Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder

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.

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.

Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Extracorporeal shockwave therapy (ESWT) was first introduced into clinical practice in 1982 and has been a beneficial inclusion to the noninvasive treatment option of numerous orthopaedic pathologies. However, clinical evidence of the use of ESWT for various foot and ankle disorders has been limited with a consensus on its efficacy yet available. Therefore, the purpose of this study is to systematically review the literature, to provide a critical evaluation and meta-analysis for the use of ESWT in foot and ankle disorders.

METHODS

The PubMed and Embase databases were systematically reviewed and clinical studies that reported ESWT use for various foot and ankle disorders included.

RESULTS

A total of 24 clinical studies that included 12 randomized controlled trials and 12 case series were identified. Analysis of the evidence has indicated that ESWT can help manage plantar fasciitis, calcaneal spur, Achilles tendinopathy and Morton's neuroma. Meta-analysis of the change in pre- to post-VAS overall scores for plantar fasciitis significantly favored ESWT compared to placebo/conservative treatment with a MD -3.10 (95% CI, -4.36 to -1.83; I2 = 68%; P < 0.00001).

CONCLUSIONS

The current evidence has suggested that ESWT can provide symptomatic benefit to plantar fasciitis treatment, with minimal and unremarkable side effects. Overall, ESWT has been demonstrated to be a safe treatment option with a favorable complication profile. Further well-designed studies of ESWT for the treatment of calcaneal spurs, Achilles tendinopathy and Morton's neuroma are warranted to more soundly and safely support its current use. Future studies are suggested to investigate the optimization of ESWT treatment protocols.

Understanding cavitation-related mechanism of therapeutic ultrasound in the field of urology: Part I of therapeutic ultrasound in urology

Shock waves are commonly used in the field of urology. They have two phases, positive and negative, and the bubble generation is roughly classified into acoustic cavitation (AC) and laser-induced cavitation (LIC). We evaluated the occurrence of cavitation, its duration, the area of interest, and the maximal diameter of the cavitation bubbles. Changes in AC occurred at 0.2 ms with the highest number of bubbles and disappeared at 0.6 ms. The bubble size was 2 mm in diameter. Changes in LIC bubbles were observed in three pulse modes. The short pulse showed an initial bubble starting at 0.005 ms, which reached its largest size at 0.4 to 0.6 ms. The long pulse showed an initial bubble starting at 0.005 ms, which reached its largest size at 0.4 ms with the formation of an additional lagena-shaped bubble at 0.6 ms. The distance mode of MOSES showed two signal peaks with the formation of two consecutive bubbles at 0.2 and 0.6 ms. The main difference in the laser beams between the long-pulse and the MOSES modes was the continuity and the peak power of the laser beam. The diameters parallel to the laser direction were 6.8, 8.6, and 9.7 mm at 1, 2, and 3 J, respectively, in the short pulse. While the cavitation bubbles rupture, ejectile force occurs in numerous directions, transmitting high enough energy to break the targets. Cavitation bubbles should be regarded as energy and the mediators of energy for stone fragmentation and tissue destruction.

Clinical evaluation and management of calcific tendinopathy: an evidence-based review

Calcific tendinopathy (CT) is an important musculoskeletal condition most commonly seen in the shoulder girdle, accounting for 10-42% of all shoulder pain. Despite the high prevalence within the shoulder region, CT has been demonstrated in many tendons throughout the axial and appendicular skeleton. Unlike degenerative tendinopathies, CT appears to be a self-limiting condition that affects otherwise-healthy tendon with deposition of calcium hydroxyapatite crystals between healthy tenocytes. In patients with functionally limiting symptoms or pain, the clinical course may be accelerated through a multitude of treatments including physical therapy and pain management, extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage (UGPL), and operative debridement. Currently, the most efficacious and frequently utilized treatment for shoulder CT is UGPL due to its ability to effectively reduce calcium burden and pain while limiting soft-tissue damage. However, more evidence regarding the treatment and course of CT is needed before determining the most appropriate treatment at all potential sites of CT.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

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.

