Is ultrasound-guided lavage an effective intervention for rotator cuff calcific tendinopathy? A systematic review with a meta-analysis of randomised controlled trials

Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline

This evidence-based clinical practice guideline (CPG) aims to guide clinicians with recommendations covering the assessment, treatment, and prognosis of adults with shoulder pain with suspected rotator cuff (RC) tendinopathy, the nonsurgical medical care and rehabilitation of adults with RC tendinopathy, as well as the return to function and sport for elite and recreational athletes. This CPG includes recommendations for managing RC tendinopathy with or without calcifications and partial-thickness RC tears. J Orthop Sports Phys Ther 2025;55(4):235-274. Epub 30 January 2025. doi:10.2519/jospt.2025.13182.

Ultrasound-guided percutaneous lavage for the treatment of rotator cuff calcific tendinopathy: a systematic review with meta-analysis of randomized controlled trials

INTRODUCTION

Ultrasound-guided lavage (UGL) is a minimally invasive percutaneous treatment for rotator cuff calcific tendinopathy (RCCT). It involves the use of a syringe containing saline and/or anesthetic solution injected directly into the calcification allowing aspiration of the fragmented calcific material. The aim of this systematic review is to investigate if UGL is effective in improving pain, function, quality of life, range of motion (ROM), and in promoting complete resorption of calcifications in patients with RCCT.

EVIDENCE ACQUISITION

Only randomized controlled trials considering people diagnosed with RCCT, at any stage and at any time of the onset of symptoms treated with UGL, were included. Embase, CENTRAL, CINHAL, PEDro and MEDLINE were explored up until May 2024. Two independent authors selected randomized controlled trials by title and abstract; afterwards, the full text was thoroughly evaluated. The risk of bias (ROB) was assessed using the Cochrane risk of bias 2 (ROB2) tool and the certainty of evidence was evaluated through the GRADE approach.

EVIDENCE SYNTHESIS

Seven studies (709 subjects) were included. Overall, three studies were judged as low risk of bias. Pooled results showed non-significant differences between UGL and extracorporeal shock-wave therapy (ESWT) at 12 weeks (SMD=-0.52, 95% CI -1.57, 0.54, P=0.34, I2=93%) and at 26 weeks (MD=-1.20, 95% CI -2.66, 0.27, P=0.11, I2=82%), while a significant difference favoring UGL (SMD=-0.52, 95% CI -0.85, -0.19, P=0.002, I2=38%) resulted at 52 weeks. In regard to function, pooled results showed non-significant difference between UGL and ESWT at 6 weeks (MD=3.34, 95% CI -11.45, 18.12, P=0.66, I2=79%) and at 52 weeks (SMD=0.10, 95% CI -0.40, 0.60, P=0.69, I2=30%). Considering the rate of resorption of calcifications between UGL combined with subacromial corticosteroid injection (SCI) versus injection alone, pooled results showed significant difference favoring UGL at <52 weeks (RR=1.63 95% CI 1.34, 1.98, P<0.00001, I2=0%). Certainty of evidence ranged from low to very low.

CONCLUSIONS

UGL seems to be a reasonable and safe treatment for RCCT, however compared to other non/mini-invasive approaches, UGL showed doubtful results in controlling pain and increasing function and rate of calcifications resorption. These results should be interpreted with caution because certainty of evidence ranged from low to very low.

Clinical significance of liver biopsy in the diagnosis of liver disease and the evaluation of the clinical efficacy of antiviral treatment for chronic hepatitis B

OBJECTIVE

To explore the diagnostic value of liver biopsy in patients with acute/chronic liver diseases and to evaluate the application value of repeated liver biopsy in assessing the efficacy of antiviral therapy in patients with chronic hepatitis B.

METHODS

This retrospective study involved 146 patients with acute and chronic liver diseases who underwent liver biopsy at the Affiliated Hospital of Putian University from January 2018 to December 2023. Differential diagnoses were made for patients with liver diseases based on their pathological results from liver biopsy. Additionally, the effectiveness of antiviral treatment and changes in liver fibrosis in patients with hepatitis B infection before and after antiviral therapy were assessed using repeated liver biopsy.

