Transcript Calcific tendinitis of the shoulder: Whom and how to treat?

Calcific tendinitis of the shoulder:
Whom and how to treat?
Rafic Baddoura MD, MPH
Head, Rheumatology Department
Hotel-Dieu Hospital
St Joseph University
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• What are the available treatment options?
• What is the evidence these options are effective?
• What prognostic factors we may use?
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Orthop Clin N Am 34 (2003) 567– 575
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Clinical assessment
• Constant and Murley score
– minimum score of 0 and
maximum score of 100
– higher scores reflecting
increased function)
• Total score is obtained by
adding the results of 4
subscales:
– subjective pain (15 points)
– function (20 points)
– objective clinician
assessment of range of
motion (40 points)
– strength (25 points)
• The UCLA Shoulder Rating Scale
is a 35-point shoulder scale that
combines scores for
– pain, from 1 to 10 points
– function, from 1 to 10 points
– active range of forward flexion,
strength of forward flexion (manual
muscle testing), scored from 0 to 5
points,
– patient satisfaction scored from 0
to 5 points.
• The outcome defined as follows:
–
–
–
–
34 to 35 points, excellent;
29 to 33 points, good;
21 to 28 points, mild;
20 points or less, poor.
Phys Ther Vol. 86, No. 5, May 2006, pp.
672-682
Calcific deposit classification
• Clearly circumscribed with a
dense appearance (type I)
• heterogeneous structure
with sharp outline or
homogenous structure with
no defined border (type II)
• Translucent and cloudy
appearance without clear
circumscription (type III)
Gartner J, Simons B. Analysis of calcific
deposits in calcifying tendinitis. Clin Orthop
Relat Res. 1990;254:111–120
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• What are the available treatment options?
• What is the evidence these options are effective?
• What prognostic factors we may use?
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Needle aspiration
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Extracorporeal Shock Wave Therapy ESWT
• ESWT classified according focal energy flux density (EFD) levels
– Low :
up to 0.08 mJ/mm2
– Moderate:
between 0.09 and 0.28 mJ/mm2
– High:
up to 0.6 mJ/mm2
Skeletal Radiol. 2007 Sep;36(9):803-11
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Arthroscopy, bursoscopy
Orthop Clin N Am 34 (2003) 567– 575
• What are the available treatment options?
• What is the evidence these options are effective?
• What prognostic factors we may use?
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Single-needle aspiration
• Prospective study, 33 patients with calcifying tendinitis had a needling
under control of an image converter. At least one year follow-up period.
• Resorption of the hydroxyapatite deposits in 23 (70%);
• Remission of symptoms or considerable improvement in 75%
– type I: complete resorption in 33%
– type II: complete resorption in 71%; only half were symptom free
– type III: complete resorption in 85%
• Surgical removal was necessary in 3 patients because of persisting pains
J. Gärtner Z Orthop Ihre Grenzgeb 1993;
131: 461-469
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Two-needle us-guided aspiration
• 219 (86 men, 133 women) cases; mean age, 40 years +/- 11
• 68 (31 men, 37 women); mean age, 40 years +/- 11) refused treatment
and served as controls.
Cases
(n=151)
Controls
(n=68)
Constant
VAS
Constant
VAS
1 month
73.2 +/- 6.2
4.8 +/- 0.6
57.5 +/- 3.9
9.1 +/- 0.5
3 months
90.2 +/- 2.6
3.3 +/- 0.4
62.6 +/- 7.2
7.3 +/- 1.8
12 months
91.7 +/- 3.1
2.7 +/- 0.5
78.4 +/- 9.5
4.5 +/- 0.9
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Needle fragmentation irrigation versus
removal under bursoscopy
•
•
•
102 shoulders (96 patients) with
calcifications >5 mm whose medical
treatment had failed (>4 months)
were first injected with corticosteroid
49 shoulders improved by >70%
The other 53 shoulders were
randomized in 3 groups:
– Needle Fragmentation Irrigation
NFI (n = 16)
– Bursoscopy BS (n = 20)
– Control group CT: NSAID and
analgesics on request (n = 17)
Joint Bone Spine Volume 76, July 2009,
Pages 369-377
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Needle fragmentation irrigation versus
removal under bursoscopy
Joint Bone Spine Volume 76, July 2009,
Pages 369-377
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ESWT at high energy versus sham ESWT
• Cases: (n = 33) ESWT in 2 sessions,
2 wks apart. Each session 1000
impulses with an energy flux
density 0.55 mJ/mm
• Controls: sham ESWT (n = 13)
Shoulder pain that failed to respond
to > 3 months of non-operative
treatment; NSAIDs, corticosteroid
injections, physical therapy, and
immobilization in a sling.
