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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Calcific Tendinopathy Atypically Located Outside the Rotator Cuff: A Systematic Review

BACKGROUND AND PURPOSE

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited. The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

METHODS

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

RESULTS

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

CONCLUSION

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

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

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

Ultrasound guided 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.

Rotator cuff debridement compared with rotator cuff repair in arthroscopic treatment of calcifying tendinitis of the shoulder: A systematic review and meta-analysis

INTRODUCTION

Although conservative treatment of calcific tendinopathy has a high success rate, arthroscopic excision of the calcific deposit is occasionally necessary. Controversy exists as to whether the remaining rotator cuff defect can be left in situ or should be repaired to achieve better functional outcomes. This study aimed to compare the results of debridement versus debridement combined with suturing in arthroscopic surgery for calcific tendinopathy.

METHODOLOGY

MEDLINE, EMBASE, Cochrane Library, and Web of Science were searched from inception to February 2023 for articles on arthroscopic treatment of calcific tendinopathy. Functional outcomes (VAS, ASES, UCLA, and Constant) and the number of complications were analyzed. The effect size was calculated using Cohen's d-index.

RESULTS

Twenty-one studies were included, including a total of 1172 patients aged between 44.7 and 55 years. The mean follow-up time was 24.7 months. The combined ES estimates for the total score of the VAS, ASES, UCLA, and Constant scales were very strong (>1.0) for both debridement and combined debridement with suture. The ES estimates for the number of total complications were 1.75 (95% CI: 0.08-3.43, I2 = 0%) for debridement and 9.07 (95% CI: -0.03-18.17, I2 = 50.4%) for combined debridement with suture.

CONCLUSIONS

Both arthroscopic procedures improve the total score significantly on the EVA, ASES, UCLA, and Constant scales. However, a higher proportion of complications was observed in the group that performed suturing. In this regard, we must consider whether it is really necessary to repair all partial tears after the calcified deposits removal.

Zero echo time MRI in shoulder MRI protocols for the diagnosis of rotator cuff calcific tendinopathy improves identification of calcific deposits compared to conventional MR sequences but remains sub-optimal compared to radiographs

OBJECTIVE

To compare the diagnostic performance of standard MRI and standard MRI + ZTE images for the detection of rotator cuff calcific tendinopathy (RCCT) and to describe the artifacts encountered with ZTE images, using computed radiography (CR) as a reference.

METHODS

In a retrospective study, patients with suspicion of rotator cuff tendinopathy who underwent standard MRI + ZTE images after radiography were enrolled between June 2021 and June 2022. Images were independently analyzed for calcific deposit presence and ZTE images artifacts, by two radiologists. Diagnostic performance was calculated individually with MRI + CR as the reference standard.

RESULTS

A total of 46 RCCT subjects (27 women; mean age, 55.3 years ± 12.4) and 51 control subjects (27 men; mean age, 45.5 ± 12.9) were evaluated. For both readers, there was an increase in the sensitivity for the identification of calcific deposits of MRI + ZTE compared to MRI (77% (95% CI: 64.5-86.8) and 75.4% (95% CI: 62.7-85.5) versus 57.4% (95% IC: 44.1-70) and 47.5% (95% IC: 34.6-60.7), for R1 and R2, respectively). Specificity was quite similar for both readers and both imaging techniques and ranged from 96.6% (95% IC: 93.3-98.5) to 98.7% (95% IC: 96.3-99.7). Hyperintense joint fluid (62.8% of patients), long head of the biceps tendon (in 60.8%), and subacromial bursa (in 27.8%) on ZTE were considered artifactual.

CONCLUSION

The addition of ZTE images to a standard MRI protocol improved MRI diagnostic performance of RCCT, but with a suboptimal detection rate and a relatively high frequency of artifactual soft tissue signal hyperintensity.

KEY POINTS

• Adding ZTE images to standard shoulder MRI improves the MR-based detection of rotator cuff calcific tendinopathy, but half of the calcification unseen with standard MRI remained unseen with ZTE MRI. On ZTE images, joint fluid and long head biceps tendon were hyperintense in about 60% of the shoulders, as well as the subacromial bursa in about 30%, without calcific deposit on conventional radiographs. • The detection rate of calcific deposits using ZTE images was dependent on the disease phase. In the calcific stage, it reached 100% in this study but remained at a maximum of 80.7% in the resorptive phase.

