1. Which Method Is More Effective In Treatment Of Calcific Tendinitis In The Shoulder? - Prospective Randomized Comparison Between US- Guided Needling and ESWT Yang-Soo Kim, M.D. Ph.D., Hyo-Jin Lee, M.D., In Park, M.D., Sung-Ho Bae, M.D., Sung-Eun Kim, M.D., Hyunwoo Jung, M.D., Hyung-Lae Cho, M.D. Seoul St. Mary’s Hospital Department of Orthopedic Surgery The Catholic University of Korea

2. COI Disclosure Information COI Disclosure Information Yang-Soo Kim M.D., Hyo-Jin Lee M.D. I have no financial relationships to disclose.

3. Even though the calcific tendinitis is usually a self-limiting process, it sometimes causes very severe pain and morbidity in nature. The treatment is still under debate : medication, extracorporeal shock wave therapy (ESWT), calcium deposit needling, lavage, and surgical removal. Introduction

4. Good to excellent in 87.9% in Constant score Calcium deposits were completely eliminated in 21.2%, partially eliminated in 36.3%, and unchanged in 45.4% ESWT is effective for pain relief and functional restoration of calcific tendinitis JSES, 2008

5. Introduction Treated patients reported a significant decrease in symptoms at 3 month, 6 months, and 1 year Ultrasound(US)-guided percutaneous needling facilitated prompt shoulder function recovery and pain relief de Witte Pb et al, Am J Sports Med. 2013

6. Yet, there is no prospective randomized study comparing the effects between ESWT and US- guided needling on calcific tendinitis. Introduction

7. To compare functional and radiologic outcomes between ESWT and US-guided needling To evaluate the correlation of Ca. deposit size with functional outcomes in each group. Purpose

8. Nov. 2005 ~ Mar. 2011 Prospective, comparative evaluation 54 patients with calcific tendinitis All patients were randomly allocated into 2 groups : ESWT (N=25) : US-Guided Needling (N=29). Materials and Methods

9. Assessed for eligibility (n=73) Enrollment Randomized (n=62) Allocated to US needling group (n=30) Allocated to ESWT group (n=32) Excluded (n=11) not meet the inclusion criteria (n=6) refused to participate (n=5) Lost to follow-up (n=5) Lost to follow-up (n=3) Group 1 (n=25)Group 2 (n=29) CONSORT

10. ESWT group -EMS Swiss DolorClast -3 courses of ESWT, 1 week apart - Sitting position -Tender point -Energy flow density (EFD) : 0.36mJ/mm² Materials and Methods

11. Ultrasound guided Needling 2% Lidocaine → US-guided multiple needling → Subacromial injection of Triamcinolone 40 mg Materials and Methods

12. Initial, 6 weeks, 12 weeks, 6 months 12 months after treatment and the last F/U period Functional outcomes : ASES score, simple shoulder test and visual analogue scale (VAS) for pain at each visit Radiologic outcomes : the size of calcium deposit with plane radiographs at each visit Materials and Methods

13. Statistical Analysis SPSS ver. 11.0 for windows (SPSS Inc., Chicago, IL) Wilcoxon signed rank test for comparison of initial & 1 year –Functional scores –Size of calcium deposit Mann-Whitney test for comparison of functional scores at each time point Spearman test for evaluation of correlation between calcium size & functional outcome

14. Results At baseline, no significant difference in age, sex, initial functional score and size of Ca. deposit before treatment between two groups (p>.05) The average follow-up period ESWT group : 25.2 months US needling group : 21.1months Avg. age 52.7 yrs (±13.6 yrs)

15. Results There were significant improvements in functional outcomes in both groups at the last F/U after treatment (p<0.05) ESWT group ASES score 49.9±2.6  78.3±7.2 Simple Shoulder Test 34.0±4.9  78.6±7.1 VAS for pain 6.3±0.3  2.4±0.8 US needling group ASES score 41.5±4.9  91.1±2.5 Simple Shoulder Test 38.2±5.6  91.7±3.5 VAS for pain 6.8±0.5  1.4±0.4 InitialLast F/U

16. Results * P <0.05 *

17. Results * * P <0.05

18. Results * * P <0.05

19. Results There were significant reduction in size of Ca. deposit in both groups after treatment at the last follow up. (p<.05) ESWT group Size of Ca. deposit(mm) 11.04±1.00  5.57±0.83 Complete elimination 42.6% Partial elimination 16.7 % No elimination 41.7% US needling group Size of Ca. deposit(mm) 14.76±1.65  0.45±0.31 Complete elimination 72.2% Partial elimination 11.1% No elimination 16.7%

20. Results Correlation between the initial size of Ca. deposit and functional outcomes in both groups ESWT group ASES : r = - 0.356, p > 0.05 Simple Shoulder Test : r = - 0.129, p > 0.05 VAS for pain : r = 0.340, p > 0.05 US Needling group ASES : r = 0.205, p > 0.05 Simple Shoulder Test : r = 0.141, p > 0.05 VAS for pain : r = - 0.150, p > 0.05

21. Limitations No control group No consideration of the stage of calcific tendinitis Small group with short FU Plain radiography only Discussion

22. Both US-guided needling and ESWT for calcific tendinitis were successful in improvement of functional outcomes and eradication of calcium deposit. US-guided needling treatment is more effective at function restoration, pain relief, and eradication Ca. deposit. There was low correlation between size of Ca. deposit and functional outcomes Conclusions

23. Thank you for your attention

26. Summary of Results Significant improvement after both treatments Better functional outcomes and pain relief with US-guided needling group (statistical significance at 1-yr time point) Better effect on elimination of calcium deposit with US-guided needling Low correlation between the size of Ca. deposit and clinical outcomes