J Shoulder Elbow Surg. 2008 JanFeb;17(1):55-9.
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High versus low energy ESWT
• 100 patients who had had
calcific tendinitis for > 12
months randomized to:
• Group 1: 1500 impulses of
0.06 mJ/mm2,
• group 2: 1500 impulses of
0.28 mJ/mm2, brachial
plexus anesthesia.
• Partial or complete
disintegration of Ca deposits in
– 50% in group 1
– 64% in group 2
(P < .01)
• Constant score increased from
– 48 to 71 in group 1 (P < .001)
– 53 to 88 in group 2 (P < .001)
(P < .01)
• At 24 weeks, percent rating
treatment as good or excellent,
– 52% in group 1
– 68% in group 2
J Shoulder Elbow Surg. 1998 SepOct;7(5):505-9
(P < .01)
High versus low energy ESWT
•
•
•
•
•
•
Shoulder pain for at least 12 months
Resistant to regular physiotherapy and
subacromial injections of steroids.
An area of radiological calcification at least
1 cm in diameter with no signs of
disintegration (type I or II)
Cloudy and transparent calcifications (type
III) were excluded.
Rotator cuff lesions were excluded by
means of sonography and in some cases
by magnetic resonance imaging
Additional reasons for exclusion were
evidence of subacromial impingement of
the rotator cuff independent of calcareous
deposits
Cases (n=40): 2000 impulses, twice, with
an energy flux density of 0.42 mJ/mm2
Controls (n=40): 2000 impulses, twice, with
an energy flux density of 0.23 mJ/mm2
J Orthop Sci (2003) 8:777–783
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High versus low energy ESWT
Constant score
Clinical versus radiographic
X-ray regression:
Cases: 22 patients (55%)
Controls: 15 patients (38%)
J Orthop Sci (2003) 8:777–783
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High versus low energy RSWT
• Cases: 4 sessions at 1-week intervals, with 2,500 impulses per session
(500 impulses with a pressure of 1.5 bar and a frequency of 4.5 Hz and
2,000 impulses with a pressure of 2.5 bar and a frequency of 10 Hz), and a
fixed impulse time of 2 milliseconds. EFD/impulse = 0.10 mJ/mm2.
• Controls: 4 sessions at 1-week intervals, with 25 impulses per session
(5 impulses with a pressure of 1.5 bar and a frequency of 4.5 Hz and
20 impulses with a pressure of 2.5 bar and a frequency of 10 Hz).
Cases
(n=45)
UCLA
After
treatment
33.1 + 2.9
At 6 months
32.1 + 3.0
Controls
(n=45)
X-ray
regression
UCLA
X-ray
regression
11.3 + 2.8
39 patients
(87%)
Phys Ther. 2006 May;86(5):672-82.
10.6 + 4.0
0 patient
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High versus low energy ESWT
•
•
•
•
•
•
•
High-energy group received 1500 shock waves
of 0.32 mJ/mm2 / treatment, 120 impulses /min
Low-energy group received 6000 shock waves of
0.08 mJ/mm2 /treatment, 120 impulses /min
Adequate IV analgesia and sedation. Local
anesthetics were prohibited.
All patients received a second ESWT treatment
at 12 to 16 days
Each treatment session lasted as long as 1 hour.
In each group patients received a cumulative
energy dose of 0.960 J/mm2.
Sham treatment: an air-chambered
polyethylene foil with coupling gel was placed
against the patient's skin, but no coupling gel
was applied to the site of the shock wave head.
•
•
•
•
Calcific deposits > 5 mm in diameter, and
symptoms for > 6 months.
