locations were affected more. ESWT has been effective in a decrease of calcium deposit (-1.70 SMD after 1 week for ESWT, -0.96 SMD after 12 weeks for ESWT and -1.20 SMD after 12 weeks UPGL). ESWT has been effective in decreasing VAS by -4.32 SMD after 1 week while UPGL showed -0.23 SMD reductions in VAS After 1 week but in time >1 week, UPGL showed better effect by more reduction in VAS. ESWT has been effective in an increase of CMS by 1.60 SMD after 4-6 weeks, by 1.79 SMD after 12 weeks, by 2.44 SMD after 24 weeks, and 2.53 SMD after 48 weeks.

Conclusion

Based on the results, ultrasound-guided lavage is more effective in reducing pain than ESWT, and this effect becomes more evident in the long term. In terms of CMS score, over time, the efficiency of ESWT becomes more visible. In long-term follow-up, UPGL had a better effect on the calcium deposit reduction.

The effectiveness of extracorporeal shock wave therapy for rotator cuff calcific tendinopathy. A systematic review with meta-analysis

PURPOSE

To investigate if Extracorporeal Shock Wave therapy (ESWT) is effective in reducing pain and disability, in improving function, quality of life and complete resorption rate of calcification in patients with Rotator Cuff Calcific Tendinopathy. To investigate which modality of ESWT brings the greatest clinical improvements between High (HE)-SWT and Low Energy (LE)-SWT and between Focal (F)-SWT and Radial (R)-SWT.

METHODS

MEDLINE, EMBASE, CENTRAL Database, and PEDro databases until February 2024 were searched. Study registers were further investigated. The Risk of Bias (RoB) was assessed with the Revised Cochrane RoB Tool (RoB 2). The certainty of evidence was rated with GRADE.

RESULTS

Twenty-one randomized controlled trials were included. None was judged as overall low RoB. Comparing ESWT and Ultrasound Guided Needling Procedures (USGNP), the pooled results reported a significant difference favoring USGNP in pain at <24 and <48 weeks (MD = 1.17, p = 0.004, I2 = 59%; MD = 1.31, p = 0.004, I2 = 42%, respectively). Comparing ESWT and sham-ESWT, the pooled results reported a clinically significant difference favoring ESWT in pain and function at 24 weeks (MD = -5.72, p < 0.00001, I2 = 0%; Standardized Mean Difference = 2.94, p = 0.02 I2 = 98%, respectively). Comparing HE-SWT and LE-SWT, HE-SWT was statistically and clinically superior in pain and function at <24 weeks (MD = -1.83, p = 0.03, I2 = 87%; MD = 14.60, p = 0.002, I2 = 77%, respectively) and showed a significantly higher complete resorption rate of calcification at 12 weeks (Risk Ratio = 2.53, p = 0.001, I2 = 0%). F-SWT and R-SWT appear equally effective in reducing pain, improving disability and resorption rate. The certainty of evidence was rated as very low through GRADE approach.

CONCLUSION

USGNP was statistically superior to ESWT in pain reduction at <24 and <48 weeks. ESWT was clinically better to sham-ESWT in pain reduction and function improvement at 24 weeks. HE-SWT was clinically more effective than LE-SWT in reducing pain, improving function at <24 weeks, and resolving calcific deposits at 12 weeks, while no differences between F-SWT and R-SWT were reported.

Effect of extracorporeal shock wave therapy for rotator cuff injury: Protocol for a systematic review and meta-analysis

BACKGROUND

Rotator cuff injury (RCI) is a common musculoskeletal ailment and a major cause of shoulder pain and limited functionality. The ensuing pain and restricted movement significantly impact overall quality of life. This study aims to systematically review the effects of extracorporeal shock wave therapy (ESWT) on RCI.

METHODS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. A literature search, spanning inception to November 1, 2023, will include databases such as PubMed, Web of Science, the Cochrane Library, Scopus, MEDLINE, EMBASE, EBSCO, and China National Knowledge Infrastructure (CNKI) to identify ESWT studies for RCI treatment. Excluding retrospectives, bias risk will be assessed with the Cochrane tool. Two researchers will independently screen, extract data, and evaluate bias risk. Revman 5.3 software will be used for data analysis.