Comparison of Subacromial Ketorolac Injection versus Corticosteroid Injection in the Treatment of Shoulder Impingement Syndrome

Objective:

Subacromial impingement syndrome is the most common cause of shoulder pain and restriction in range of motion in the world. The aim of this study was to compare the efficacy of subacromial injection of ketorolac with the injection of corticosteroid for the treatment of subacromial impingement syndrome.

Methods:

A total of forty patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and Group B received 60 mg of ketorolac as a subacromial injection along with lidocaine. Each patient was evaluated in terms of visual analog scale (VAS) for evaluating pain and Constant's score for function evaluation (pain, activity level, and range of motion with standard goniometry). The patients were re-examined 1 and 3 months after intervention. All the patients educated for simple home exercise.

Findings:

At 1 and 3 months of follow-up, both treatment arms resulted in an increased range of motion and decreased pain. The difference between the groups was not statistically significant (P > 0.05). In ketorolac group, mean pre- and post-treatment (at 12 weeks) VAS scores were 8.6 (range, 3–9) and 4.5 (range 2–4), respectively. In steroid group, mean pre- and post-treatment (at 12 weeks) VAS scores were 8.3 (range, 3–10) and 3.9 (range, 0–7), respectively. The difference was statistically significant within groups at baseline and 1 (P < 0.001) and 3 (P < 0.001) months after the injection.

Conclusion:

Subacromial injection of ketorolac has an equivalent outcome to subacromial injection of corticosteroid. The use of ketorolac injections can substantially decrease the pain and increase the range of motion of the shoulder and could be a reasonable alternative in case of corticosteroid contraindications.

Ultrasound Guidance Does Not Improve the Results of Shock Wave for Plantar Fasciitis or Calcific Achilles Tendinopathy: A Randomized Control Trial

OBJECTIVE

To establish whether the use of ultrasound to direct shock waves to the area of greater calcification in calcaneal enthesopathies was more effective than the common procedure of directing shock waves to the point where the patient has the most tenderness.

DESIGN

Two-armed nonblinded randomized control trial with allocation concealment.

SETTING

The Sports Clinic at Sydney University.

PATIENTS

Participants 18 years or older with symptomatic plantar fasciitis (PF) (with heel spur) or calcific Achilles tendinopathy (CAT). Seventy-four of 82 cases completed treatment protocol and 6-month follow-up.

INTERVENTIONS

Patients were randomized to receive either ultrasound-guided (UG) or patient-guided (PG) shock wave at weekly intervals over 3 to 5 weeks.

MAIN OUTCOME MEASURES

Reduced pain on visual analog scale (VAS) and improved functional score on Maryland Foot Score (MFS) (for PF) or Victorian Institute of Sport Assessment-Achilles (VISA-A) (for CAT). Follow-up was at 6 weeks and 3 and 6 months.

RESULTS

Comparative 6-month improvements in MFS for the 47 PF cases were PG +20/100 and UG +14/100 (P = 0.20). Comparative 6-month improvement in VISA-A score for the 27 CAT cases were PG +35/100 and UG +27/100 (P = 0.37). Comparative (combined PF and CAT) 6-month improvement in VAS pain scores for all 38 PG cases were +38/100 with +37/100 for all 36 UG shock wave cases.

CONCLUSIONS

Although both treatment groups had good clinical outcomes in this study, results for the 2 study groups were almost identical.

CLINICAL RELEVANCE

This study shows that there is no major advantage in the addition of ultrasound for guiding shock waves when treating calcaneal enthesopathies (PF and CAT).

Insights into the mechanism of a novel shockwave-assisted needle-free drug delivery device driven by in situ-generated oxyhydrogen mixture which provides efficient protection against mycobacterial infections

BACKGROUND

Needle-free, painless and localized drug delivery has been a coveted technology in the area of biomedical research. We present an innovative way of trans-dermal vaccine delivery using a miniature detonation-driven shock tube device. This device utilizes~2.5 bar of in situ generated oxyhydrogen mixture to produce a strong shockwave that accelerates liquid jets to velocities of about 94 m/s.