Rotator cuff tears and subacromial bursitis were
ruled out in all patients by clinical and
sonographic examination, and when in doubt,
by MRI prior to randomization and at all followup visits.
Type III Gärtner deposits were excluded
All participants had previous conservative
treatments, including both physiotherapy
(active and passive exercise, mobilization,
manual therapy and massage, muscle
strengthening) and local anesthetic or
corticosteroid injections.
Gerdesmeyer JAMA Vol. 290 No. 19,
November 19, 2003
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High versus low energy ESWT
Pain and Constant score
Gerdesmeyer JAMA Vol. 290 No. 19,
November 19, 2003
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High versus low energy ESWT
Calcium deposits
Gerdesmeyer JAMA Vol. 290 No. 19,
November 19, 2003
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ESWT with or without localization
• 3 sessions of low-energy focused shock wave therapy was administered in
weekly intervals in both groups.
• Cases: calcium deposit was localized using a radiographically guided, 3-D,
computer-assisted device.
• Controls: calcium deposit was localized using the point of maximum
tenderness through palpation with feedback from the patient.
Cases
(n=25)
Constant
At 12 weeks
Controls
(n=25)
X-ray
regression
6 patients
(24%)
Constant
X-ray
regression
1 patient
(4%)
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High versus low energy
fluoroscopy-guided ESWT
• High-energy ESWT, low-energy ESWT, or placebo (sham therapy).
• The 2 ESWT groups received the same cumulative energy dose.
• Patients in all 3 groups received 2 treatment sessions approximately 2
weeks apart, followed by physical therapy.
Cases
(n=40)
Controls
(n=40)
Constant
High Energy
Low Energy
Sham
At 6 months
31.0 [26.7-35.3]
15.0 [10.2-19.8]
6.6 [1.4-11.8]
P<0.001
P<0.001
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ESWT versus conventional surgery
in calcifying tendinitis of the shoulder
A prospective quasirandomized chronic calcifying tendinitis
•surgical extirpation (Group I, 29 patients)
•high-energy ESWT (Group II, 50 patients) 3,000 impulses, EFD 0.6 mJ/mm2
•
University of California Los Angeles
Rating
– 12 months
• Group I 30 points with 75%
good or excellent results
• Group II 28 points with 60%
good or excellent results
– 24 months
• 32 points with 90% good or
excellent results after.
• 29 points with 64% good or
excellent results
•
Radiologically, at 12 months
– Group I no calcific deposit in 85% of
the patients
– Group II no calcific deposit in in 47%
of the patients
•
•
homogenous deposit: surgery
superior to high-energy ESWT
inhomogenous deposit: high-energy
ESWT equivalent to surgery
Arthroscopy surgery versus ESWT
for chronic calcifying tendinitis of the shoulder
• Retrospective study in patients
with chronic calcific deposit
• Arthroscopic extirpation (group I,
22 cases)
• Low ESWT: 3 treatment sessions
with 1,500 impulses/session of
0.10-0.13 mJ/mm2. (group II, 24
cases).
• Patients included in the study had
– unsuccessful conservative therapy
for six months
– no evidence of subacromial
impingement of the rotator cuff
detected by sonography or
magnetic resonance imaging.
• (UCLA) rating system after 24
months,
–
(P =0.38)
–
group I: mean score rose from 9.36 (+/-5.2)
to 30.3 (+/-7.62), with 81.81% reporting
good or excellent results (P < 0.001).
group II mean score rose from 12.38 (+/6.5) to 28.13 (+/-9.34), with 70.83%
reporting good or excellent results (P <
0.001).
• Radiologically, after 24 months,
–
–
No calcific deposit in 86.35% (P < 0.001) of
group I
No calcific deposit in 58.33 % (P < 0.001) of
group II.
• Ca deposits had to be types I and
II / Gärtner classification.
J Orthop Traumatol. 2008 Dec;9(4):179-85.
• What are the available treatment options?
• What is the evidence these options are effective?
• What prognostic factors we may use?