RESULTS

This study aims to objectively and comprehensively evaluate the effectiveness and safety of randomized controlled trials of ESWT in the treatment of RCI, and analyze in detail the effect of ESWT in the treatment of RCI. Results will be analyzed using the Pain Visual Analogue Scale (VAS), Constant-Murley score, University of California Los Angeles score (UCLA), and American Shoulder and Elbow Surgeons form (ASES). If applicable, subgroup analysis will also be performed to divide patients into groups according to the energy level of ESWT, the time of intervention, and the degree of tearing of RCI. Finally, the results are submitted for publication in a peer-reviewed journal.

DISCUSSION AND CONCLUSION

There is existing evidence suggesting that ESWT may contribute to the amelioration of pain and functional limitations associated with Rotator Cuff Injury (RCI). This systematic review aims to update, consolidate, and critically evaluate relevant evidence on the effects of ESWT for RCI. The anticipated outcomes may serve as a valuable reference for clinical ESWT practices, covering treatment methods, timing, and intensity. Moreover, this review aspires to provide high-quality evidence addressing the impact of ESWT on RCI-related pain. Simultaneously, the findings of this systematic review are poised to offer guidance to clinicians and rehabilitation therapists. This guidance is intended to enhance the management of pain and functional impairments experienced by individuals with RCI, ultimately leading to improvements in their physical well-being.

TRIAL REGISTRATION

Protocol registration number CRD42023441407. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441407.

Effect of extracorporeal shockwave therapy for rotator cuff tendinopathy: a systematic review and meta-analysis

BACKGROUND

Rotator cuff tendinopathy (RCT) is a widespread musculoskeletal disorder and a primary cause of shoulder pain and limited function. The resulting pain and limited functionality have a detrimental impact on the overall quality of life. The purpose of this study was to perform a systematic review of the effects of extracorporeal shock wave therapy (ESWT) for RCT.

METHODS

The literature search was conducted on the following databases from inception to February 20, 2024: PubMed, Web of Science, the Cochrane Library, Scopus, MEDLINE, EMBASE, EBSCO, and China National Knowledge Infrastructure (CNKI) were checked to identify the potential studies exploring the effect of ESWT for the treatment of Rotator cuff tendinopathy (Calcification or non-calcification), control group for sham, other treatments (including placebo), without restriction of date, language. Two researchers independently screened literature, extracted data, evaluated the risk of bias in the included studies, and performed meta-analysis using RevMan 5.3 software.

RESULTS

A total of 16 RCTs with 1093 patients were included. The results showed that compared with the control group, ESWT for pain score Visual Analogue Scale/Score (VAS) (SMD = -1.95, 95% CI -2.47, -1.41, P < 0.00001), function score Constant-Murley score (CMS) (SMD = 1.30, 95% CI 0.67, 1.92, P < 0.00001), University of California Los Angeles score (UCLA) (SMD = 2.69, 95% CI 1.64, 3.74, P < 0.00001), American Shoulder and Elbow Surgeons form (ASES) (SMD = 1.29, 95% CI 0.93, 1.65, P < 0.00001), Range of motion (ROM) External rotation (SMD = 1.00, 95% CI 0.29, 1.72, P = 0.02), Total effective rate (TER) (OR = 3.64, 95% CI 1.85, 7.14, P = 0.0002), the differences in the above results were statistically significant. But ROM-Abduction (SMD = 0.72, 95% CI -0.22, 1.66, P = 0.13), the difference was not statistically significant.

CONCLUSION

Currently limited evidence suggests that, compared with the control group, ESWT can provide better pain relief, functional recovery, and maintenance of function in patients with RCT.

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.

Treatment Algorithm for the Resorption of Calcific Tendinitis Using Extracorporeal Shockwave Therapy: A Data Mining Study

Background

Although evidence indicates that extracorporeal shockwave therapy (ESWT) is effective in treating calcifying shoulder tendinitis, incomplete resorption and dissatisfactory results are still reported in many cases. Data mining techniques have been applied in health care in the past decade to predict outcomes of disease and treatment.

Purpose

To identify the ideal data mining technique for the prediction of ESWT-induced shoulder calcification resorption and the most accurate algorithm for use in the clinical setting.

Study Design

Case-control study.

Methods

Patients with painful calcified shoulder tendinitis treated by ESWT were enrolled. Seven clinical factors related to shoulder calcification were adopted as the input attributes: sex, age, side affected, symptom duration, pretreatment Constant-Murley score, and calcification size and type. The 5 data mining techniques assessed were multilayer perceptron (neural network), naïve Bayes, sequential minimal optimization, logistic regression, and the J48 decision tree classifier.