Hydroxyapatite Deposition Disease: A Comprehensive Review of Pathogenesis, Radiological Findings, and Treatment Strategies

Hydroxyapatite deposition disease (HADD) represents a multifaceted condition characterized by the accumulation of hydroxyapatite crystals in soft tissues, leading to subsequent inflammation and discomfort. The intricate etiology of HADD is the subject of this comprehensive review, which encompasses an in-depth analysis of the four proposed pathogenic mechanisms and a deliberation on the predisposing factors that instigate the development of this disease. In order to provide a thorough understanding of the disease's progression, this manuscript delineates the stages of HADD-those preceding calcification, occurring during calcification, and following calcification-in meticulous detail. This chronology forms the basis of a complete portrayal of the evolution of HADD. Moreover, this review encompasses an examination of the radiological findings associated with HADD, furnishing an extensive discourse on imaging characteristics. The potential of HADD to mimic other diseases, thereby posing diagnostic challenges, is also articulated. The discourse continues with an investigation of HADD's differential diagnosis. This section furnishes a robust framework for distinguishing HADD from other conditions based on imaging results. To enrich the understanding of this diagnostic process, case studies illustrating real-world applications are provided. An overview of treatment modalities for HADD, including both conservative and interventional approaches, forms the concluding discussion. The pivotal role of imaging specialists in the diagnosis and management of HADD is emphasized, highlighting their vital contribution to image-guided procedures and disease monitoring.

Kalkschulter – konservative und operative Therapie

Erkrankungen der Rotatorenmanschette beinhalten ein breites Spektrum, unter denen die Kalkschulter oder Tendinosis calcarea (TC) eine häufige Pathologie der Schulter darstellt und eine herausragende Rolle einnimmt. Das Erscheinungsbild kann dabei enorm variieren. Die Kalkschulter kann als Zufallsbefund bei der radiologischen Diagnostik auffallen, jedoch auch bis hin zu einem der stärksten Schulterschmerzen avancieren. Nachfolgend wird ein Überblick für das diagnostische und therapeutische Vorgehen gegeben.

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.

Imaging of Crystal Disorders:: Calcium Pyrophosphate Dihydrate Crystal Deposition Disease, Calcium Hydroxyapatite Crystal Deposition Disease and Gout Pathophysiology, Imaging, and Diagnosis

Crystal arthropathies are a group of joint disorders due to deposition of crystals in and around joints that lead to joint destruction and soft tissue masses. Clinical presentation is variable and diagnosis might be challenging. In this article the pathophysiology is addressed, the preferred deposition of crystal arthropathies and imaging findings. Case studies of calcium pyrophosphate dihydrate crystal deposition disease, hydroxyapatite crystal deposition disease, and gout are shown. Guidelines for the use of dual-energy computed tomography are given to enable the diagnosis and follow-up of gout.

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.

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.

Ultrasound-Guided Treatments for the Painful Shoulder

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Long-term evolution of calcific tendinitis of the rotator cuff: clinical and radiological evaluation 10 years after diagnosis

BACKGROUND

Calcific tendinitis of the shoulder has a tendon involvement that could evolve to rotator cuff tear and shoulder osteoarthritis. This study aimed to evaluate the prevalence of glenohumeral osteoarthritis and rotator cuff tears in patients affected by calcific tendinitis at a minimum follow-up of 10 years after diagnosis.

METHODS

Patients diagnosed with calcific tendinitis of the shoulder with a minimum follow-up of 10 years were contacted and invited for a clinical and radiological evaluation. Information on the demographics, affected and dominant side, bilateral shoulder pain, type of treatment, habits, systemic or musculoskeletal diseases, reoperation of the index shoulder, and subjective satisfaction was collected. The clinical evaluation was performed using Constant-Murley score (CMS), American Shoulder and Elbow Surgeons Score (ASES), and numerical rating scale (NRS); isometric strength in forwarding flexion and abduction was also measured. Each patient also underwent an ultrasound examination to evaluate rotator cuff tendon integrity and a shoulder radiograph to evaluate osteoarthritis.

RESULTS

Seventy-nine patients were available for a phone interview, and 35 agreed to be examined. The mean age was 58.89 (± 7.9) years at follow-up. The prevalence of glenohumeral osteoarthritis was 17.14% in the study population, with significant progression in 14.29% of the cases, without rotator cuff full-thickness tears. x-Ray examination showed residual calcifications in 31 patients, with a mean diameter of 5.54 mm. In 30 cases, there was a reduction of the diameter; in 4 cases, the calcification increased in size; and in 1 case, the size did not change. The mean ASES score was 74.1 (± 22.7) in the group with calcifications larger than 2 mm and 89.4 (± 8.2) in patients with smaller calcifications (p = 0.08) without correlation with the type of treatment performed.

CONCLUSIONS

Calcific tendinitis is a self-resolving disease without rotator cuff tears at long-term follow-up or degenerative glenohumeral progression.

LEVEL OF EVIDENCE

3, cohort study.

