Calcific tendinitis of the shoulder: Whom and how to treat? Rafic Baddoura MD, MPH Head, Rheumatology Department Hotel-Dieu Hospital St Joseph University

What are the available treatment options? What is the evidence these options are effective? What prognostic factors we may use?

Orthop Clin N Am 34 (2003) 567– 575

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

What are the available treatment options? What is the evidence these options are effective? What prognostic factors we may use?

Needle aspiration

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

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?

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

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 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

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

Needle fragmentation irrigation versus removal under bursoscopy Joint Bone Spine Volume 76, July 2009, Pages 369-377

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 Jan-Feb;17(1):55-9.

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 Constant score increased from 48 to 71 in group 1 (P < .001) 53 to 88 in group 2 (P < .001) At 24 weeks, percent rating treatment as good or excellent, 52% in group 1 68% in group 2 (P < .01) (P < .01) (P < .01) J Shoulder Elbow Surg. 1998 Sep-Oct;7(5):505-9

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

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

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) Controls (n=45) UCLA X-ray regression After treatment 33.1 + 2.9 11.3 + 2.8 At 6 months 32.1 + 3.0 39 patients (87%) 10.6 + 4.0 0 patient Phys Ther. 2006 May;86(5):672-82.

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 follow-up 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

High versus low energy ESWT Pain and Constant score Gerdesmeyer JAMA Vol. 290 No. 19, November 19, 2003

High versus low energy ESWT Calcium deposits Gerdesmeyer JAMA Vol. 290 No. 19, November 19, 2003

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) Controls (n=25) Constant X-ray regression At 12 weeks 6 patients (24%) 1 patient (4%)

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

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

J Orthop Traumatol. 2008 Dec;9(4):179-85. 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. Ca deposits had to be types I and II / Gärtner classification. (UCLA) rating system after 24 months, 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. (P =0.38) 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?

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 Jan-Feb;17(1):55-9.

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) No Controls Constant X-ray regression After treatment 57 (71%) X-ray regression by calcium deposit shape: Amorphous: 100% Mixed: 64.7-77% Homogeneous: 44.4%

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 P< 0.0001 P<0.0049 P<0.01 Archives of Orthopaedic and Trauma Surgery 2000

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

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) No Controls Constant X-ray regression At follow-up (82%) improved (88%) Results were better when the calcification had been removed Acromioplasty gave no better results: necessary only when no calcification is found (12 %)

Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):516-21. 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 For the radiological evaluation, the classifications according to Gartner and Bosworth were used. 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 Ca deposits 37 type I 6 type II 2 type III 37 Absent 6 type I No significant correlation of the clinical results with the pre- or post-op findings Patients who underwent ESWT before surgery (n=24) did not show significantly better results than patients without ESWT Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):516-21.

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