Results

A total of 248 patients with calcified shoulder tendinitis were enrolled in this study. Shorter symptom duration yielded the highest gain ratio (0.374), followed by smaller calcification size (0.336) and calcification type (0.253). With the J48 decision tree method, the accuracy of 3 input attributes was 89.5% by 10-fold cross-validation, indicating satisfactory accuracy. A treatment algorithm using the J48 decision tree indicated that a symptom duration of ≤10 months was the most positive indicator of calcification resorption, followed by a calcification size of ≤10.82 mm.

Conclusion

The J48 decision tree method demonstrated the highest precision and accuracy in the prediction of shoulder calcification resorption by ESWT. A symptom duration of ≤10 months or calcification size of ≤10.82 mm represented the clinical scenarios most likely to show resorption after ESWT.

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.

Effectiveness of extracorporeal shockwave therapy in treatment of upper and lower limb tendinopathies: A systematic review and meta-analysis

BACKGROUND

Tendinopathy is caused by repetitive motion, excessive stress on the tendon, overstretch, and motion past the critical angle of rotation or translation. There are various treatment options available for tendinitis, including those affecting both the upper and lower limbs and those of calcific and non-calcific types.

HYPOTHESIS/PURPOSE

Few reviews have analyzed the efficacy of Extracorporeal Shockwave Therapy (ESWT) in treating upper and lower limb tendinopathies while considering calcific and non-calcific-type tendinitis. This paper provides a review and meta-analysis on Randomized Controlled Trials (RCTs), which compared results from a group undergoing ESWT treatment to another group under different treatments.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, the Cochrane Central Register of Control Trials (CENTRAL), and Physiotherapy Evidence Database (PEDro) databases for articles published up to January 2022. The reference lists of identified articles were further scanned. Twenty-two studies were included in the meta-analysis.

RESULTS

Meta-analysis showed no difference in pain reduction in ESWT when compared with a comparison group at 4 (p = 0.26) and 12 weeks (p = 0.33). There were no differences in DASH scores at 12 months between the two groups (p = 0.32).

CONCLUSION

Extracorporeal Shockwave Therapy (ESWT) is effective when used to treat lower limb and calcific tendinitis. It does not yield any better results than other treatment options in managing upper limb tendinopathies and non-calcific tendinopathies.

Treatment of Calcific Tendonitis of the Rotator Cuff: An Updated Review

Rotator cuff calcific tendonitis (RCCT) is a disorder that can greatly impair patients' quality of life. A literature review was conducted to find the most effective and newest treatments for RCCT. PubMed and Cochrane Review databases were searched, without strict inclusion/exclusion criteria, for peer-reviewed articles between 1941 and 2021 that discussed RCCT etiology and treatments. If nonoperative measures (non-steroidal anti-inflammatory drugs, physical therapy, and corticosteroids) are unsuccessful, other options include extracorporeal shockwave therapy, ultrasound-guided injection techniques, and minimally invasive surgery. Because RCCT can resolve spontaneously, patients should progress to invasive options only if conservative first-line treatments have failed. [Orthopedics. 2023;46(6):e326-e332.].

Ultrasound Guided Arthroscopic Removal of Calcific Tendonitis: A Minimum of 2-Year Followup