Clinical and Structural Results of Rotator Cuff Repair Compared With Rotator Cuff Debridement in Arthroscopic Treatment of Calcifying Tendinitis of the Shoulder

BACKGROUND

Arthroscopic treatment of calcifying tendinitis of the shoulder reveals good to excellent results. However, whether the tendon needs to be repaired after removal of the calcific deposit or simply debrided remains unclear.

PURPOSE

To evaluate the structural and clinical results after arthroscopic calcific deposit removal with additional rotator cuff repair or rotator cuff debridement.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 44 patients (46 shoulders) were enrolled in this retrospective cohort study with a mean follow-up of 58.4 months. Patients underwent arthroscopic removal of a calcific deposit and bursectomy after failed nonoperative treatment. A total of 22 patients received additional rotator cuff repair irrespective of the degree of debridement (the repair group), whereas 22 patients received a simple rotator cuff debridement without additional repair (the debridement group). Groups were comparable in sex, age, and size and consistency of the deposits according to the Gärtner and Bosworth classifications. Clinical evaluation was performed by the Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and numerical rating scales for pain, function, and satisfaction. In 29 patients (14 in the debridement group and 15 in the repair group), additional magnetic resonance imaging at follow-up was performed to evaluate the structural results using the Sugaya classification.

RESULTS

All patients were satisfied with the results of surgery; 100% of the repair group and 95.7% of the debridement group reported they would undergo the surgical procedure again. Comparison of the clinical results showed significantly better results in the repair group versus the debridement group for the Constant score (86.2 vs 80.6, respectively; P = .04), the ASES score (98.3 vs 88.9; P = .004), the Simple Shoulder Test (11.6 vs 10; P = .005), and the numerical rating scales for pain (0.1 vs 0.8; P = .007), function (9.6 vs 8.8; P = .008), and satisfaction (9.8 vs 9.1; P = .036). Comparison of the postoperative tendon integrity showed 80% Sugaya grade I in the rotator cuff repair group and 64% Sugaya grade II in the debridement group, with a statistically significant difference in favor of the repair group (P = .004). Postoperative clinical evaluation revealed no positive O'Brien tests in the repair group, whereas approximately one-third of the debridement group showed a positive O'Brien test during examination.

CONCLUSION

Arthroscopic removal of calcific deposits with rotator cuff debridement or cuff repair showed good to excellent clinical and structural midterm results. However, patients who underwent additional repair of the tendon defect had significantly better clinical results as well as better structural results in terms of tendon integrity.

Ultrasound-guided needle decompression and steroid injection for calcific tendinitis of the shoulder: risk factors for repeat procedures and outcome analysis

Background

Although ultrasound-guided needle decompression (US-GND) can treat calcific tendinitis of the shoulder effectively, repeat procedures might be required for unresolved symptoms. We evaluated the overall clinical outcomes of US-GND with subacromial steroid injection and the final results and factors predisposing toward repeat procedures.

Methods

Ninety-eight patients who underwent US-GND for calcific tendinitis of the supraspinatus/infraspinatus were analyzed between March 2017 and December 2018. The clinical outcomes (pain visual analog scale, functional visual analog scale [FVAS], and American Shoulder and Elbow Surgeons [ASES] score) and final subjective satisfaction were compared between groups A (single US-GND) and B (repeat US-GND). The factors predisposing toward repeated US-GNDs were analyzed.

Results

We found that 59.3% (58/98) of patient ASES scores were ≥80, and 73.5% of patients (72/98) were satisfied with the outcome. Group B (n=14) demonstrated a significantly higher rate of dominant-arm involvement compared to group A (78.6% vs. 48.8%, p=0.046). However, initial calcification size, shape, number, density, subscapularis involvement, lavage, and procedure time did not differ significantly between the groups. Group B showed poorer final FVAS (7 [interquartile range, 6–8] vs. 8 [interquartile range, 7–9], p=0.036) and subjective satisfaction compared to group A (satisfied: 5 [35.7%] vs. 67 [79.8%], p<0.001].

Conclusions

US-GND with subacromial steroid injection is a viable treatment option for calcific tendinitis of the shoulder. Dominant-arm involvement was the only independent factor for repeated US-GND. Final outcome of repeated US-GND for unimproved patients was promising; however, these outcomes were poor compared to those of the patients who improved after the first procedure.

Endoscopic Treatment of Calcific Tendinitis of the Gluteus Maximus: A Case Report

CASE

Calcific tendinitis of the gluteus maximus is a rare condition with poorly described operative treatment options. We present a 51-year-old man with chronic left posterolateral hip pain because of gluteus maximus calcific tendinitis that was refractory to conservative treatment. Endoscopy was pursued given the severity and chronicity of his symptoms. The patient remains asymptomatic without recurrence.

