A Novel Ultrasound-Guided Bilateral Vagal Nerve Hydrodissection With 5% Dextrose Without Local Anesthetic for Recalcitrant Chronic Multisite Pain and Autonomic Dysfunction.

Chronic pain is a complex condition that often poses diagnostic and management challenges due to its multifactorial etiology. This case report describes a 49-year-old pastor who presented with a three-year history of chronic pain affecting multiple sites, including the neck, bilateral shoulders, thoracic region, lower back, and bilateral knees. Additionally, he experienced shortness of breath on mild exertion, which adversely affected his ability to converse and speak publicly. The patient had a rapid resting heart rate of 100-120 beats per minute, occasional palpitations, and a 24-hour electrocardiogram that confirmed 15% premature ventricular complexes with bigeminy and trigeminy. He complained of limited appetite with early satiety, intermittent nausea, and regurgitation. Despite consultations with multiple specialists, no underlying causes were identified in the cardiac, respiratory, gastrointestinal, or psychological domains. Ultrasound-guided bilateral vagus nerve hydrodissection using 5% dextrose without local anesthetics was administered three times at monthly intervals, resulting in remarkable pain relief within three months and the effects persisted at the nine-month follow-up. Tachycardia was no longer perceived, resting heart rate slowed to 70-80 beats per minute, shortness of breath improved, and public speaking ability was restored. The patient's early satiety, nausea, and reflux complaints were resolved. This case report highlights the potential effectiveness of this novel intervention for chronic pain. Further research is warranted to validate these findings and explore the mechanism of action.

Volume Effect of Nerve Hydrodissection for Carpal Tunnel Syndrome: A Prospective, Randomized, and Single-Blind Study.

OBJECTIVES: This study compared ultrasound-guided nerve hydrodissection (HD) outcomes using two commonly used injectate volumes (10 and 5 mL) of normal saline to explore if there is a volume effect of HD for patients with moderate carpal tunnel syndrome (CTS). METHODS: Twenty-four participants were randomly assigned to treatment with HD using ultrasound-guidance and either 10 mL or 5 mL of normal saline (HD-10 and HD-5 groups respectively). Our primary outcome measures were the change scores of the two subscales of the Boston Carpal Tunnel Syndrome Questionnaire: The Symptom Severity Scale (SSS) and Functional Status Scale (FSS). We conducted a one-way repeated analysis of variance for 3 time points (4, 12, and 24 weeks) for both SSS and FSS, respectively, for change scores from time 0, and percentage change from time 0. RESULTS: All participants (n = 12 per group) completed the study. From 0 to 24 weeks the HD-10 group outperformed the HD-5 group for improvement in SSS (median ± IQR; -0.8 ± 0.4 versus -0.5 ± 0.5; P = .024) and FSS scores (mean ± SD; -0.8 ± 0.2 versus -0.5 ± 0.5; P = .011). The HD-10 group improvement in FSS subtest significantly exceeded the MCID percentage-change-based threshold of 27% (34%; P = .039). CONCLUSIONS: Despite the limitations of small study size, a largely inert injectate, and a single injection approach, these findings in favor of the 10 mL group suggest that the volume used for ultrasound-guided HD in moderate CTS matters, and a higher volume is more effective.

Infraspinatus Fascial Dysfunction as a Cause of Painful Anterior Shoulder Snapping: Its Visualization via Dynamic Ultrasound and Its Resolution via Diagnostic Ultrasound-Guided Injection.

This report presents the first case of painful anterior shoulder snapping due to a thickened, fibrotic bursa snapping between the subscapularis and the short head of the bicep during external and internal rotation of the humerus. A 46-year-old presented with a 10-month history of on-and-off anterolateral right shoulder pain and snapping. Direct treatment to the anterior suspected lesions partially and temporarily relieved the pain but did not reduce the snapping. Further musculoskeletal examination and dynamic ultrasound scanning showed dysfunction in the scapulothoracic movement and defects of the muscles that interact with the infraspinatus aponeurotic fascia. An ultrasound-guided diagnostic injection to the suspected lesions in the infraspinatus fascia and its muscles attachments improved the scapulothoracic movement, and the snapping and pain were eliminated immediately after the injection, which further shows that the defects in the infraspinatus fascia may be the root cause of the painful anterolateral snapping. The importance of the infraspinatus fascia and its related muscle in maintaining the harmony of the scapulothoracic movement and flexibility of the shoulder is considerable.