Background: We have developed a novel technique for managing rotator cuff calcific tendonitis, involving arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance. While we have demonstrated encouraging results at six-month follow-up, the medium-term outcomes and the long-term outcomes of this technique at 2 years or beyond are unknown. The aim of this paper was to determine if this technique was successful in resolving symptoms after two years and beyond. Study Design: Retrospective Cohort Study. Methods: Patients who underwent arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance by a senior surgeon were evaluated using patient-rated pain scores and functional status with the use of the Likert scales and via examiner-rated shoulder range-of-motion and strength at the pre-operative visit, at 1, 6, 12, and 24 weeks post-operatively, and long-term at a mean of 249 weeks after surgery. Results: At a mean follow-up period of 4.8 years (range, 2-10 years), 31 patients (33 shoulders) experienced significant improvement in the severity of pain at rest, with overhead activities, and during sleep compared to their pre-operative presentation (p < 0.001). The patient experienced less frequent pain during activities and sleep, and a decreased frequency of extreme pain (p < 0.001). Passive range of abduction (p = 0.003), forward flexion (p < 0.001), and supraspinatus strength (p = 0.018) improved compared to the presurgical presentation. Out of 27 patients, 24 patients (89%) had complete resolution of calcific tendonitis, and 26 patients (96%) had an intact rotator cuff. Conclusion: Arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance was very effective. Patients had significant pain relief, improved range of motion, and a reduction in stiffness at a mean post-operative period of 4.8 years. Patients had a significant reduction in residual calcification, and rotator cuff integrity was largely preserved by long-term follow-up. What is known about this subject: Calcific tendonitis of the rotator cuff is one of the most painful and debilitating disorders of the shoulder. This condition is characterized by the deposition of calcium-phosphate crystals within the rotator cuff tendons. Arthroscopic debridement and excision of rotator cuff calcifications have proven to be efficacious treatments with regards to clinical and functional outcomes in the short and medium term. Identifying the calcific lesion intra-operatively, however, can prove to be challenging. Furthermore, inadequate excision of the calcific deposit has been shown to have poorer clinical outcomes. We designed a technique that utilizes the assistance of ultrasound to guide a localization-biopsy wire to the calcific lesion. This technique aids in precisely identifying the location of the lesion intra-operatively to optimize accuracy in removing the maximum amount of calcific deposit possible. A short-term follow-up study by us has demonstrated successful outcomes with regards to the return of function and relief of pain. However, there have been no studies evaluating the effectiveness of this particular technique beyond six months. What this study adds to current knowledge: At a mean of 4.8 years, arthroscopic debridement of calcific tendonitis, using our technique, was successful in relieving the severity and frequency of pain with overhead activities, pain at rest, and pain during sleep, as well as improving range of motion.

The impact of low-intensity extracorporeal shock waves on testicular spermatogenesis demonstrated in a rat model

BACKGROUND

In rodent models, low-intensity extracorporeal shock wave therapy has been shown to negatively impact semen concentration after treatment on the penis, implying that the reproductive system in close proximity may be indirectly affected by this modality. We hypothesized that shock waves are detrimental to spermatogenesis, and the aim of this study was to evaluate the effect of shock waves on spermatogenesis after direct shockwave treatment on testes using different energy settings.

METHODS

Twenty-five male Sprague Dawley rats, 8 weeks old, were divided into five groups, including one control group and four treatment groups each treated using shock waves of different intensities. All rats in the treatment groups received 2000 shocks on the left testis twice a week for 4 weeks, with shock wave intensity and frequency varied by treatment group: 0.1 mJ/mm 2 at 4 Hz for Group A, 0.15 mJ/mm 2 at 4 Hz for Group B, 0.35 mJ/mm 2 at 4 Hz for Group C, and 0.55mJ/mm 2 at 3 Hz for Group D. At the end of the experiment, sperm collected from the epididymis was evaluated for concentration and motility. Testicular spermatogenesis, the apoptotic index of germ cells, and the expression of a meiotic-specific gene were also analyzed.

RESULTS

The treatment group receiving shock wave intensity at 0.55 mJ/mm 2 showed a significant decrease in sperm concentration, motility, and Johnsen score as compared to other groups. The apoptotic index of spermatogenic cells increased as the intensity of the shock wave treatment escalated, and reach a statistically significant difference at 4 weeks posttreatment. Treating testes with intensity levels of 0.55 mJ/mm 2 at 3 Hz interfere with the quality or quantity of spermatogenesis and also increases in spermatogenic cell apoptosis, whereas the expression of the SYCP3 gene significantly decreased after treatment with intensity levels of 0.10 mJ/mm 2 , 0.15 mJ/mm 2 , and 0.35 mJ/mm 2 at 4 Hz.

CONCLUSION

Treating testes with intensity levels of 0.55 mJ/mm 2 at 3 Hz interfere with the quality or quantity of spermatogenesis and also increases spermatogenic cell apoptosis, whereas the expression of the SYCP3 gene significantly decreased after treatment with intensity levels of 0.10 mJ/mm 2 , 0.15 mJ/mm 2 , and 0.35 mJ/mm 2 at 4 Hz.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

Efficacy of Unfocused Medium-Intensity Extracorporeal Shock Wave Therapy (MI-ESWT) for Plantar Fasciitis