CONCLUSION

This is the first description of endoscopic management of calcific tendinitis of the gluteus maximus. This is a minimally invasive, efficacious option for management of this pathology.

Factors Associated With Clinical Improvement and the Disappearance of Calcifications After Ultrasound-Guided Percutaneous Lavage of Rotator Cuff Calcific Tendinopathy: A Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Calcific tendinitis of the rotator cuff is a frequent cause of shoulder pain. Ultrasound-guided percutaneous lavage (UGPL) is an effective treatment, but factors associated with good clinical and radiological outcomes still need to be identified.

PURPOSE

To study the clinical, procedural, and radiological characteristics associated with improved shoulder function and the disappearance of calcification on radiograph after UGPL.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This is a post hoc analysis of the CALCECHO trial, a double-blinded randomized controlled trial conducted on 132 patients. The trial assessed the effect of corticosteroid injections after UGPL, and patients were randomly assigned to receive either corticosteroid or saline solution in the subacromial bursa. We analyzed all patients included in the randomized controlled trial as 1 cohort. We collected the patients' clinical, procedural, and radiological characteristics at baseline and during follow-up (3, 6, and 12 months). Univariable analysis, followed by multivariable stepwise regression through forward elimination, was performed to identify the factors associated with clinical success (Disabilities of the Arm, Shoulder and Hand [DASH] score <15) or the disappearance of calcification.

RESULTS

Good clinical outcomes at 3 months were associated with steroid injections after the procedure (odd ratio [OR], 3.143; 95% CI, 1.105-8.94). At 6 months, good clinical evolution was associated with a lower DASH score at 3 months (OR, 0.92; 95% CI, 0.890-0.956) and calcium extraction (OR, 10.7; 95% CI, 1.791-63.927). A lower DASH at 6 months was also associated with a long-term favorable outcome at 12 months (OR, 0.939; 95% CI, 0.912-0.966). Disappearance of calcification at 3 and 12 months occurred more frequently in patients in whom communication was created between the calcification and the subacromial bursa during the procedure (OR, 2.728 [95% CI, 1.194-6.234] at 3 months; OR, 9.835 [95% CI, 1.977-48.931] at 12 months). Importantly, an association between calcification resorption and good clinical outcome was found at each time point.

CONCLUSION

Assessing patients at 3 months seems to be an essential part of their management strategy. Calcium extraction and creating a communication between the calcific deposits and subacromial bursa are procedural characteristics associated with good clinical and radiological evolution.

Efficacy of Adjuvant Application of Platelet-Rich Plasma After Needle Aspiration of Calcific Deposits for the Treatment of Rotator Cuff Calcific Tendinitis: A Double-Blinded, Randomized Controlled Trial With 2-Year Follow-up

BACKGROUND

Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD.

PURPOSE

To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL).

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures.

RESULTS

Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P < .001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P = .003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P < .001; DASH, P = .002; OSS, P = .010; EQ-5D, P < .001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P = .081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P = .036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P = .11).

CONCLUSION

NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT.

REGISTRATION

NCT02173743 (ClinicalTrials.gov identifier).

Arthroscopic removal of arch-shaped rotator cuff calcifying tendinitis without rotator cuff repair and acromioplasty is an excellent treatment regarding pain relief and function

PURPOSE

The aim of this study is to evaluate clinical outcome for arthroscopic removal of calcium deposit without acromioplasty and rotator cuff repair for patients with ultrasound-diagnosed arch-shaped calcifying tendinitis of the rotator cuff (type I), homogenic (x-ray) with chronic pain.

METHODS

We retrospectively reviewed 50 patients with homogenous, arch-shaped calcifying tendinitis, suffering from chronic pain and who underwent arthroscopic treatment and 50 patients with the same type of tendinitis treated conservatively. All patients had calcium deposit located in supraspinatus tendon, pre-operatively and post-operatively evaluated by ultrasound. Clinical outcome was assessed by using Quick DASH, UCLA, and VAS score.

RESULTS

There were 29 male and 71 female patients; none had bilateral involvement. We divided patients into group A-operatively treated-and group B-conservatively treated-by shock wave therapy. Patients from group A had higher improvement of all used tests, QDash (from 19.3 to 2.7), UCLA (from 10 to 34), and VAS score (from 3 to 0) when compared with group B.

CONCLUSION

Patients with arch-shaped calcium deposits and acoustic shadow have better results after arthroscopic treatment than the conservative one. There was no need for acromioplasty or tendon repair. The lack of performing the same did not have any impact on the post-operative rehabilitation and recovery.