The Potential of Glucose Treatment to Reduce Reactive Oxygen Species Production and Apoptosis of Inflamed Neural Cells In Vitro.

Neuroinflammation is a key feature in the pathogenesis of entrapment neuropathies. Clinical trial evidence suggests that perineural injection of glucose in water at entrapment sites has therapeutic benefits beyond a mere mechanical effect. We previously demonstrated that 12.5-25 mM glucose restored normal metabolism in human SH-SYFY neuronal cells rendered metabolically inactive from TNF-α exposure, a common initiator of neuroinflammation, and reduced secondary elevation of inflammatory cytokines. In the present study, we measured the effects of glucose treatment on cell survival, ROS activity, gene-related inflammation, and cell cycle regulation in the presence of neurogenic inflammation. We exposed SH-SY5Y cells to 10 ng/mL of TNF-α for 24 h to generate an inflammatory environment, followed by 24 h of exposure to 3.125, 6.25, 12.5, and 25 mM glucose. Glucose exposure, particularly at 12.5 mM, preserved apoptotic SH-SY5Y cell survival following a neuroinflammatory insult. ROS production was substantially reduced, suggesting a ROS scavenging effect. Glucose treatment significantly increased levels of CREB, JNK, and p70S6K (p < 0.01), pointing to antioxidative and anti-inflammatory actions through components of the MAPK family and Akt pathways but appeared underpowered (n = 6) to reach significance for NF-κB, p38, ERK1/2, Akt, and STAT5 (p < 0.05). Cell regulation analysis indicated that glucose treatment recovered/restored function in cells arrested in the S or G2/M-phases. In summary, glucose exposure in vitro restores function in apoptotic nerves after TNF-α exposure via several mechanisms, including ROS scavenging and enhancement of MAPK family and Akt pathways. These findings suggest that glucose injection about entrapped peripheral nerves may have several favorable biochemical actions that enhance neuronal cell function.

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

A novel infrapatellar approach of ultrasound-guided intra-articular injection of the knee from both lateral and medial side: a case series.

Knee osteoarthritis (OA) is common. Ultrasound-guided intra-articular injection (UGIAI) using the superolateral approach is currently the gold standard for treating knee OA, but it is not 100% accurate, especially in patients with no knee effusion. Herein, we present a case series of chronic knee OA treated with a novel infrapatellar approach to UGIAI. Five patients with chronic grade 2-3 knee OA, who had failed on conservative treatments and had no effusion but presented with osteochondral lesions over the femoral condyle, were treated with UGIAI with different injectates using the novel infrapatellar approach. The first patient was initially treated using the traditional superolateral approach, but the injectate was not delivered intra-articularly and became trapped in the pre-femoral fat pad. The trapped injectate was aspirated in the same session due to interference with knee extension, and the injection was repeated using the novel infrapatellar approach. All patients who received the UGIAI using the infrapatellar approach had the injectates successfully delivered intra-articularly, as confirmed with dynamic ultrasound scanning. Their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, stiffness, and function scores significantly improved 1 and 4 weeks post-injection. UGIAI of the knee using a novel infrapatellar approach is readily learned and may improve accuracy of UGIAI, even for patients with no effusion.