Extracorporeal shock wave therapy (ESWT) is a promising treatment for plantar fasciitis (PF), however, treatment results have varied due to inconsistencies among types of shock wave treatment and devices used. This retrospective chart review includes patients who underwent ESWT using the OrthoGold 100™ shock wave device (MTS, Konstanz, Germany) for PF between January, 2013 and September, 2018. There were 108 patients (119 heels) identified, with a mean age of 51.7 ± 16.5 (Range 21-83) years. Patients were treated weekly for 3 weeks, with 2000 impulses per session at an energy flux density between 0.10 and 0.17 mJ/mm². Mean follow-up duration was 11.5 ± 9.7 (Range 3-51) months. Mean pre-ESWT pain visual assessment scale improved from 6.7 ± 1.7 to 2.6 ± 2.7 (p < .001). The Foot and Ankle Outcome Score subscales: pain, function of daily living, function of sports and recreational activities and quality of life domains improved from 53.7 ± 14.9 to 75.7 ± 16.7 (p < .001), from 38 ± 15.2 to 71.8 ± 23 (p < .001), from 55.8 ± 16.4 to 71.4 ± 18 (p < .001), from 42.4 ± 21.5 to 59.4 ± 20.3 (p < .001) and from 44.9 ± 16.4 to 69 ± 23.9 (p < .001), respectively. Eighty-eight (81.5%) patients were satisfied with the procedure at final follow-up. Treatment of PF with unfocused shock waves was well tolerated and led to significant pain reduction, functional improvement, and patient satisfaction.

Calcific tendinopathy of the rotator cuff: a review of operative versus nonoperative management

Calcific tendinopathy of the shoulder involves calcification and degeneration of the rotator cuff tendon near its insertion point on the greater tuberosity. The purpose of this review is to analyze recent literature evaluating the clinical outcomes of non-operative and operative treatment for calcific tendinopathy of the shoulder. Conservative management, extracorporeal shockwave therapy (ESWT), ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT), and surgical intervention will be reviewed.

Ultrasound-Guided Percutaneous Irrigation of Rotator Cuff Calcific Tendinopathy (US-PICT): Patient Experience

Purpose

To assess patients' experience of ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinopathy (US-PICT).

Methods

Ninety-one patients (58 females; mean age: 50.5 ± 8.3 years) treated by US-PICT (local anesthesia, single-needle lavage, and intrabursal steroid injection) answered to a list of questions regarding their experience of the procedure before treatment, immediately after treatment, and three months later. The Borg CR10 scale was used to evaluate perceived pain, discomfort during anesthetic injection, and anxiety. The Wilcoxon, Spearman's rho, linear regression, and chi-square statistics were used.

Results

81/91 patients complained mild discomfort during the injection of anesthetics (2, 1-2). Pain scores during US-PICT were very low (0, 0-1), with 70% patients having not experienced pain. After treatment, we found a significant reduction of pain (before: 8, 7-8; 3-month: 3, 1-6; p < .001) and anxiety (before: 5, 2-7; during treatment: 2, 1-7; p = 0.010), with high overall satisfaction (immediately after: 10, 9-10; 3-month: 9, 7-10) and confidence in the possibility of recovery (immediately after: 9, 8-10; 3-month: 10, 8-10), respectively. Treatments performed before US-PICT were not statistically associated with pain relief (p = 0.389) and clinical improvement (p = 0.937). We found a correlation between satisfaction immediately postprocedure and confidence in the possibility of recovery (p = 0.002) and between satisfaction three months after treatment and clinical improvement (p < 0.001) and patients' reminds about the description of the procedure (p = 0.005) and of the potential complications (p = 0.035).

Conclusions

US-PICT is a mildly painful, comfortable, and well-tolerated procedure, regardless of any previous treatments. Patients' satisfaction is correlated with clinical benefit and full explanation of the procedure and its complications.

The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

BACKGROUND

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT.

METHODS

A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects.

RESULTS

Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes.

CONCLUSIONS

SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

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.

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.

Calcific deposit needling in combination with extracorporeal shock wave therapy (ESWT): A proposed treatment for supraspinatus calcified tendinopathy

Background: Calcified tendinopathy of the rotator cuff is one of the most common conditions concerning the shoulder pathology. It is characterized by a reactive calcification that affects the tendons being part of the rotator cuff. The reported prevalence varies from 2.7% to 22%. Most of the patients can be treated effectively with non-operative measures such as anti-inflammatory drugs, subacromial injection of steroid, physiotherapy, extracorporeal shock wave therapy (ESWT) and needle aspiration irrigation. Results of a treatment combining some of these methods have not been reported.

Objectives: The purpose of this study is to present the radiological as well as the clinical results of our proposed protocol which combines drilling of the calcium deposits with xylocaine under ultrasound guidance, with a specific program of physiotherapy for 1 month without the use of NSAIDs.