Calcification of the Anterior Acromial Insertion of the Deltoid Muscle

A 45-year-old man presented with severe left shoulder pain that was not associated with trauma. Plain radiography with the arm in an elevated position and ultrasonography demonstrated calcium deposits at the anterior acromial insertion site of left deltoid muscle. Conservative management could successfully relieve pain. At the 3-year follow-up, the calcification completely disappeared. To the best of our knowledge, calcium deposits at the acromial insertion site of the deltoid have not been reported in the literature. Clinicians who suspect calcific tendinitis but do not observe calcification around the rotator cuff should carefully palpate and examine other sites, such as the deltoid origin, and use ultrasonography or radiography.

Non-rotator cuff calcific tendinopathy: ultrasonographic diagnosis and treatment

Calcific tendinopathy is a condition that is related to the deposition of calcium, mostly hydroxyapatite crystals, within the tendons. The shoulder and the hip are commonly affected joints, but calcific tendinopathy may occur in any tendon of the body. While there is an extensive literature on the ultrasound diagnosis of calcific tendinopathy of the shoulder, there are only sporadic reports on other sites. This review combines the experience of our centers and a thorough analysis of the literature from the last 45 years (1972-2017) in order to highlight the localizations beyond the rotator cuff, their ultrasound characteristics and therapeutic possibilities.

Post-surgical Achilles calcific tendinopathy treated with ultrasound-guided percutaneous irrigation

Calcific tendinopathy typically affects the shoulder rotator cuff tendons. Its management includes shock wave therapy and US-guided percutaneous irrigation, with surgery being less and less used. Extra-shoulder calcific tendinopathy is relatively infrequent and typically affects the hip. While the diagnostic techniques and the treatment options for shoulder calcific tendinopathy have been extensively described, there are only anecdotic reports on the other sites. In this paper, we have reported an unusual case of non-insertional Achilles calcific tendinopathy which occurred many years after Achilles surgical repair. This condition, which presented similar appearance to that of the rotator cuff calcific tendinopathy, is totally different from the well-known and more common insertional calcific Achilles tendinopathy in terms of pathophysiological, imaging, and clinical findings. Further, we have shown that US-guided percutaneous irrigation might be a safe, technically feasible, mini-invasive, and effective treatment also for Achilles calcific tendinopathy.

MRI findings in calcific deposits in and around shoulder: atypical locations beyond supraspinatus

Hydroxyapatite deposition disease is a spectrum of disorders including calcific tendinitis, calcific periarthritis, and hydroxyapatite-induced arthritis. These usually present with acute onset of pain, and clinically, may be confused with acute infection or adhesive capsulitis. Supraspinatus calcific tendinitis and its imaging appearance is well known; however, calcific deposits may occur less commonly in other structures in and around the shoulder joint. We describe nine cases of relatively uncommon locations of calcific deposits around the shoulder with their imaging appearances.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Recovery pattern after arthroscopic treatment for calcific tendinitis of the shoulder

INTRODUCTION

The purpose of this study was to investigate serial outcomes in the early postoperative period in patients who have undergone arthroscopic treatment for calcific tendinitis of the shoulder and to determine prognostic factors affecting outcomes.

HYPOTHESIS

Our hypothesis was that functional recovery will take more than three months but additional procedures such as rotator cuff repair and subacromial decompression will have a slower recovery and poorer outcomes.

MATERIAL AND METHODS

We retrospectively reviewed 35 patients with a mean follow-up of 50.6 months. Arthroscopic surgery was performed in all patients. The visual analog scale (VAS) pain score; University of California, Los Angeles (UCLA) score; American Shoulder and Elbow Surgeons (ASES) score were evaluated preoperatively; 3, 6, and 12 months after surgery; and at the final follow-up. To evaluate the extent of calcific deposit removal and recurrence of calcification, we conducted plain radiography at each follow-up.

RESULTS

Nine patients had complete removal of all calcium deposits, and 26 had partial removal. At the final follow-up, all patients sustained complete resorption without any recurrence. All clinical scores showed improvement significantly in each follow-up period (p<0.001). However, VAS pain score decreased to less than 3 points at 6 months after surgery, UCLA and ASES scores also increased more than 75 percent at 6 months. Subacromial decompression was negatively correlated with VAS pain score and rotator cuff repair was negatively correlated with UCLA score, respectively (p=0.041 and p=0.028). On multivariate analysis, rotator cuff repair was negatively correlated with the final UCLA score (p=0.009).

CONCLUSION

This study revealed that all clinical scores were significantly improved from 3 months after arthroscopic treatment for calcific tendinitis of shoulder. However, clinical scores improved slowly, recovery of shoulder function and pain relief required up to 6 months. Subacromial decompression and rotator cuff repair were poor prognostic factors after arthroscopic treatment.