Effect and Optimal Timing of Extracorporeal Shock-Wave Intervention to Patients With Spasticity After Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: This study investigated the efficacy of extracorporeal shock wave therapy as well as the optimal intervention timing for extracorporeal shock wave therapy for patients with spasticity after stroke. DESIGN: A search of randomized controlled trials was conducted in different electronic databases. We performed a meta-analysis to measure the effect of extracorporeal shock wave therapy versus sham interventions on spasticity and limb functionality. The meta-regression analysis was performed to determine the adequate intervention timing of extracorporeal shock wave therapy. The follow-up period of the outcomes was divided into the short (<2 wks), mid (>2 wks and ≤4 wks), and long (>4 wks and ≤3 mos) terms. RESULTS: Thirteen studies with 677 participants were evaluated. Spasticity significantly improved throughout the follow-up duration. Limb functionality significantly improved in the short-term follow-up period. The meta-regression analysis showed that patients with stroke duration less than 45 mos may be benefited from extracorporeal shock wave therapy in improving limb function in all follow-up periods. CONCLUSIONS: Extracorporeal shock wave therapy is an effective method for reducing spasticity in patients with stroke, and the effect could be maintained for up to 3 mos. Its effects on limb functionality could persist for at least 2 wks. Patients who had stroke for less than 45 mos may have significant benefit from extracorporeal shock wave therapy in all follow-up periods.

18 F-FDG PET/CT imaging for haemophilic arthropathy compared with clinical, radiological and power Doppler sonographic characteristics of 20 haemophilia patients.

INTRODUCTION AND OBJECTIVES: Repeated joint bleeding in haemophilia patients may lead to haemophilic arthropathy with marked inflammation and synovitis. This study investigated the potential of 18 F-fluorodeoxyglucose positron emission tomography-computed tomography (18 F-FDG PET/CT) as a novel diagnostic method for haemophilic arthropathy. MATERIALS AND METHODS: We recruited 20 adult haemophilia patients who reported history of hemarthroses in the shoulder, elbow, hip, knee, or ankle joints. All joints were assessed by power Doppler ultrasonography and radiography, and graded by hyperaemia score and Pettersson score, respectively. Joint pain was evaluated by visual analogue score (VAS). Range of motion (ROM), Haemophilia Joint Health Score (HJHS) and annual joint bleeding rate (AJBR) were recorded. Finally, all participants had whole-body 18 F-FDG PET/CT, and maximum standardized uptake value (SUVmax) of the joints being studied was measured. RESULTS: Thirteen patients had severe haemophilia, and seven had moderate haemophilia. The mean age was 36 years. PET SUVmax showed significant correlations with VAS, ROM, Pettersson score, hyperaemia score, HJHS score and AJBR in all large joints except hip. Joints with pain, hyperaemia and radiographic changes were found to have higher SUVmax than those without these features. Using Youden's index, the optimal cut-off value for early radiographical arthropathy was found to be between 1.9 and 2.0. CONCLUSION: Our study indicates that 18 F-FDG PET/CT imaging correlated well with various conventional diagnostic techniques. It also demonstrated high sensitivity and specificity for early radiographic arthropathy. 18 F-FDG PET/CT imaging may quantitatively evaluate disease activity of most large joints in a single examination and help detect early haemophilic arthropathy.

Novel Ultrasound-Guided Cervical Intervertebral Disc Injection of Platelet-Rich Plasma for Cervicodiscogenic Pain: A Case Report and Technical Note.

Ultrasound-guided needle placement into the cervical intervertebral discs using a lateral-to-medial approach is reportedly possible. Clinically, however, patients commonly present with very high uncovertebral joints or narrowed intervertebral spaces, making the method difficult or impossible. This report presents a novel ultrasound-guided needle placement technique to the cervical intervertebral discs using a more medial approach between the trachea/thyroid gland and the carotid sheath. A patient presented with neck pain radiating to the right shoulder and right-sided interscapular regions that affected his sleep and daily functioning. Physiotherapy, selective nerve root block, and percutaneous endoscopic right C7 laminotomy did not sufficiently improve his condition, which progressed to bilateral interscapular and bilateral shoulder pain. Provocative discography was performed with injection of leukocyte-poor and red blood cell-poor platelet-rich plasma to provoke the discogenic pain, which was treated with platelet-rich plasma mixed with lidocaine. The patient recovered well. A month later, there was a significant decrease in the neck disability index score from the initial 28/50 to 14, and there was a further decrease to 5 after 2 months. In conclusion, this medial approach of ultrasound-guided cervical disc needle placement is feasible, even in patients where disc access by previously described approaches is impossible.