RESULTS

The overall concordance rate between clinical and histopathological diagnoses was 79.45% (116/146). Specifically, the highest concordance rate was for chronic hepatitis B at 82.61% (76/92), followed by fatty liver disease at 77.78% (7/9), autoimmune liver disease at 75% (12/16), and drug-induced liver injury at 72.72% (16/22), and lastly, hepatitis B-related cirrhosis at 71.43% (5/7). After antiviral therapy, the number of cases with positive HBeAg and HBV-DNA significantly decreased compared to before treatment, while the number of cases with negative HBeAg increased, showing a statistically significant difference (P<0.001). The number of patients at fibrosis stages S3-S4 decreased after antiviral therapy compared to before treatment (P=0.040 and P=0.028), while the number of patients at stage S2 increased (P=0.040).

CONCLUSION

Liver biopsy aids in the diagnosis of liver diseases and can effectively evaluate the degree of liver fibrosis before and after antiviral therapy for chronic hepatitis B.

Reporting and Methodological Quality of Systematic Reviews and Meta-Analyses Evaluating Effects of Extracorporeal Shock Wave Therapy on Tendinopathies: A Scoping Review

Objective

The purpose of this study was to evaluate the methodological and reporting quality of the published systematic reviews with or without meta-analyses (SRs/MAs) that looked at the effects of extracorporeal shock wave therapy (ESWT) on tendinopathies and to summarize its effectiveness.

Methods

A search of PubMed, Scopus, PEDro, Web of Science, Cochrane, Embase, and REHABDATA was conducted. SRs/MAs that assessed the effectiveness of ESWT for treating tendinopathy were included. The methodological and reporting quality of the eligible SRs/MAs were assessed using AMSTAR-2 and the PRISMA checklist. In addition, the ROBIS tool was applied to evaluate the risk of bias (RoB).

Results

Eighteen SRs/MAs were included. The overall methodological quality was "critically low." Furthermore, the reporting quality of the included reviews according to PRISMA criteria was not optimal. Based on the ROBIS, a total of 16.2% of the studies had a low RoB, 38.9% had an unclear RoB, and 44.4% of the studies were appraised as having a high RoB.

Conclusion

In this scoping review we found substantial limitations regarding the quality and RoB of SRs/MAs. Therefore, reviewers must consider the AMSTAR-2, PRISMA, and ROBIS tools to improve the quality of future studies.

Surgical approaches of shoulder calcific tendonitis: a systematic review and meta-analysis

Background

Calcific tendonitis is a painful shoulder disorder characterized by calcium deposits (CDs) in the rotator cuff tendon. This systematic review and meta-analysis examined the most efficient surgical procedure for calcific tendonitis. This includes the comparison between the three main surgical techniques: CD removal, CD removal with subacromial decompression (SAD) and CD removal with tendon repair with respect to functional outcomes and pain control scores.

Methods

Four electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) were searched in February 2023. Studies were eligible for inclusion if they were peer-reviewed, and participants were patients diagnosed with calcific tendonitis of one or more rotator cuff tendon based on diagnostic imaging who underwent shoulder calcific tendonitis surgery. Other shoulder pathology diagnoses were excluded. Meta-analyses were conducted for results that were sufficiently homogeneous in terms of statistical, clinical, and methodological characteristics. Subgroup analyses were performed to determine if effect sizes differed based on the patient's position during the surgery, physiotherapy, and follow-up time.

Results

All surgical interventions resulted in significant improvements in shoulder function and pain control. There were no significant differences between CD removal vs. CD removal with SAD or CD removal vs. CD removal with tendon repair. However, there was a trend in favor of CD removal alone or CD removal with SAD approaches, as they provided better outcome scores than CD removal with tendon repair in terms of shoulder function and pain control.

Conclusions

All surgical interventions provide substantial improvement in shoulder functions and pain control scores with no significant difference between these surgical techniques.

Effectiveness of non-surgical management in rotator cuff calcific tendinopathy (the effect trial): protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT.

METHODS AND ANALYSIS

A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis.

ETHICS AND DISSEMINATION

Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05478902.

Needling and Lavage in Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Technique

Background

Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain1,2. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively3. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course1,4, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT5. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa.

Description

It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder.

Alternatives

RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy3. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered8. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort.

