Comparative Effectiveness of Nonoperative Treatments for Chronic Calcific Tendinitis of the Shoulder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: To investigate the effectiveness of various nonoperative treatments for chronic calcific tendinitis of the shoulder, a systematic review and network meta-analysis of randomized trials was performed to evaluate changes in pain reduction, functional improvements in patients with calcific tendinitis, and the ratio of complete resolution of calcific deposition. DATA SOURCES: Studies were comprehensively searched, without language restrictions, on PubMed, Embase, Cochrane Controlled Trials Register, the Cochrane, and other databases. The reference lists of articles and reviews were cross-checked for possible studies. STUDY SELECTION: Randomized controlled trials from before August 2016 were included. Study selection was conducted by 2 reviewers independently. DATA EXTRACTION: The quality of studies was assessed and data extracted by 2 independent reviewers. Disagreements were settled by consulting a third reviewer to reach a consensus. DATA SYNTHESIS: Fourteen studies with 1105 participants were included in the network meta-analysis that used a random-effect model to investigate the mean difference of pooled effect sizes of the visual analog scale, Constant-Murley score, and the ratio of complete resolution of calcific deposition on native radiographs. CONCLUSIONS: The present network meta-analysis demonstrates that ultrasound-guided needling (UGN), radial extracorporeal shockwave therapy (RSW), and high-energy focused extracorporeal shockwave therapy (H-FSW) alleviate pain and achieve complete resolution of calcium deposition. Compared with low-energy focused extracorporeal shockwave therapy, transcutaneous electrical nerve stimulation, and ultrasound therapy, H-FSW is the best therapy for providing functional recovery. Physicians should consider UGN, RSW, and H-FSW as alternative effective therapies for chronic calcific tendinitis of the shoulder when initial conservative treatment fails.

Effectiveness of Extracorporeal Shock Wave Therapy and kinesio taping in calcific tendinopathy of the shoulder: a randomized controlled trial.

BACKGROUND: Extracorporeal Shock Wave Therapy (ESWT) is effective in the treatment of calcific tendinopathy of the rotator cuff, eliciting an analgesic/anti-inflammatory action and promoting tissue regeneration. Kinesio taping (KT), another recently-introduced rehabilitative tool, exerts an analgesic and biomechanical action on joints and muscles. ESWT and KT may have a synergic effect when used in combination, but the effectiveness of the association has not been established. AIM: The aim of this study was to test if the association of KT with ESWT is superior to ESWT alone in the treatment of rotator cuff calcific tendinopathy. DESIGN: Randomized controlled trial. SETTING: Rehabilitation Institute outpatients. POPULATION: Forty-two patients with rotator cuff calcific tendinopathy were randomly assigned to the experimental group (ESWT+KT, N.=21) or control (ESWT, N.=21). METHODS: In the experimental group, patients underwent three sessions (once a week for 3 weeks) of ESWT with KT applied at the end of each session. Controls underwent three sessions of ESWT only. All patients were assessed before treatment (T0) and at 1 (T1), 4 (T2) and 12 weeks (T3) after the end of treatment with the following outcome measures: a visual analogue scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Subjective Shoulder Rating Questionnaire (SSRQ), and Oxford Shoulder Score (OSS). RESULTS: Both groups showed significant improvement in all outcome measures, but the time course differed between the two groups. At T1 vs. T0, the improvement was significantly better in ESWT+KT than ESWT on VAS (P=0.007), DASH (P<0.0001) and SSRQ (P=0.0001). Successive improvements at T2 vs. T1 and T3 vs. T2 did not differ significantly between the groups. At the end of follow-up, ESWT+KT still showed significantly greater improvement than ESWT on VAS (P=0.02) and SSRQ (P=0.038). CONCLUSIONS: KT associated with ESWT seems to improve the recovery in rotator cuff calcific tendinopathy with a faster therapeutic response compared to ESWT only. CLINICAL REHABILITATION IMPACT: Our results suggest the effectiveness of using KT as adjuvant therapy to ESWT in rotator cuff calcific tendinopathy, through enhancing the short-term analgesic action and the medium- to long-term biological-regenerative effects.

Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain.

INTRODUCTION: A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of shoulder pain. METHODS: Evidence from randomized controlled trials (RCTs) and observational studies was identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analysis was conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. DEVELOPING RECOMMENDATIONS: An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. VALIDATING THE RECOMMENDATIONS: A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. RESULTS: Only 1 positive recommendation of clinical benefit was developed. Ultrasound provided clinically important pain relief relative to a control for patients with calcific tendinitis in the short term (less than 2 months). There was good agreement with this recommendation from practitioners (75%). For several interventions and indications (eg, thermotherapy, therapeutic exercise, massage, electrical stimulation, mechanical traction), there was a lack of evidence regarding efficacy. CONCLUSIONS: This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with shoulder pain where evidence was insufficient to make recommendations.

Calcific trochanteric bursitis: resolution of calcifications and clinical remission with non-invasive treatment. A case report.

Calcific trochanteric bursitis, a common regional pain syndrome, is characterized by chronic, intermittent aching pain over the lateral aspect of the hip and limitation of function. Effective treatment is invasive, including infiltration therapy and surgical intervention. The therapeutic effects of conservative treatment modalities have not been proven. A 59-year-old woman presented at the department of physical medicine and rehabilitation with a 2-year history of pain in the right hip. She had been treated with several agents such as glucocorticoids and local anesthetics (via injection) for two years, but without success. Physical examination revealed the clinical diagnosis of bursitis trochanterica. Radiographic findings showed calcified rounded masses measuring about 1.5 cm in diameter around the greater trochanter; a calcific bursitis trochanterica was diagnosed. The patient presented for conservative treatment in order to avoid surgical intervention for removing the calcification and the bursal sac. A non-invasive treatment regimen including intensive pulsed ultrasound therapy, physiotherapy and iontophoresis was started. The conservative treatment led to a remission of both, symptoms as well as radiographic findings, which revealed complete resolution of calcifications. This case report shows that, in cases of calcific trochanteric bursitis (including those with extensive calcifications), a non-invasive conservative treatment regimen including intensive high-dosed pulsed ultrasound therapy should be attempted before more invasive treatment (injections, surgery) is considered.

Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach.

Calcific tendinopathy of the rotator cuff is a chronic disease that mostly in the acute phase compromises the articular function. The aim of this study is to estimate the effectiveness of the ultrasonic-guided percutaneous treatment (UGPT) in association with the rehabilitative treatment. We evaluated 106 patients with calcific tendinopathy, treated by UGPT. They underwent clinical evaluation by a physiatrist at T0 (the same day of UGPT), and were reassessed at follow-up 1 month (T1) after treatment. The assessment at T0 and T1 was done by the Constant-Murley scale. Analyzing the results, we found that at T0, the average Constant score was 43.5 out of 100; at T1 it was 83.2 out of 100. The improvement was statistically significant (P < 0.0005). We found that UGPT and rehabilitation associated with the multidisciplinary management of the patient (orthopedic surgeon-radiologist-physiatrist) was able to prevent adhesive bursitis, and to achieve clinical cure in most of the treated cases.

Calcifying tendinitis.

Calcifying tendinitis is not due to a dystrophic calcification of the degenerative tendinous tissue but due to a cell mediated reactive process. In fact, following formation of a deposit resorption usually ensues which in turn will be followed by a tendon reconstitution. If patent conservative measures fail, surgery should only be contemplated in the presence of radiologically dense, homogenous and well delineated deposits which indicate that the resorptive activity has not set in. If, on the other hand, there is evidence of ongoing resorption the decision for surgery should be postponed since only exceptionally natural resorption will not occur.

Calcific tendinitis of the rotator cuff as a cause of drooping shoulder.