The Effectiveness of Hydrodissection with 5% Dextrose for Persistent and Recurrent Carpal Tunnel Syndrome: A Retrospective Study.

Patients with failure of primary surgery for carpal tunnel syndrome (CTS) present a frustrating clinical problem because there are no relevant treatment guidelines, and the effect of current conservative management or revision surgery is unsatisfactory. Hydrodissection with 5% dextrose is emerging as an effective treatment for primary CTS and may be an effective alternative treatment method for persistent or recurrent post-surgical CTS. We retrospectively investigated the long-term effectiveness of hydrodissection with 5% dextrose for persistent or recurrent CTS. Thirty-six of forty consecutively-treated patients with either persistent or recurrent symptoms of CTS after surgery, who were treated with ultrasound-guided hydrodissection of the median nerve using 10 mL of 5% dextrose, were available to provide outcome data by a structured phone interview at least six months after treatment completion. Symptom relief ≥ 50% represented an effective outcome, while symptom relief < 50% was rated as a poor outcome. Nearly 2/3 (61.1%) of patients reported an effective outcome after a mean of 3.1 injections, with a post-injection follow-up mean of 33 (6−67) months. A non-significant trend toward a more frequently-effective outcome was observed in those with recurrent versus persistent symptoms following CTS (76.9% vs. 52.2%, p = 0.165). However, a significantly higher percentage of those with recurrent symptoms reported an excellent outcome, defined as a greater than 70% improvement (8/13 [61.6%] vs. 3/23 [13%], p = 0.006). The percentage of patients achieving an effective outcome was not significantly different between <2, 2−4, and >4 years of post-treatment follow-up (36.4% vs. 77.8% vs. 57.1%; p = 0.077). Hydrodissection with 5% dextrose may result in a clinically important and durable benefit in those experiencing persistent or recurrent CTS after surgery.

Efficacy of a Novel Intra-Articular Administration of Platelet-Rich Plasma One-Week Prior to Hyaluronic Acid versus Platelet-Rich Plasma Alone in Knee Osteoarthritis: A Prospective, Randomized, Double-Blind, Controlled Trial.

Recent studies have suggested that the combined injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) may have additive benefits for knee osteoarthritis over PRP alone, but there is insufficient evidence to support this combined injection. Moreover, the simultaneous injection of PRP and HA may offset the combined effect. Hence, the aim of this prospective, randomized, double-blind study was to assess their combined efficacy with a novel injection protocol. Forty-six study subjects with unilateral knee osteoarthritis were randomized to receive either a single-dose injection of HA (intervention group) or normal saline (control group) 1 week after a single-dose injection of leukocyte-poor PRP. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and static balance and the risk of falls measured by Biodex Balance System were, respectively, the primary and secondary outcome measures. Evaluations were performed at baseline, 1 month, 3 months, 6 months, and 12 months post-injection. The intervention group exhibited significant declines in WOMAC pain, stiffness, and total scores, as well as static balance, compared to the control group (p < 0.05). These randomized double-blind control trials, with novel protocol of intra-articular injection of PRP 1-week prior to HA, provide greater symptom relief and improve static balance compared to PRP alone in patients with knee osteoarthritis.

Mechanism of Glucose Water as a Neural Injection: A Perspective on Neuroinflammation.