Methods: Sixty-six consecutive patients (68 shoulders) were treated for calcified tendinitis of supraspinatus, which was diagnosed clinically and radiologically, with needle drilling using xylocaine under ultrasound guidance. After the drilling the patient followed a physiotherapy protocol with ESWT which included five visits within a month. After the end of the physiotherapy, the patients were evaluated clinically and radiologically. The Visual Analogue Scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were measured before and after the end of the therapy.

Results: All the patients showed clinical improvement of the symptoms at the follow-up. The mean VAS score showed improvement from 8.1 to 3.3 whereas the mean DASH score was 27 and after the end of the therapy 5. Radiologically all but one calcific deposits were disappeared.

Conclusions: The ultrasound-guided drilling of the calcific deposit using xylocaine, in combination with physiotherapy using ESWT provides a reliable alternative treatment for the calcific tendinitis of the supraspinatus

Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment

Calcific tendinopathy (CT) of the shoulder is a common, painful condition characterized by the presence of calcium deposits in the rotator cuff tendons. Current theories indicate that CT may be the result of a cell-mediated process in which, after a stage of calcium deposition, calcifications are spontaneously resorbed. However, in a minority of cases, this self-healing process is somehow disrupted, resulting in symptoms. Recent literature shows an emerging role of biological and genetic factors underlying CT. This new evidence could supplement the classic mechanical theory of rotator cuff tendinopathy complicated by calcium precipitation, and it may also explain why the majority of the therapies currently in use are only able to provide partially satisfactory outcomes. This review aims to summarize the current knowledge about the pathological processes underlying CT of the shoulder and thereby justify the quest for advanced biological treatments of this condition when it becomes symptomatic.

Effect of radial shock wave on chronic pelvic pain syndrome/chronic prostatitis

[Purpose] This study aimed to evaluate the effect of radial extracorporeal shock wave therapy (rESWT) on patients with chronic pelvic pain syndrome (CPPS). [Participants and Methods] Forty male CPPS patients were randomly assigned into either an rESWT group or a control group. The first group was treated with rESWT two times per week for four weeks with a protocol 3,000 pulse, 12 Hz at 3 to 5 bar. The control group was treated with the same protocol, but the device’s probe had been turned off. The follow-up assessment was done using the National Institutes of Health-developed Chronic Prostatitis Symptom Index (NIH-CPSI) before treatment, as well as one week, four weeks, and 8 weeks after treatment. [Results] No significant difference was found in terms of age, sub-domain, or the total score of the NIH-CPSI between the rESWT group and the control group at the baseline. A statistically significant decrease was determined in the pain domain, urine score, quality of life, and the total NIH-CPSI score of the rESWT group at all post-treatment time points. All domains and the total score of the NIH-CPSI at all three follow-up time points decreased more significantly in the rESWT group as compared to the control group. [Conclusion] The findings of this study confirmed that rESWT is an effective method for treating CPPS.

Tendinopathy: injury, repair, and current exploration

Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.

Effectiveness and Safety of Shockwave Therapy in Tendinopathies

Introduction:

People suffering from tendinopathies exhibit reduced mobility due to the pain caused by the movement of the tendons involved. Recently, shockwave therapy has been used as a treatment option, which is non-invasive, simpler, faster and safer.

Aims:

To record the intensity of the pain, the functionality of the upper and lower limbs and quality of life before treatment with shock waves, immediately after the treatment and the 4-week follow-up.

Methodology:

The sample consisted of 384 patients, suffering from a tendinopathy. 326 patients constituted the shockwave intervention groups and 58 patients made up the control groups. The researchers created a self-administered questionnaire (University of Peloponnese Pain, Functionality and Quality of Life Questionnaire) in which the intensity of pain, functionality and quality of life were evaluated on a five-point Likert scale, before, immediately after the treatment and at a 4-week follow-up.

Results:

The pain reduction and the improvement of functionality and quality of life after shockwave treatment increased by at least two points on the five-point Likert scale both post-treatment (p<0,001) and at a 4-week follow-up (p<0,001) compared to post-treatment in elbow tendinopathy, Achilles tendinopathy, plantar fasciitis and rotator cuff tendinopathy.

Conclusions:

Shockwave therapy significantly reduced the pain that accompanies tendinopathies and improves functionality and quality of life. It might be first choice because of its effectiveness and safety.

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.

Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs

Treatment of calcific tendinitis using extracorporeal shock wave therapy (ESWT), ultrasound-guided percutaneous lavage (UGPL or barbotage), subacromial corticosteroid injection (SAI) and combined treatment is still controversial. This systematic review and meta-regression aimed to compare clinical outcomes between treatments. Relevant RCTs were identified using PubMed and Scopus search engines to date of September 23, 2015. Seven of 920 studies identified were eligible. Compared to the other treatments, the results of this study indicate that ESWT significantly improved CMS and VAS when compared to placebo. Barbotage plus ESWT significantly improved CMS, VAS and decreased size of calcium deposit when compared to ESWT, while barbotage plus SAI significantly improved CMS and decreased size of calcium deposit when compared to SAI. There have no different adverse effects of all treatment groups. Multiple active treatment comparisons indicated that barbotage plus SAI significantly improved VAS and size of calcium deposit when compared to other groups, while barbotage plus SAI improved CMS when compared to other groups. But there was no significant difference. The network meta-analysis suggested that combined US-guided needling and subacromial corticosteroid injection significantly decreased shoulder pain VAS, improved CMS score and decreased the size of calcium deposits, while also lowering risks of adverse event when compared to barbotage plus ESWT, ESWT and subacromial corticosteroid injection; therefore, the evidence points to UGPL as being the treatment of choice for nonsurgical options of treatment in calcific tendinitis of the shoulder. Level of evidence I.

Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment

Calcific tendinitis is a painful shoulder disorder characterised by either single or multiple deposits in the rotator cuff tendon. Although the disease subsides spontaneously in most cases, a subpopulation of patients continue to complain of pain and shoulder dysfunction and the deposits do not show any signs of resolution. Although several treatment options have been proposed, clinical results are controversial and often the indication for a given therapy remains a matter of clinician choice. Herein, we report on the current state of the art in the pathogenesis, diagnosis and treatment of calcific tendinitis of the rotator cuff.

The Effectiveness of High-Energy Extracorporeal Shockwave Therapy Versus Ultrasound-Guided Needling Versus Arthroscopic Surgery in the Management of Chronic Calcific Rotator Cuff Tendinopathy: A Systematic Review

PURPOSE

The objectives of this comprehensive quantitative review of the treatment of calcific tendinopathy of the rotator cuff were to investigate if there is a sustainable positive effect on outcomes after treatment with high-energy extracorporeal shockwave therapy (ESWT) or ultrasound (US)-guided needling and to compare these results with those of treatment with arthroscopic surgery.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to conduct this review. A systematic literature search was conducted in December 2014 to identify relevant clinical articles in peer-reviewed journals with at least 6 months' follow-up. Each article was scored using the Coleman Methodology Score. The primary endpoints were functional outcome and radiologic change in the size of the calcific deposit.

RESULTS

Twenty-two studies were included (1,258 shoulders). The mean Coleman Methodology Score for the included studies was 77.1 ± 9.1. Overall, good to excellent clinical outcomes were achieved after treatment with either high-energy ESWT, US-guided needling, or arthroscopic surgery, with an improvement in the Constant-Murley score ranging between 26.3 and 41.5 points after 1 year. No severe side effects or long-term complications were encountered.

CONCLUSIONS

Patients can achieve good to excellent clinical outcomes after high-energy ESWT, US-guided needling, and arthroscopy for calcific tendinopathy of the shoulder. Side effects and post-treatment complications should be taken into account when a decision is being made for each individual patient. Physicians should consider high-energy ESWT and US-guided needling as minimally invasive treatment options when primary conservative treatment fails. Arthroscopy can safely be used as a very effective but more invasive secondary option, although the extent of deposit removal and the additional benefit of subacromial decompression remain unclear.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, II, and IV studies.

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.

Ultrasound-guided interventional procedures around the shoulder

Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.

Arthroscopic Removal and Rotator Cuff Repair Without Acromioplasty for the Treatment of Symptomatic Calcifying Tendinitis of the Supraspinatus Tendon

Background:

Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. Although most patients respond well to conservative treatment, some eventually require surgical treatment.

Purpose:

To evaluate the clinical outcome with arthroscopic removal of calcific deposit and rotator cuff repair without acromioplasty for the treatment of calcific tendinitis of the supraspinatus tendon.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study retrospectively evaluated 30 consecutive patients with a mean age of 49.2 years. The mean follow-up was 35 months (range, 24-88 months). Pre- and postoperative functional assessment was performed using the Constant score, University of California Los Angeles (UCLA) score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH). Pain was assessed by visual analog scale (VAS). Radiographs and magnetic resonance imaging (MRI) were performed to evaluate the recurrence of calcifications and the indemnity of the supraspinatus tendon repair.