METHOD

Oxyhydrogen driven shock tube was optimized for efficiently delivering vaccines in the intradermal region in vivo. Efficiency of vaccination was evaluated by pathogen challenge and host immune response. Expression levels of molecular markers were checked by qRT-PCR.

RESULTS

High efficiency vaccination was achieved using the device. Post pathogen challenge with Mycobacterium tuberculosis, 100% survival was observed in vaccinated animals. Immune response to vaccination was significantly higher in the animals vaccinated using the device as compared to conventional route of vaccination.

CONCLUSION

A novel device was developed and optimized for intra dermal vaccine delivery in murine model. Conventional as well in-house developed vaccine strains were used to test the system. It was found that the vaccine delivery and immune response was at par with the conventional routes of vaccination. Thus, the device reported can be used for delivering live attenuated vaccines in the future.

Ultrasound guided Needling vs Radial Shockwave Therapy in calcific tendinitis of the shoulder: A prospective randomized trial

PURPOSE

Ultrasound Needling(UN) and Radial Shockwave(RSWT) aim to dissolve deposits in Shoulder Calcific tendinitis.

METHODS

RCT in 25 patients to compare short term effectiveness. Outcome measures were pain and functional outcome at 6 weeks and 1 year and decrease of deposits after 6 weeks.

RESULTS

UN decreased deposit more than RSWT(P = 0.029). After 6 weeks, Constant, NRS and Oxford improved more in UN. After 1 year, there was no significant difference in NRS(p = 0.45) or Oxford(p = 0.32).

CONCLUSION

Compared to RSWT, UN resulted in lower pain and faster resorption of calcifications after 6 weeks. No significant differences were found after 1 year.

Arthroscopic Removal and Tendon Repair for Refractory Rotator Cuff Calcific Tendinitis of the Shoulder

BACKGROUND

The purpose of this study was to evaluate clinical and radiological outcomes of arthroscopic treatment for refractory rotator cuff calcific tendinitis of the shoulder.

METHODS

Subjects were 37 patients (35 women and 2 men; mean age, 47.8 years; age range 34-61 years) who had undergone arthroscopic treatment for calcific tendinitis of the shoulder. Despite sufficient nonsurgical treatments, all patients had residual calcific deposit with persistent or recurrent pain. Before surgery, all patients underwent 3-directional radiographs of the shoulder and three-dimensional computed tomography to determine the location and size of calcific deposit. Arthroscopic surgery was performed with the patient under general anesthesia in the lateral decubitus position. A 2-cm single longitudinal incision was made with a radiofrequency hook blade on the tendon surface above calcific deposit. Calcific deposit was removed as much as possible with a curette and a motorized shaver. The incised tendon was repaired with a side-to-side suture with strong sutures. The Japanese Orthopaedic Association shoulder score was used to evaluate clinical outcomes. The extent of calcific deposit removal was evaluated with radiographs obtained before surgery, 1 week after the surgery and at the final follow-up examination.

RESULTS

The mean follow-up duration was 30.4 (range, 13-72) months. The mean shoulder score significantly improved from 69.7 (range, 58-80) points before surgery to 97.8 (range, 89-100) points at the final follow-up examination. Postoperative radiographs in all patients, showed that the calcific deposit was resolved or reduced and those from 1 week after surgery to the final examination showed no evidence of recurrence or enlargement of calcific deposit. The calcific deposit had completely resolved in 34 patients but remained in 3 patients.

CONCLUSION

When treating calcific tendinitis of the shoulder, it is important to accurately determine the size and location of calcific deposit by radiographs and 3-dimensional computed tomography. Satisfactory clinical and radiological outcomes can be expected after reliable removal of calcific deposit through a single longitudinal incision and side-to-side repair with strong sutures, in association with an appropriate rehabilitation program.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

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.