Rationale

Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function8. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up9-11. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process, which is promoted by the perforation of the deposits. Clinical outcomes are not associated with the success of the aspiration7,12. Patients with ≥1 larger deposit show greater improvement following barbotage than patients with small deposits12, in contrast with ESWT, in which larger deposits have been associated with worse outcomes. The inferior outcome of barbotage in patients with small deposits remains the subject of debate, but outcomes may be confounded by the fact that patients with smaller deposits might be less symptomatic at baseline and are therefore less likely to demonstrate improvement4.

Expected Outcomes

In the first weeks after barbotage, there is generally a substantial reduction in symptoms. Symptoms can recur at around 3 months, presumably because the effect of the corticosteroids is temporary5. After 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life, with results superior to those shown for subacromial injections and ESWT9,10,13,14. At 5 years postoperatively, there are no significant differences in outcomes between barbotage and subacromial injections15. This may demonstrate a self-limiting course in the long term.

Important Tips

Good candidates for barbotage are those with RCCT who have ≥1 large calcific deposit.If a patient has a solid deposit, the physician can gently rotate and repeatedly puncture the deposit to promote disaggregation and fragmentation.Barbotage generally results in adequate pain relief and functional improvement even in patients in whom calcium deposits cannot be aspirated12.

Acronyms and Abbreviations

SAI = injection in the subacromial bursaNSAIDs = nonsteroidal anti-inflammatory drugs.

Intramuscular migration of calcium deposits into the deltoid muscle: two cases of a rare complication of rotator cuff calcific tendinopathy

Rotator cuff calcific tendinopathy is a common non-traumatic shoulder pain condition that occurs predominantly in the supraspinatus tendon. Ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) is a valid treatment in the resorptive phase. A complication of calcific tendinopathy is migration of calcium deposits outside the tendon. The most common site of migration is the subacromialsubdeltoid bursa (SASD). Another, but not frequent, type of migration is the intramuscular migration which mostly affects the supraspinatus, the infraspinatus and the biceps brachii muscles. This paper reports two cases of migration of calcification from the supraspinatus tendon to the deltoid muscle. The aforementioned site of migration has so far never been described in literature. Both patients presented calcification in the resorptive phase and therefore were treated by US-PICT.

Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study

OBJECTIVE

To compare treatment effects between ultrasound guided lavage with corticosteroid injection and sham lavage with and without corticosteroid injection in patients with calcific tendinopathy of the shoulder.

DESIGN

Pragmatic, three arm, parallel group, double blinded, sham controlled, randomised, superiority trial with repeated measurements over 24 months.

SETTING

Six hospitals in Norway and Sweden.

PARTICIPANTS

220 adults with calcific tendinopathy of the shoulder, persistent for at least three months.

INTERVENTIONS

Ultrasound guided deposit lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (lavage+steroid); sham lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (sham lavage+steroid); or sham lavage plus subacromial injection of 10 mL 1% lidocaine hydrochloride (sham). All patients received a physiotherapeutic treatment regimen consisting of four home exercises.

MAIN OUTCOME MEASURES

The primary outcome was the result on the 48 point scale (0=worst; 48=best) of the Oxford Shoulder Score (OSS) at four month follow-up. Secondary outcomes included measurements on the short form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and of pain intensity up to 24 months. The influence of the size of the deposit at baseline and of the persistence or disappearance of the deposit was investigated.

RESULTS

Data from 218 (99%) participants were included in the primary analysis. Differences between groups on the OSS at four months were not significant: lavage+steroid versus sham 0.2 (95% confidence interval -2.3 to 2.8; P=1.0); sham lavage+steroid versus sham 2.0 (-0.5 to 4.6; P=0.35); lavage+steroid versus sham lavage+steroid -1.8 (-4.3 to 0.7; P=0.47). After four months, 143 patients with insufficient treatment effect received supplementary treatment. At 24 months, none of the study procedures was superior to sham. No serious adverse events were reported.

CONCLUSIONS

This study found no benefit for ultrasound guided lavage with a corticosteroid injection or for sham lavage with a corticosteroid injection compared with sham treatment in patients with calcific rotator cuff tendinopathy of the shoulder.