The entrapment of peripheral nerves is associated with chronic neuroinflammation and neuropathic pain, and perineural injection therapy with glucose is emerging as an effective treatment for peripheral entrapment neuropathy. However, the mechanism underlying the pharmacological effect of glucose on nerves remains unclear. One of the hypothesized mechanisms is that glucose reduces neurogenic inflammation. Therefore, we investigated the effects of high glucose concentrations on cytokine-induced neuroinflammation in vitro. Human SH-SY5Y neuronal cells were challenged with 10 ng/mL TNF-α for 16 h and subsequently treated with different glucose concentrations (0-25 mM) for 24 h. Cell viability was evaluated using the diphenyltetrazolium bromide assay, and proinflammatory cytokine levels were assessed using ELISA and quantitative PCR. In addition, mRNA levels of NF-κB and cyclooxygenase-2 were analyzed using quantitative PCR. Exposure to 10 ng/mL TNF-α resulted in decreased viability of SH-SY5Y cells and significant upregulation of IL-6, IL-1ß, NF-κB, and cyclooxygenase-2. Subsequent exposure to high glucose levels (25 mM) markedly reduced the upregulation of IL-6, IL-1ß, cyclooxygenase-2, and NF-κB, and restored the functional metabolism of SH-SY5Y cells, compared with that of the normal glucose control. Our findings suggest that high glucose concentrations can mitigate TNF-α-induced NF-κB activation, upregulation of proinflammatory cytokines, and metabolic dysfunction.

Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates.

Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome (CTS). The usage of normal saline (NS), 5% dextrose water (D5W), platelet-rich plasma (PRP), and hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic can limit anesthetic-related toxicity and preserve the motor functions of the median nerve. Here, we describe a novel motor-sparing neural injection and compare the effect of these four injectates for severe CTS. We retrospectively reviewed the outcomes of 61 severe CTS cases after a single neural injection with NS, D5W, PRP, or HA. Outcomes were evaluated on the 1st and 6th months postinjection, including the Boston Carpal Tunnel Questionnaire (BCTQ) scores and the nerve cross-sectional area (CSA). The results revealed that PRP, D5W, and HA were more efficient than NS at all measured time points (p < 0.05), except for CSA at the 1st month between the NS and D5W groups. Single-injections of PRP and D5W seemed more effective than that of HA within 6 months postinjection for symptom and functional improvement (6th-month BCTQ-symptom, D5W vs. HA, p = 0.047; 1st-month BCTQ-symptom, PRP vs. HA, p = 0.018; 1st- and 6th-month BCTQ-function, D5W vs. HA, p = 0.002 and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA, p < 0.001). For reducing CSA, PRP and HA seemed more effective than D5W (HA > PRP > D5W on the 1st month and HA vs. D5W, p = 0.001; PRP > HA > D5W on the 6th month and PRP vs. D5W, p = 0.012).

The Long-Term Analgesic Effectiveness of Platelet-Rich Plasma Injection for Carpal Tunnel Syndrome: A Cross-Sectional Cohort Study.

OBJECTIVE: Interest in perineural platelet-rich-plasma (PRP) injections for the treatment of carpal tunnel syndrome (CTS) has increased in recent years. However, evidence supporting the long-term effectiveness of PRP is lacking. Therefore, the aim of our cross-sectional cohort study was to investigate the long-term results of PRP injections for CTS. METHODS: Eighty-one patients diagnosed with CTS of any grade who received a single PRP injection at least 2 years prior were enrolled. Through structured telephone interviews, all patients were asked of their post-injection outcomes compared to their pre-injection condition. Symptom relief ≥50%, compared to the pre-injection condition, was considered an effective outcome. Binary logistic regression was applied to analyze each baseline variable as a regressor for determining the prognostic outcome factors. RESULTS: In total, 70% of patients reported positive outcomes ≥2 years post-injection. Shorter duration of symptoms before treatment (odds ratio: 0.991; 95% confidence interval [CI] 0.983-0.999; P = .023) and lower electrodiagnostic severity of CTS were the main prognostic factors for an effective outcome (mild grade vs severe grade, odds ratio: 17.652; 95% CI 1.43-221.1; P = .025). Although there was a trend toward positive outcomes at longer follow-up durations (2-3 years vs 3-4 years vs 4-5 years), the difference was not statistically significant. CONCLUSIONS: A single perineural PRP injection has a long-term analgesic effect on CTS, especially in mild-to-moderate cases.