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Effect of Ca deposit radiographic shape
on ESWT outcome
Cases: (n = 33) ESWT in 2 sessions,
2 wks apart. Each session 1000
impulses with an energy flux density
0.55 mJ/mm
Controls: sham ESWT (n = 13)
No significant difference in Constant
score between type I and type II
Gartner Classification
J Shoulder Elbow Surg. 2008 JanFeb;17(1):55-9.
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Effect of Ca deposit radiographic shape
on ESWT outcome
• Case-series of 80 subjects
• ESWT: one to five sessions at an interval of 4-6 weeks. Each patient
received 1800 impulses in each session. EFD 0.08-0.42 mJ/mm2
Cases
(n=80)
Constant
After
treatment
No Controls
X-ray
regression
57 (71%)
X-ray regression by calcium deposit shape:
Amorphous: 100%
Mixed: 64.7-77%
Homogeneous: 44.4%
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Effect of MRI negative contrast reaction
around Ca deposit on ESWT outcome
• Case-series 62 patients with chronic courses of calcifying tendinitis
• Clinical assessment before and after low-energy ESWT
• Size (p = 0.61) and morphology (p = 0.7) of the deposits before ESWT not
associated with the clinical outcome
MRI negative contrast reaction around
Constant > 75
Ca deposit
Synovia
Bursae
Se
0.38
0.49
0.44
Sp
0.95
0.82
0.86
PPV
0.94
0.84
0.86
P< 0.0001
P<0.0049
Archives of Orthopaedic and Trauma
Surgery 2000
P<0.01
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Effect of subacromial decompression
on calcific tendinitis
• 50 patients reviewed after arthroscopic subacromial decompression.
– Cases: 25, had calcific deposits in the rotator cuff visible on x-rays.
Calcific deposits were left untouched in all cases.
– Controls: 25, without calcification, similar state of the rotator cuff,
date of surgery, age, and sex.
• No significant difference in postoperative Constant score
Calcification
Before surgery
2 yrs after surgery
> 5 mm
18 (72%)
4 (17%)
< 5 mm
7 (28%)
20 (83%)
p < 0.001
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Effect of Ca deposit resection and
acromioplasty in rotator cuff tendinopathy
• Multi-center study (112 patients) / French Society of Arthroscopy
• Several arthroscopic procedures on
– the calcification (respect or removal),
– The coracoacromial arch (respect, ACL release or acromioplasty)
Cases (n=112)
Constant
At follow-up
(82%) improved
No Controls
X-ray regression
(88%)
Results were better when the calcification had been removed
 Acromioplasty gave no better results: necessary only when no calcification is found (12 %)

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Influence of deposit stage and failed ESWT on the
results of arthroscopic resection of calcific tendonitis
• 45 (17 men, 28 women)
– mean age of 49 +/- 8 years
– mean follow-up 36 months (14-89)
• 24 patients (53.3%) underwent
preoperative ESWT.
• For the clinical evaluation the
– Constant and Murley Score
– Simple Shoulder Test (SST)
– Western Ontario Rotator Cuff
Index (WORC)
– visual analog scales for pain,
function and satisfaction
•
P value
Constant
63.5 +/- 11.4
93.9 +/- 9.9
< .0001
SST
1.7 +/- 2
9.9 +/- 2.8
<.0001
WORC
1,591.2 +/337.4
345.4 +/392 points
<.0001
Ca
deposits
37 type I
6 type II
2 type III
37 Absent
6 type I
2 type III
1. No significant correlation of the clinical
results with the pre- or post-op findings
For the radiological evaluation,
2. Patients who underwent ESWT before
the classifications according to
surgery (n=24) did not show significantly
Gartner and Bosworth were used.
better results than patients without ESWT
Knee Surg Sports Traumatol Arthrosc. 2008
May;16(5):516-21.
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Take home message
• Type III Ca deposits are likely to resolve spontaneously
• Needling is a simple low-cost straight forward procedure
in type II Ca deposits with persistent pain despite
conservative therapy
• No significant difference in terms of pain and function
between high energy ESWT and arthroscopic removal in
type II Ca deposits
• Type I Ca deposits are associated with lower rate of
radiographic regression with ESWT
• No significant correlation between radiographic and
clinical outcomes
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