TRIAL REGISTRATION

NCT02419040EudraCT 2015-002343-34; Ethical committee Norway 2015-002343-34; Ethical committee Sweden 2015/79-31; Clinicaltrials.gov NCT02419040.

Arthroscopic decompression of calcific tendinitis without cuff repair

Aims

The aim of this study was to investigate the outcomes of arthroscopic decompression of calcific tendinitis performed without repairing the rotator cuff defect.

Methods

A total of 99 patients who underwent treatment between December 2013 and August 2019 were retrospectively reviewed. Visual analogue scale (VAS) and American Shoulder and Elbow Surgeons (ASES) scores were reviewed pre- and postoperatively according to the location, size, physical characteristics, and radiological features of the calcific deposits. Additionally, the influence of any residual calcific deposits shown on postoperative radiographs was explored. The healing rate of the unrepaired cuff defect was determined by reviewing the 29 patients who had follow-up MRIs.

Results

Statistically significant improvement from pre- to postoperation was seen in all VAS and ASES scores for each group, but no statistical differences were seen between the postoperative scores according to the differences in the features of the calcific deposits. When residual calcification was observed postoperatively, the mean ASES and VAS (rest) scores improved significantly to 95.0 (SD 5.6) and 0.0 (SD 0.0), respectively (p = 0.006 and p < 0.001), and did not differ from those who had the complete removal. Of 29 patients who had follow-up MRIs, six (20.7%) showed signs of an interstitial tear. This group's mean postoperative ASES and VAS (rest) scores improved to excellent levels of 96.0 (SD 3.7) and 0.0 (SD 0.0), respectively, and were similar to those of the 23 patients with normal MRI appearances.

Conclusion

Arthroscopic removal of calcific deposits without repairing the rotator cuff defect resulted in significant improvement in function and pain level, regardless of the deposit's location, size, type, and whether or not complete excision was achieved. Despite leaving the defects unrepaired, in the limited number of patients with follow-up MRIs, 23 of 29 patients (79.3%) showed good healing, and the rest, who had persistent signs of interstitial defects on the MRIs, still had excellent outcomes. The removal of calcific deposits without repairing the cuff defects provided excellent outcomes.

Arthroscopic treatment and subacromial decompression of calcific tendinitis without removal of the calcific deposit results in rapid resolution of symptoms and excellent clinical outcomes in commercial airline pilots and cabin crew

PURPOSE

The purpose of this study was to report the results of subacromial arthroscopic decompression (SAD) without removal of the calcific deposits in patients with calcifying tendinitis.

METHODS

All patients between 2016 and 2019 were included if they were aged between 18 and 60 years and had an isolated calcific deposit. The Constant-Murley score (CMS), Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, the Shoulder Pain and Disability Index (SPADI), the simple shoulder test (SST), and the single assessment numeric evaluation (SANE) were used for assessment. Time to return to work was recorded.

RESULTS

24 patients (13 pilots, 11 cabin crew) with a mean age of 47.1 ± 7.8 years were included. Quick Dash improved from 68.8 preoperative, to 8.4 at 3 months, and 0.1 at 24 months. CMS improved from 37.4 preoperative, to 83 at 3 months, and 94 at 24 months. SPADI improved from 73.8 preoperative, to 5.4 at 3 months, and 1 at 24 months. SST improved from 22.5 preoperative, to 94.2 at 3 months, and 100 at 24 months. SANE improved from 33.5 preoperative, to 78.7 at 3 months, and 95.6 at 24 months. MCID, SCB, and PASS reached values above 83% at 3 months and 100% at 6 months, with the exception of SANE which reached 29% at 3 months and plateaued to 96% at 6 months. The mean time to return to work was 7.1 ± 2.1 weeks. Pilots returned at a mean of 6.9 ± 1.8 weeks; cabin crew returned to work at a mean of 7.8 ± 2.5 weeks.

CONCLUSIONS

The results of this study suggest excellent short- and mid-term clinical outcomes can be achieved in patients with calcific tendinitis undergoing arthroscopic debridement and subacromial decompression without removal of calcific deposits. In this patient population, early surgical intervention was a potentially viable alternative to nonoperative treatment, and allowed early return to work.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline

OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306.