LEVEL OF EVIDENCE

IV, Retrospective Case Series.

Prognostic factors for the outcome of needle aspiration of calcific deposits for rotator cuff calcific tendinitis

Objective

To identify prognostic factors for the effectiveness of needle aspiration of calcific deposits (NACD) for rotator cuff calcific tendinitis (RCCT)

Methods

One hundred forty-nine patients with symptomatic RCCT were included in a prospective cohort study. Pain (VAS), shoulder function (SST and DASH), and quality of life (EQ-5D) were assessed at baseline and at 3, 6, and 12 months post-NACD. Univariate analyses (independent t tests or Mann-Whitney U tests depending on the distribution of data) were performed to build a multivariable linear regression model. Stepwise regression analysis through backward elimination was performed to evaluate the effect of predefined prognostic factors on the outcome.

Results

Patients who underwent multiple NACD procedures had less reduction of pain (p < 0.01). Furthermore, a larger reduction in VAS pain scores at 3 months post-NACD was associated with a larger reduction in VAS pain scores at 12 months (p < 0.01). More improvement of SST and DASH scores at 3 months was associated with better SST, DASH, and EQ-5D scores at 12 months (p < 0.01). Smaller-size calcific deposits were associated with less improvement of DASH (p = 0.03) and EQ-5D scores (p = 0.01). A longer duration of symptoms prior to NACD was associated with less improvement of EQ-5D scores (p = 0.01).

Conclusions

A good initial response after NACD is associated with better outcomes at 12 months. Patients with a longer duration of symptoms prior to NACD and patients who require multiple procedures showed inferior outcomes in terms of pain reduction and improvement of quality of life. Smaller-size calcific deposits are associated with a less favorable outcome of shoulder function and quality of life scores and might therefore be less susceptible for NACD.

Key Points

• A good initial response to NACD is associated with a better outcome in the longer term.

• A longer duration of symptoms and the need for multiple NACD procedures are associated with inferior outcomes.

• Smaller-size calcific deposits seem less susceptible for NACD.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06669-0) contains supplementary material, which is available to authorized users.

Tolerance and effect of sodium thiosulfate in calcific tendinitis of the rotator cuff

BACKGROUND

Calcific tendinitis of the rotator cuff is one of the most common causes of shoulder pain. Ultrasound-guided percutaneous lavage of calcific tendinopathy is performed when conservative treatments have failed. Sodium thiosulfate (STS) has recently been used with success in the treatment of tumoral calcinosis. The goal of this phase II study was to assess the tolerance and the feasibility of STS lavage of calcific tendinopathy.

METHODS

We included patient with type hard calcifications. Patients were treated with puncture and lavage followed by injection of STS in the calcification. VAS pain at rest and during activities, ultrasound, and X-ray were evaluated at 1 week and 1 and 3 months.

RESULTS

Seventeen patients were included. Baseline VAS at rest and during daily activities was a mean 40.2 ± 25.9 and 65.5 ± 21.6 respectively. All patients underwent the entire procedure with no adverse event. Calcium backflow could be obtained in 15 patients (88.2%). Five patients (30%) had more than 50% decrease of their calcific deposit size at 1 month and 8 (47%) patients at 3 months. VAS pain during activities and at rest decreased significantly at 3 months (p = 0.0004; p = 0.001). Efficacy would be demonstrated if 60% of the patients had more than 50% decrease size of their calcification CONCLUSION: Overall, STS was well tolerated with no side effect occurring during the procedure and the follow-up. However, no significant effect on calcium disappearance could be demonstrated compared with what is expected without STS. New studies using larger volume and repeated injections of STS are now needed.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02538939Key Points• Lavage of calcific tendinopathy of the rotator cuff with sodium thiosulfate is feasible• No adverse events have been observed after or in the 3 months after the procedure• We could not demonstrate that sodium thiosulfate increases the chance of calcium disappearance• New studies using larger volume and repeated injections of STS are needed to further explore the interest of sodium thiosulfate in the treatment of calcific tendinopathy.

Questioning the therapeutic value of corticosteroid bursal injection after ultrasound-guided irrigation and lavage for the treatment of shoulder calcific tendinosis

Objectives

The therapeutic value of corticosteroid bursal injection after ultrasound-guided irrigation and lavage for the treatment of shoulder calcific tendinosis has not been established yet in the long term.

Methods

41 patients suffering from chronic symptomatic rotator cuff calcific tendinopathy were recruited for this study. Group A (20 patients) received a double needle ultrasound-guided irrigation and lavage of the calcification with xylocaine injection, while group B (21 patients) underwent a double needle ultrasound-guided irrigation and lavage of the calcification with a xylocaine and betamethazone bursal injection.