Efficacy of 5% Dextrose Water Injection for Peripheral Entrapment Neuropathy: A Narrative Review.

Current non-surgical treatment for peripheral entrapment neuropathy is considered insignificant and unsustainable; thus, it is essential to find an alternative novel treatment. The technique of perineural injection therapy using 5% dextrose water has been progressively used to treat many peripheral entrapment neuropathies and has been proven to have outstanding effects in a few high-quality studies. Currently, the twentieth edition of Harrison's Principles of Internal Medicine textbook recommends this novel injection therapy as an alternative local treatment for carpal tunnel syndrome (CTS). Hence, this novel approach has become the mainstream method for treating CTS, and other studies have revealed its clinical benefit for other peripheral entrapment neuropathies. In this narrative review, we aimed to provide an insight into this treatment method and summarize the current studies on cases of peripheral entrapment neuropathy treated by this method.

Comparison of short- and long-axis nerve hydrodissection for carpal tunnel syndrome: A prospective randomized, single-blind trial.

Background: This study is to compare the efficacy of short-axis hydrodissection with long-axis hydrodissection for patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: Forty-seven patients with mild-to-moderate CTS were enrolled in a prospective, randomized, single-blinded, controlled trial (6 months follow-up). With ultrasound guidance, patients in both groups (short-axis or long-axis groups) were injected with normal saline (5 mL per session). Assessments were performed before and 2 weeks after the injection, as well as at 1, 3, and 6 months post-intervention. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score and secondary outcomes included the cross-sectional area of the median nerve and electrophysiological studies. Results: Forty-four patients (21 wrists in the short-axis group and 23 wrists in the long-axis group) completed the study. Compared with the baseline, both groups showed improved BCTQ and cross-sectional area at all follow-up assessments (p<0.05). The short-axis group was not more effective except significant improvements in BCTQ-severity and BCTQ-function 1 month post-injection compared to the long-axis group (p = 0.031 and p = 0.023, respectively). Conclusions: Both short- and long-axis hydrodissection were effective for patients with mild-to-moderate CTS and the short-axis approach was not more effective than long-axis injection. Further studies with larger sample sizes, multiple injections, and larger injection volume are encouraged in the future.

Increased risk of shoulder calcific tendinopathy in diabetes mellitus: A nationwide, population-based, matched cohort study.

BACKGROUND: Calcific tendinopathy of the rotator cuff is a common cause of painful disability in the shoulder with unclear aetiology. Diabetes mellitus (DM) is associated with calcific tendinopathy; however, large epidemiological data are lacking. Thus, we conducted a nationwide population-based matched cohort study to investigate the risk for calcific tendinopathy of the shoulder in diabetic patients. METHODS: The National Health Insurance Research Database of Taiwan was used to include 42 915 patients newly diagnosed with DM between 1 January 2000 and 31 December 2015 and randomly extract the data of 171 660 individuals, as a matched control group. All individuals were followed-up until the development of calcific tendinopathy or the end of 2015. RESULTS: Overall, 122 patients from the DM group (0.284%) developed calcific tendinopathy compared with 340 individuals from the non-DM group (0.198%). The Kaplan-Meier analysis indicated that patients with DM had a higher risk of calcific tendinopathy since the eighth year of follow-up (log-rank test, P = .006). Cox proportional hazard regression revealed that the adjusted hazard ratio of calcific tendinopathy in diabetic patients to that in non-diabetic patients was 1.276 (95% confidence interval 1.037-1.571, P = .002). Moreover, the stratified analysis disclosed that DM was a strong independent risk factor for calcific tendinopathy irrespective of the existing comorbidities. CONCLUSIONS: This study demonstrated that patients with DM had a 27% increased risk of developing calcific tendinopathy of the shoulder, 8 years after initially being diagnosed with DM.