Calcific Tendinopathy of the Shoulder: A Retrospective Comparison of Traditional Barbotage Versus Percutaneous Ultrasonic Barbotage

OBJECTIVE

The purpose of this study was to compare a traditional barbotage technique with percutaneous ultrasonic barbotage (PUB) for the treatment of rotator cuff (RC) calcific tendinopathy.

DESIGN

Three-year retrospective review.

SETTING

Participants aged 18 to 75 presenting at 2 highly specialized outpatient orthopedic referral centers with symptomatic RC calcific tendinopathy.

PATIENTS

There were 75 patients included (23 patients in the traditional barbotage group; 52 patients in the PUB group) with an average age of 55.3(6.5) and 55.9(9.8), respectively. There was no significant difference in demographics between groups.

INTERVENTIONS

Traditional barbotage or PUB.

MAIN OUTCOME MEASURES

Primary outcome measure was pain rated on the Numeric Pain Rating Scale (NPRS) with secondary outcomes investigating patient satisfaction.

RESULTS

The barbotage and PUB group demonstrated a significant improvement in pain (barbotage 2.4, P = 0.01; PUB = 2.6, P < 0.001) with no statistically significant difference between the 2 treatment modalities (95% CI: -1.8 to 2.2; P = 0.83, P = 0.83). Median follow-up for NPRS recordings was 17-weeks in the barbotage group and 8-weeks in the PUB group ( P = 0.004). Both groups demonstrated similar patient-reported satisfaction, without major complications.

CONCLUSION

The traditional barbotage and PUB procedures improved pain with a high patient satisfaction rate.

LEVEL OF EVIDENCE

Level III.

Hydroxyapatite crystal deposition disease around the hip: a rare cause of piriformis syndrome and ischiofemoral impingement

Hydroxyapatite crystal deposition disease (HADD) around the hip is typically described involving the gluteal tendons. However, HADD can occur in any location and result in varied clinical presentations. Even with small deposits, symptoms can be significant and imaging findings may appear aggressive, mimicking infection and malignancy particularly when in an atypical location.

We illustrate cases of both common and rare locations of HADD around the hip, in particular presenting as greater trochanteric pain syndrome, piriformis syndrome and ischiofemoral impingement. The latter two manifestations have not been previously described in the literature.

Low signal deposits were identified on MRI at the greater trochanter (gluteus medius tendon), proximal piriformis (adjacent to the sciatic nerve), and quadratus femoris (in the ischiofemoral space), respectively. Associated inflammatory changes with tendinopathy, bursitis and oedema were also demonstrated. The patient with piriformis syndrome underwent steroid injections and shockwave therapy with significant symptom improvement.

HADD should be within the differential diagnosis for hip pain and nerve compression syndromes. Knowledge of tendon anatomy and correlation with radiographs or CT, even after MRI, is crucial in recognising unusual manifestations and preventing unnecessary investigation. Therefore, we review the spectrum of imaging features of HADD, as well as the current evidence on its management, to confidently diagnose this condition.

Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment

Objective

To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.

Data sources

Medline from inception to June 2020.

Study eligibility

All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.

Data extraction and synthesis

Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.

Results

A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.

Conclusions

In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.

Ultrasonic Tenotomy and Debridement for Calcific Tendinopathy of the Shoulder: A Pilot Case Series

Calcific tendinopathy of the rotator cuff is a common cause of shoulder pain and debility. Minimally invasive treatment options have been employed for management; however, ultrasonic tenotomy has not been previously described for management of calcific tendinopathy of the shoulder. The purpose of the current case series was to provide preliminary evidence in support of a novel treatment modality for calcific tendinopathy of the rotator cuff. This descriptive pilot case series included a total of 8 patients with calcific tendinopathy of the supraspinatus that underwent ultrasound-guided ultrasonic debridement in the sports medicine clinic. All procedures were performed by the same physician (JLE). All patients had confirmation of the diagnosis with MRI and ultrasound imaging. Pain was measured pre-procedure and followed until 3-months post-procedure. Very large, statistically significant, reductions (P < .01) in pain scores were observed at 1 (ES = 1.93), 2 (ES = 1.84) and 3 (ES = 2.20) months post-procedure, respectively. All patients experienced a significant reduction in pain scores, regardless of hardness of the calcium deposit, at 1 month post-procedure with pain scores remaining lower than at baseline at 2 and 3 months post-procedure. No adverse events were noted in any patients. Ultrasonic tenotomy and debridement appears to be a safe and effective treatment option for patients with calcific tendinopathy of the supraspinatus.