Steroid Injection and Nonsteroidal Anti-inflammatory Agents for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of Randomized Controlled Trials

Advantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for shoulder pain are not fully understood. To compare the efficiency and safety of steroid injection versus NSAIDs for patients with shoulder pain. PubMed, Embase, and the Cochrane Library were searched through July 2015. Study eligibility criteria, participants, and interventions: randomized controlled trials (RCTs) that assessed steroid injection versus NSAIDs for patients with shoulder pain. Study appraisal and synthesis methods: predefined primary efficacy outcome was functional improvement; and secondary efficacy outcomes included pain relief and complications. Relative risks (RRs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model accounting for clinical heterogeneity. Eight RCTs involving 465 participants were included in the meta-analysis. Five trials compared steroid injection with oral NSAIDs, and 3 compared steroids injection with NSAIDs injection. Compared with steroid injection, oral NSAIDs were less effective in 4 or 6 weeks for functional improvement (SMD 0.61; 95% CI, 0.08-1.14; P = 0.01), while there was no significant difference in pain relief (SMD 0.45; 95% CI, -0.50-1.40; P < 0.00001) or complication rate (RR 1.10; 95% CI, 0.26-4.58; P = 0.29). Meta-analysis was not performed for NSAIDs injection due to considerable heterogeneity. Conflicting results were observed in favor of either steroid or NSAIDs injection. Not all diseases that can lead to shoulder pain were included, detailed intervention protocols were inconsistent across studies, and some estimated data were input into comparison while some data were lost, which could exert an influence on pooled results. Steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks. Treatment decision should be made based on diseases. NSAIDs injection might be a treatment method for shoulder pain.

Short-Term Outcome After Arthroscopic Bursectomy Debridement of Rotator Cuff Calcific Tendonopathy With and Without Subacromial Decompression: A Prospective Randomized Controlled Trial

PURPOSE

To conduct a prospective randomized controlled trial to assess whether arthroscopic bursectomy and debridement of the calcific deposit, with or without subacromial decompression, influences the functional outcome of patients with calcific tendonitis.

METHODS

During a 4-year period, 80 patients were recruited who presented to the study center with refractory calcific tendonitis of the shoulder. Forty patients were randomized to have a subacromial decompression, and 40 were randomized not to have a subacromial decompression in combination with bursectomy and arthroscopic removal of the calcific deposit. All surgery was performed by one surgeon who was blinded to the functional assessment of the patients. Patient demographics, body mass index (BMI), and length of symptoms were recorded at the time of randomization. Patients were asked to complete a pain visual analog score (VAS), short form (SF-12), disability arm shoulder and hand (DASH), and Constant score (CS) preoperatively and at 1 year postoperatively.

RESULTS

There were 21 male and 59 female patients with a mean age of 49 (range, 32 to 75) years. The mean time of follow-up was 13 (range, 12 to 15) months. There were no significant differences in gender, age, BMI, length of symptoms, or preoperative outcome measures assessed between the groups. Overall, for both groups there was a significant improvement in the pain VAS (P < .001), DASH (P < .001), and CS (P < .001) at 1 year compared with preoperative scores. There were no significant differences demonstrated between the groups for improvement in the pain VAS (P = .57), DASH (P = .93), SF-12 physical component score (P = .58), or CS (P = .27) at 1 year.

CONCLUSIONS

This study has demonstrated that the short-term functional outcome of patients with calcific tendonitis after arthroscopic bursectomy and debridement of the calcific deposit is not influenced if performed in combination with or without a subacromial decompression.

LEVEL OF EVIDENCE

Level I therapeutic study, randomized controlled trial.

Effectiveness of extracorporeal shockwave therapy in three major tendon diseases

BACKGROUND

Extracorporeal shockwave therapy is a conservative treatment for several painful musculoskeletal disorders. The aim of the study was the assessment of the relief from pain by the shockwave therapy in a population of consecutive patients affected by specific pathologies.

MATERIALS AND METHODS

A group of consecutive patients were studied and treated. They were affected by calcific tendonitis of the shoulder (129 patients), chronic Achilles tendinopathy (102 patients), and lateral epicondylitis of the elbow (80 subjects). Each patient had 3 applications with a monthly interval, and was followed up at 1, 6, and 12 months after treatment. Results were evaluated by the numeric rating scale (NRS) in all cases, the Constant Murley Score for the assessment of the shoulder function, the American Orthopaedic Foot and Ankle Society Score for subjects affected by chronic Achilles tendinopathy, and the Oxford Elbow Score for those affected by a lateral epicondylitis of the elbow.