Results

After twelve months, we documented full -or almost full- decline (VAS: 0-20/100) of the symptoms in 70% of the group A patients and in 61.9% of the group B patients. There was no statistical difference (chi square, p < 0.05) in group success ratio. We also did not find any statistical difference as for the mean Q-DASH difference between the two groups (t-test).

Conclusions

It was proven that the additional use of corticosteroid bursal injection did not provide with any additional short- to mid-term therapeutic benefit those patients with shoulder calcific tendinopathy who were treated with ultrasound-guided aspiration.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

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

OBJECTIVE

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

CONCLUSION

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

Calcific tendinopathy of the direct head of rectus femoris: a rare cause of groin pain treated with ultrasound guided percutaneous irrigation

Groin pain can be caused by a myriad of pathologies. Abnormalities of the rectus femoris are a very rare cause of groin pain; calcific tendinopathy of the direct head is particularly so, with only two case reports in the literature. We report the first case of calcific tendinopathy of the direct head of the rectus femoris that was treated effectively with ultrasound-guided percutaneous irrigation of calcific tendinopathy (USPICT). The anatomy of the rectus femoris and the technique for US-PICT of the rectus femoris are also described.

Upper Limb Interventions

Ultrasound has been reported to be a quick, cheap, and effective imaging modality to guide the interventional procedures in the musculoskeletal system. The use of ultrasound results in increased accuracy of needle placement associated with a reduction of complications. In the upper limb, ultrasound-guided procedures are applied to joints and soft tissues around the shoulder, elbow, wrist, and hand. This article reviews the clinical and technical aspects of the most common procedures performed in this anatomic area.

Efficacy of ultrasound-guided percutaneous lavage for rotator cuff calcific tendinopathy: A systematic review and meta-analysis

BACKGROUND

Rotator cuff calcific tendinopathy (RCCT) is frequently diagnosed in patients with shoulder pain, but there is no consensus on its treatment such as rest, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, subacromial corticosteroid injection (SAI), extracorporeal shock wave therapy (ESWT), and ultrasound-guided percutaneous lavage (UGPL). The aim of the study was to compare the effectiveness of UGPL with other techniques in the treatment of RCCT.

METHODS

Literature searches of PubMed, EMBASE, OVID, Cochrane Library, Web of Science, Chinese Biomedical Literature, Wanfang, Weipu Journal, and CNKI databases were performed up to August 2018. Only randomized controlled trials (RCTs) comparing UGPL vs other methods for RCCT were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

RESULTS

Eight RCTs were included with 617 cases in all. The result of meta-analysis showed that: there were significant differences between the UGPL and ESWT group in 12-month follow-up VAS, constant shoulder score (CSS), the average particle size of the calcium deposition, and the calcification disappearance rate. However, there was no significant difference in complication between 2 groups.

CONCLUSION

The present meta-analysis indicates that UGPL has certain clinical effect for calcifying tendinitis of rotator cuff. Compared with ESWT, UGPL may be superior in clinical pain relief and calcification clearance. However, owing to the limited quality and quantity of the included studies, additional high-quality RCTs are needed to confirm these findings.

Ultrasound-guided percutaneous irrigation of calcific tendinopathy: technical developments

Rotator cuff calcific tendinopathy (RCCT) is a common and painful shoulder disease characterised by deposition of calcium into the rotator cuff’s tendond. Different therapeutic options have been proposed, but the ultrasound-guided percutaneous irrigation (US-PICT) is been proved as an effective and safe first-line treatment. It can be performed with a single- of a double-needle tecnique, using warm saline solution to improve the dissolution of the calcific deposit. The procedure is ended with an intrabursal injection of local anaesthetics and slow-release steroids to improve the pain relief and to prevent complications. US-PICT leads to significative improvement in the shoulder funtion and pain relief in the short and long term, with a low complications rate. (www.actabiomedica.it)

Are corticosteroid injections needed after needling and lavage of calcific tendinitis? Randomised, double-blind, non-inferiority trial

OBJECTIVE

Steroid injections are common after an ultrasound-guided puncture and lavage (UGPL) of calcific tendonitis of the rotator cuff. However, steroids may prevent calcification resorption and negatively affect tendon healing. Our study was designed to determine whether saline solution was non-inferior to steroids in the prevention of acute pain reactions in the week following UGPL.

METHODS

This was a randomised, double-blinded, controlled non-inferiority trial with 12-month follow-up. We included 132 patients (66 in each group) with symptomatic calcification measuring more than 5 mm. Patients received 1 mL of saline or steroid (methylprednisolone 40 mg) in the subacromial bursa at the end of UGPL. Primary outcome was the maximal pain during the week following the procedure with a prespecified non-inferiority margin of 10 mm (0-100 visual analogue scale). Secondary outcomes included pain at rest and during activity, function (disabilities of the arm, shoulder and hand score) and radiological evolution of the calcification over the 12-month follow-up.