The Impact of Minimally Invasive Treatment for Rotator Cuff Calcific Tendinitis on Self-Reported Work Ability and Sick Leave

Purpose

To examine the impact of rotator cuff calcific tendinitis on patients' self-reported work ability and sick leave, to compare work ability and sick leave with shoulder function after minimally invasive treatment, and to assess which prognostic factors influence the change in work ability.

Methods

A prospective cohort was analyzed in this study. The primary outcome measure was the single-question work ability score (0-10 points). Secondary outcome measures were quality and quantity of work, sick leave, functional outcome, and radiographic resorption. Potential predictive factors (treatment method, age, sex, resorption of the calcific deposit, physical work load, and work status) were tested in a statistical model. Follow-up was at 6 months and 1 year.

Results

The study cohort consisted of 67 patients. The mean age was 49.6 ± 6.4 years and 45 (67%) were female. Physical workload was categorized as light (58%), medium (24%), and heavy (18%). Work ability score improved from a mean of 6.1 ± 2.8 to 8.5 ± 2.0 points after 1 year. Treatment with minimally invasive treatment techniques was associated with a reduction in partial or full-time sick leave from 28% to 6%. The mean days of sick leave a month declined from 3.3 to 0.8 days. Functional disability was greater in patients with partial or full-time sick leave. The physical workload turned out to be the most important patient associated factor predicting change in work ability.

Conclusions

This study supports the hypothesis that rotator cuff calcific tendinitis has a significant impact on work ability and sick leave. Minimally invasive treatment resulted in a clinically relevant improvement in work ability score and decline in sick leave. In particular, patients with medium and high physically demanding work for the shoulder benefit from minimally invasive treatment to improve their work ability.

Level of Evidence

Level II, prospective comparative study.

Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial

PURPOSE

To compare clinical and radiographic outcomes after treatment with standardized high-energy extracorporeal shock wave therapy (ESWT) and ultrasound-guided needling (UGN) in patients with symptomatic calcific tendinitis of the rotator cuff who were nonresponsive to conservative treatment.

METHODS

The study was designed as a randomized controlled trial. The ESWT group received ESWT (2000 pulses, energy flux density 0.35 mJ/mm²) in 4 sessions with 1-week intervals. UGN was combined with a corticosteroid ultrasound-guided subacromial bursa injection. Shoulder function was assessed at standardized follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant Murley Score (CMS), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and visual analog scale for pain and satisfaction. The size, location, and morphology of the deposits were evaluated on radiographs. The a priori sample size calculation computed that 44 participants randomized in each treatment group was required to achieve a power of 80%.

RESULTS

Eighty-two patients were treated (56 female, 65%; mean age 52.1 ± 9 years) with a mean baseline CMS of 66.8 ± 12 and mean calcification size of 15.1 ± 4.7 mm. One patient was lost to follow-up. At 1-year follow-up, the UGN group showed similar results as the ESWT group with regard to the change from baseline CMS (20.9 vs 15.7; P = .23), Disabilities of the Arm, Shoulder, and Hand questionnaire (-20.1 vs -20.7; P = .78), and visual analog scale for pain (-3.9 and -2.6; P = .12). The mean calcification size decreased by 13 ± 3.9 mm in the UGN group and 6.7 ± 8.2 mm in the ESWT group (<P = .001). In total, 22% of the UGN and 41% of the ESWT patients received an additional treatment during follow-up because of persistent symptoms.

CONCLUSIONS

This RCT compares the clinical and radiographic results of UGN and high-energy ESWT in the treatment of calcific tendinitis of the rotator cuff. Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. However, UGN is more effective in eliminating the calcific deposit, and the amount of additional treatments was greater in the ESWT group.

LEVEL OF EVIDENCE

II, randomized controlled trial.

Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments

While the pathoetiology is disputed, a wide array of treatments is available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions; however, their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8 ± 1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy-related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy-related pain and improve self-reported function.