Results:

Significant improvement was obtained for pain (mean VAS, 8.7 before surgery to 0.8 after; P < .001). The mean Constant score increased from 23.9 preoperatively to 85.3 postoperatively (P < .001), the mean Quick DASH score decreased from 47.3 preoperatively to 8.97 postoperatively (P < .001), and the UCLA score increased from 15.8 preoperatively to 32.2 postoperatively (P < .001). MRI examination at last follow-up (70% of patients) showed no tendon tears, and 96.2% of patients were satisfied with their results.

Conclusion:

Arthroscopic removal and rotator cuff repair without acromioplasty can lead to good results in patients with symptomatic calcifying tendonitis of the supraspinatus tendon.

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.

Shockwave treatment for musculoskeletal diseases and bone consolidation: qualitative analysis of the literature

Shockwave treatment is an option within orthopedics. The exact mechanism through which shockwaves function for treating musculoskeletal diseases is unknown. The aim of this study was to make a qualitative analysis on the effectiveness of shockwave treatment among patients with musculoskeletal pathological conditions and pseudarthrosis. Searches were conducted in the Cochrane Library, Medline and Lilacs databases. Thirty-nine studies that reported using shockwave treatment for musculoskeletal diseases were found. Their results varied greatly, as did the types of protocol used. The studies that evaluated the effectiveness of shockwave treatment for lateral epicondylitis, shoulder tendinopathy, knee osteoarthrosis, femoral head osteonecrosis and trochanteric bursitis reported inconsistent results for most of their patients. Those that evaluated patients with calcifying tendinopathy, plantar fasciitis, Achilles tendinopathy, patellar tendinopathy and pseudarthrosis showed benefits. Shockwave treatment is a safe and non-invasive method for chronic cases in which conventional techniques have been unsatisfactory and should be used in association with other treatment methods for tendinopathy. Further quality studies are needed.

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.

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.

Calcific tendinitis of the shoulder

Calcific tendinitis is a common disease that predominantly affects individuals aged between 40 and 60 years. Women seem to be more affected than men. Various factors have been suggested to play a role in this condition, such as abnormal activity of the thyroid gland, metabolic diseases (e.g. diabetes), and genetic predisposition. Various etiological hypotheses have been advanced: the degenerative and multiphasic theories are the two most accredited ones. Clinically, calcific tendinitis is characterized by severe, disabling pain which occurs spontaneously, usually in the morning. There can be concomitant stiffness, giving rise to a frozen shoulder-like clinical picture. Conventional radiography of the shoulder is the most appropriate imaging approach. Most cases resolve spontaneously. Many conservative treatments have been reported in the literature, showing varying levels of evidence of efficacy. Arthroscopic surgery is the orthopedic specialist's last option. It is to be noted that post-surgical pain can persist for many weeks after the operation. Finally, it is important not to forget the variant characterized by osteolytic involvement of the greater tuberosity, which has been associated with a worse clinical outcome, both after conservative treatment and after surgery.

Periodontal cytokines profile under orthodontic force and extracorporeal shock wave stimuli in a rat model

BACKGROUND AND OBJECTIVE

Extracorporeal shock wave therapy has been used in various clinical conditions as a result of its ability to stimulate healing processes in acute and chronic inflammatory states. Orthodontic force application triggers an inflammatory reaction in the periodontal tissue surrounding the involved teeth, resulting in tooth movement. Preliminary work revealed that extracorporeal shock wave therapy increased the expression of the inflammatory cytokines involved. Our aim was to investigate the expression of inflammatory cytokines in the periodontal tissues following orthodontic force induction, with and without shock wave therapy, in experimental rats.

MATERIAL AND METHODS

An orthodontic appliance was fabricated and applied between the molars and the incisors of adult Wistar rats. In conjunction with orthodontic force commencement, the rats were treated with a single episode of 1000 shock waves. Every day, during the 3 d of the study, rats were killed and the immunolocalization of RANKL, interleukin (IL)-1β, IL-6 and tumor necrosis factor-alpha was evaluated.

RESULTS

The percentage of the area staining positively for all inflammatory cytokines during the first 2 d decreased statistically significantly more in the shock wave-treated group compared with the nontreated control group. On the first day, the percentage of the area staining positively for IL-1β and RANKL on the compression side peaked in both groups, with a sequential rise in the number of TRAP-positive cells.

CONCLUSION

The induction of shock wave therapy during orthodontic tooth movement influences the expression of different inflammatory cytokines in the tissue and might alter the expected periodontal remodeling rate.

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.

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.

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.