RESULTS

The estimated mean difference in the first week's maximal pain between these two groups was 11.76 (95% CI 3.78 to 19.75). Steroids significantly improved VAS pain at rest and during activities, as well as function at 7 days and 6 weeks. They did not change the rate of calcification resorption, which occurred in 83% and 74% of patients at 12 months in the saline and steroid groups.

CONCLUSION

Non-inferiority of saline when compared with steroids could not be established. However, steroid injection improved pain in the 6 weeks following the procedure, and function in the 3 months after, with no significant effect on calcification resorption.

TRIAL REGISTRATION NUMBER

NTC02403856.

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

Background

Rotator cuff calcific tendinopathy is characterised by the deposition of hydroxyapatite crystals in one of the rotator cuff tendons and can be managed by ultrasound-guided lavage. However, evidence regarding the efficacy of ultrasound-guided lavage for rotator cuff calcific tendinopathy remains inconclusive. The aim of this systematic review and meta-analysis is to update the available evidence on the efficacy of ultrasound-guided lavage in adults with rotator cuff calcific tendinopathy.

Methods

A literature search was conducted up to April 2018 in four bibliographic databases to identify randomised control trials that compared ultrasound-guided lavage alone with other interventions to treat rotator cuff calcific tendinopathy. Randomised control trials were assessed with the Cochrane Risk of Bias Tool. Meta-analyses and/or qualitative synthesis of the evidence were performed.

Results

Three randomised control trials were included. Pooled results for pain (n=226) indicated that ultrasound-guided lavage may significantly decrease pain when compared with shockwave therapy, with a mean difference of −1.98 out of 10 points (95% CI −2.52 to −1.45) in the short term and of −1.84 (95% CI −2.63 to −1.04) in the long term. Based on one trial (n=25), ultrasound-guided lavage significantly improved function when compared with shockwave therapy (p<0.05). Based on another trial (n=48), the addition of ultrasound-guided lavage to a corticosteroid injection significantly improves function in the long term (p<0.05).

Conclusion

For individuals with rotator cuff calcific tendinopathy, low-quality evidence suggests that ultrasound-guided lavage is more effective than shockwave therapy or a corticosteroid injection alone. Future trials could modify the present conclusions.

Trial registration number

CRD42018095858.

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa's calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

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

Objectives

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

Patients and methods

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

Results

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

Conclusion

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

Electroacupuncture for the treatment of supraspinatus calcific tendonitis

BACKGROUND

Conservative treatment of calcific tendonitis includes rest, medications, and physical therapy. Several physiotherapy interventions such as shockwave therapy are commonly used. The aim of this study was to investigate the efficacy of an electrotherapy method called electroacupuncture, in the treatment of calcific tendonitis.

METHODS

40 patients with calcific tendonitis were randomly divided to receive either a combination of medications and electroacupuncture, or just a course of medications. Evaluated outcomes included pain using the visual analog scale, shoulder range of motion with the use of goniometer, and quality of life along with functional status using the Instrumental Activities of Daily Living Scale (IAOLDS) and the Beck Depression Inventory (BDI). Radiological evaluation for the progression of the calcific deposits was also performed. All these evaluations were performed before and at the end of treatment. A final interview with the patients regarding any recurrent episodes was performed 18-24 months after the end of treatment.

RESULTS

The intervention group showed greater improvement in pain intensity (2.8 points), range of motion (forward flexion, +30; abduction +29) when compared with the control group (for all, P < .05) while there was no statistically significant difference regarding the quality of life (IOLDS +0.2; BDI 0). Radiological evaluation demonstrated total or nearly total absorption of calcific deposits in 15 patients of the intervention group and in 8 patients of the control group.

CONCLUSION

The successful clinical results of electroacupuncture and the regression of calcific depositions after treatment showed that electroacupuncture may have a role as a treatment modality in calcific tendonitis.

Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: Ultrasound image and treatment

Calcific tendinopathy is characterized by the deposition of calcium, mostly hydroxyapatite crystals, in tendons. Women are more frequently affected than men, with prevalence in the fourth and fifth decades of life. This condition has been reported between 2.5 and 7.5% of healthy shoulders in adults, but other tendons may also be affected. A complication of this condition is the migration of calcium deposits from tendons, usually the supraspinatus, into the subacromial-subdeltoid bursa. We reported a rare complication of calcific tendinopathy, that is, calcium deposits migrated from the long head of the biceps tendon over the proximal tract of the biceps brachii muscle.