US-guided percutaneous irrigation of calcific tendinopathy of the rotator cuff in patients with or without previous external shockwave therapy

OBJECTIVES

To compare the outcome of US-guided percutaneous irrigation of calcific tendinopathy (US-PICT) of the rotator cuff in patients with or without previous external shockwave therapy (ESWT).

METHODS

We analyzed all patients treated with US-PICT from March 1, 2016, to October 1, 2019, with shoulder pain refractory to conservative management for rotator cuff calcific tendinopathy, diagnosed with ultrasound. Each patient was examined using the Constant-Murley Score (CMS) questionnaire (score 0-100) before and after treatment. We tested CMS differences using the Mann-Whitney U (Wilcoxon rank-sum) test in the two groups. US-PICT was performed placing two or multiple 14G needles, according to the calcification size, inserted under US guidance to create a circuit of irrigation in the calcified tendon. NaCl solution at 38 °C was then injected from the entry needle in a variable amount to hydrate and fragment the calcification, finally allowing for its expulsion through the exit needle. All patients also received an intrabursal steroid injection.

RESULTS

From 2016 to 2019, 72 US-PICT treatments were performed on 70 patients (females = 46; males = 26) with a mean age of 49.7 years (SD = 8.7. Thirty-three (47%) underwent previous ESWT, while thirty-seven (53%) had no previous treatments. No treatment-related complications were observed. Follow-up was averagely 14.4 months (median = 11.6, SD = 11.9, range 1-45); 37 patients had a follow-up shorter than 12 months (1-11.6); 35 patients were visited after more than 1 year (12.2-45.6, Table W). Before treatment, the mean CMS was 35 (SD = 21); after treatment, it reached 75.4, with an average CMS improvement of 40.3 points (SD = 23.7, p < 0.001). The comparison of improvement between the ESWT and non-ESWT group yielded no significant difference (p = 0.3).

CONCLUSIONS

US-PICT of the rotator cuff is an effective procedure to reduce shoulder pain and increase mobility in patients with calcific tendinopathy, both in short- and long-term time intervals. Previous unsuccessful ESWT does not affect the outcome of US-PICT.

Common Musculoskeletal Disorders in the Elderly: The Star Triad

Musculoskeletal disorders are debilitating conditions that significantly impair the state of health, especially in elderly subjects. A pathological triad of inter-related disorders that are highly prevalent in the elderly consists of the following main “components”: sarcopenia, tendinopathies, and arthritis. The aim of this review is to critically appraise the literature relative to the different disorders of this triad, in order to highlight the pathophysiological common denominator and propose strategies for personalized clinical management of patients presenting with this combination of musculoskeletal disorders. Their pathophysiological common denominator is represented by progressive loss of (focal or generalized) neuromuscular performance with a risk of adverse outcomes such as pain, mobility disorders, increased risk of falls and fractures, and impaired ability or disability to perform activities of daily living. The precise management of these disorders requires not only the use of available tools and recently proposed operational definitions, but also the development of new tools and approaches for prediction, diagnosis, monitoring, and prognosis of the three disorders and their combination.

Ultrasound-guided percutaneous treatment of a calcific acromioclavicular joint: A case report

RATIONALE

Calcific tendinopathy is one of the most frequent causes of nontraumatic shoulder pain. However, intra-articular calcifications appear to be an infrequent condition. We herein report a rare case study of an intra-articular calcification of the acromioclavicular joint.

PATIENT CONCERNS

A 46-year-old man presented with an acute pain in the anterior superior region of the left shoulder which also radiated to the left cervical region. The man during the physical evaluation also presented severe functional limitation of the shoulder movements in all planes of motion.

DIAGNOSES

The diagnosis was carried out through a radiographic and an echotomographic examination, highlighting the intra-articular calcific formation associated to a reactive inflammatory reaction.

INTERVENTIONS

An ultrasound-guided percutaneous treatment following the guidelines for calcific tendinopathy of the shoulder was carried out.

OUTCOMES

The posttreatment was satisfactory with the disappearance of the pain and the recovery of the shoulder movements in all planes of motion.

LESSONS

We can affirm that the ultrasound-guided percutaneous treatment in patients with calcification of the acromion-clavicular joint represents a valid and nonpainful therapeutic treatment.