RESULTS

One year after treatment, the results were considered satisfactory with an almost complete resolution of symptoms. There were statistically significant results at the 12-month follow-ups regarding the mean NRS score (from 6.25 to 0.2), the Constant Murley Score (from 66.7 to 79.4), the Oxford Elbow Score (from 28 to 46), and the AOFAS (from 71 to 86).

CONCLUSIONS

Extracorporeal shockwave therapy may be considered a safe, economic, and effective treatment for several chronic musculoskeletal disorders, allowing satisfactory pain relief and improvement of function ability.

LEVEL OF EVIDENCE

Level IV.

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.

Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis

BACKGROUND

The treatment of adhesive capsulitis is a dilemma for orthopaedic rehabilitation specialists. In this study, we assessed whether extracorporeal shockwave therapy (ESWT) improves the functional outcome of primary shoulder adhesive capsulitis.

METHODS

In this prospective, randomized, controlled, single-blind clinical trial, we enrolled 40 patients with primary adhesive capsulitis to assess whether ESWT can improve the functional outcome of primary adhesive capsulitis better than oral steroid therapy. Patients were allocated to the oral steroid group or ESWT group with randomization. Functional outcome evaluations were performed using the Constant Shoulder Score (CSS) and Oxford Shoulder Score.

RESULTS

Both groups showed significant improvement in the Oxford Shoulder Score evaluation throughout the study period. In the ESWT group, the total CSS and range of motion (ROM) parameter of the CSS in the ESWT group showed significant improvement from the fourth week that was better than that in the steroid group; the activities–of–daily living (ADL) parameter of the CSS achieved significance and was better than that in the steroid group at the sixth week. For the steroid group, pain was significantly reduced from baseline to the fourth week of the study; ADL and ROM improved at the fourth to 12th week. For the ESWT group, ADL and ROM improvements were significant from baseline to the sixth week.

CONCLUSION

Our results showed that ESWT can be an alternative treatment, at least in the short-term, for primary adhesive capsulitis of the shoulder. In addition, all of the side effects of ESWT were transient and tolerable.

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.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Extracorporeal shock wave therapy for non-calcific supraspinatus tendinitis - 10-year follow-up of a randomized placebo-controlled trial

Evidence for the efficacy of extracorporeal shock wave therapy (ESWT) in supraspinatus tendinopathy without calcification is sparse, and therefore this treatment option is often controversial. Patients of a randomized placebo-controlled study to analyze the effects of ESWT on function and pain were revisited 10 years after the initial consultation. The former verum group received 6000 impulses (energy flux density, 0.11 mJ/mm²) in three sessions after local anesthesia between 1999 and 2000. The placebo group had 6000 impulses of a sham ESWT after local anesthesia in the same period. Re-evaluation of the patients included a relative Constant score as well as pain measurements (visual analogue scale) during activity and at rest. No significant changes (p>0.05) in relative Constant scores, pain at rest, or pain during activity could be found after a 10-year follow-up between the placebo and verum groups after ESWT. The treatment of non-calcific supraspinatus tendinopathy with ESWT does not seem to have an effect on function or pain improvement in the long run. The results of the present study cannot advise the use of ESWT in cases of non-calcific supraspinatus tendinopathy.

Tendinopathy: a review of the pathophysiology and evidence for treatment

The understanding of tendinopathy has evolved over the past several decades. Initially thought to be a primarily inflammatory process, histologic evaluation has revealed that there is an absence of inflammatory cells, and rather, tendinopathy is more of a degenerative process. Various types of medications, rehabilitation, modalities, injections, and minimally invasive procedures have been described as treatment for this condition. The purpose of our article is to describe the pathophysiology of tendinopathy as currently understood and the evidence for the various available treatments. We performed a literature search to determine the types of reviews that have been performed previously regarding treatment for tendinopathy, and summarized these reviews. We then performed a systematic review of randomized controlled trials for treating patients with tendinopathy. It is our hope that our review of trial data will help providers to determine optimal management for their patients with tendinopathy.