We describe a case of inferior glenohumeral subluxation or drooping shoulder secondary to acute calcific tendinitis of the rotator cuff. The various etiologies of drooping shoulder and the specific causes determining glenohumeral widening in our report are discussed. The importance in recognizing this uncommon complication of a common abnormal finding and correction by aspiration is stressed.

[Calcifying subacromial syndrome--clinical and ultrasound outcome of non-surgical therapy]. / Kalzifizierendes Subakromialsyndrom--Klinische und sonographische Ergebnisse unter nicht-operativer Therapie.

PURPOSE: The aim of this study is to analyse the mid-term clinical and sonographical results of non-operative therapy of calcifying tendinitis. METHODS: Retrospectively the anamnestical, clinical and sonographical results after various non-operative treatment of patients with calcifying tendinitis were reviewed. For this purpose 159 patients with 178 calcifying deposits in the rotator cuff were evaluated on an average of 60 months after their first examination in our clinic (mean age: 49.2 years; sex ratio: 58% women). RESULTS: During a mean symptomatic period of 49 months, an average of 4.2 different therapeutic modalities were applied. After this time 70% of all patients showed an excellent or good result. With regard to the age-correlated Constant-Score 85% of all patients had more than 81 points, i.e. a good result. The mid-term results on a visual analogous scale from 10 (pain) to 0 (no pain) showed a decrease from 7.7 to 2.2 and this correlated with the shoulder function scores (Constant-/Patte-Score, r -0.8). After an average of 104 months 82% of the hydroxyapatite deposits could not be diagnosed by sonography (7.5 MHz.) anymore. CONCLUSION: In the treatment of calcifying tendinitis the conservative methods achieve good and excellent results in 70%. Patients should be treated with analgetics, subacromial injections, physiotherapy and ice therapy up to a period of twelve months, above all with small deposits and radiologic resorptive stadiums. The results of this study should be compared with any invasive regimen.

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients.

Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35-60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery.

Calcificación de tendones de Aquiles bilateral / Calcification of the bilateral Achilles tendons

Introducción. Existen muy pocos casos publicados sobre la presencia de calcificaciones bilaterales en los tendones de Aquiles, aunque la etiopatogenia es desconocida, casi siempre existe un antecedente traumático que requiere inmovilización prolongada. Observaciones clínicas. Presentamos el caso de un paciente con dolor en ambos talones de larga evolución, en la radiología simple observamos una calcificación de 40 ¥ 11 mm en el derecho y de 35 ¥ 9 mm en el izquierdo. Inicialmente presentaba engrosamiento y aumento de temperatura en ambos tendones de Aquiles y dificultad para la marcha, el tratamiento fue conservador con antiinflamatorios no esteroideos (AINE), riserdronato sódico, ultrasonidos y ortesis, obteniéndose una importante mejoría clínica que se mantiene a los 6 y 12 meses. Comentarios. Es importante establecer el diagnóstico diferencial, mediante pruebas de imagen, con la ruptura de los tendones de Aquiles o de las calcificaciones. Respecto al tratamiento, existe una gran controversia en relación con el momento más adecuado para la intervención y en qué tipo de pac

Introduction. There are very few cases published on the presence of bilateral calcifications in Achilles tendon. Although the etiopathogeny is unknown, there is almost always a traumatic background that has required prolonged immobilization. Clinical observations. We present the case of a patient with long-duration pain in both heels. The plain X-ray showed 40 ¥ 11 mm calcification in the right one and 35 ¥ 9 mm in the left one. Initially, there was thickening and increase of temperature in both Achilles tendon and gait difficulty. Treatment was conservative, using NSAIDs, risedronate sodium, ultrasound and orthesis, with which significant clinical improvement was obtained, this being maintained at 6 and 12 months. Comments. It is important to establish the differential diagnosis using imaging tests when there is rupture of the Achilles tendon or calcifications. Regarding treatment, there is great controversy in relationship to the best time for the intervention and in what type of patients