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Ultrasound therapy led to clinical improvement in calcific shoulder tendinitis

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Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med. 1999 May 20;340: 1533-8.

Question

In patients with calcific tendinitis of the shoulder, is pulsed ultrasound therapy clinically effective?

Design

Randomized (allocation concealed), double-blind, placebo-controlled trial with 9-month follow-up.

Setting

Outpatient clinic at a university hospital in Vienna, Austria.

Patients

63 patients (mean age 52 y) with unilateral or bilateral, radiographically dense (Gärtner and Heyer classification type 1 or 2) calcific tendinitis of the shoulder (70 shoulders were included). Exclusion criteria were radiographically nondense, ill-defined calcific tendinitis (type 3); systemic diseases associated with calcification; previous surgery, percutaneous needle aspiration, ultrasound, or shock-wave therapy for calcifications; injection of glucocorticoids in the shoulder in the previous 3 months; or regular use of analgesic or anti-inflammatory drugs. 61 shoulders (87%) at the end of therapy and 56 shoulders (80%) at 9 months were included in the analysis.

Intervention

Shoulders were allocated to ultrasound therapy (n = 32) or to sham therapy (n = 29). Ultrasound therapy consisted of 15-minute sessions given daily (5 times/wk) for the first 15 sessions and 3 times weekly for 3 weeks thereafter. Sham therapy was given in the same way but without turning on the ultrasonic generator.

Main outcome measures

Changes from baseline in shoulder calcium deposits on radiography. Pain, active range of motion and power of shoulder, and activities of daily living (ADLs) were assessed with the Constant scale (range 0 to 100 [optimal score] points). Quality of life was assessed with a visual analogue scale (range 0 [optimal score] to 10 cm).

Main results

More shoulders showed complete resolution of calcium deposits at the end of treatment (P = 0.003) and at 9 months (P = 0.002) in the ultrasound therapy group than in the sham therapy group (Table). Ultrasound therapy led to greater improvement in pain, joint function, and ADLs (mean change in score 17.8 vs 3.7, P = 0.002) (Table) and quality of life (mean change in score 2.6 vs 0.4, P = 0.002) than did sham therapy at the end of treatment but not at 9 months.

Conclusion

In patients with calcific tendinitis of the shoulder, pulsed ultrasound was clinically effective, but only in the short term.

Source of funding: Not stated.

For correspondence: Dr. G.R. Ebenbichler, Department of Physical Medicine and Rehabilitation, University Hospital of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria. FAX 43-1-40400-5280.

Abstract and Commentary also published in ACP Journal Club. 1999;131:73.

Ultrasound vs sham therapy for calcific tendinitis of the shoulder*

Outcomes Ultrasound Sham RBI (95% CI) NNT (CI)

Resolution after therapy 19% 0% Infinity 6 (4 to 20)

Resolution at 9 mo 42% 8% 424% (53 to 1880) 3 (2 to 9)

Normal constant score 75% 34% 118% (33 to 287) 3 (2 to 7)

after therapy

Normal constant score 61% 48% 28% (­21 to 117) Not significant

at 9 mo

*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.

Commentary

The results of this well-designed study by Ebenbichler and colleagues are similar to studies comparing therapeutic doses of extracorporeal shock-wave therapy (1).

The natural history of rotator-cuff calcification is not well understood. Calcifications are probably most symptomatic during resorption (2). One retrospective study showed that if acromioplasty is done without removing rotator-cuff calcifications, 82% of these calcifications will have disappeared radiographically within 1 year of surgery (3).

In my experience using dynamic high-resolution ultrasound, pain from supra-spinatus calcification usually coincides with impingement of the calcified area on the subacromial arch. In addition, hyperemia or inflammation exists in the bursae and tendons adjacent to symptomatic areas of supraspinatus calcification shown on color Doppler ultrasonography and contrast-enhanced, fat-suppressed magnetic resonance imaging. A possible explanation of the short-term benefit of ultrasound therapy in patients with symptomatic supraspinatus calcification is that it helps reduce the local soft-tissue inflammatory process, which subsequently reduces the mass effect of the calcification. If, however, the underlying cause of the local tendon injury is not removed, symptoms will return; this may explain the lack of difference between the 2 groups in pain and quality of life at 9 months.

In conclusion, ultrasound therapy is noninvasive and clinically effective for treating symptomatic calcific tendinitis.

Wayne W. Gibbon, FRCS

United Leeds Teaching Hospitals NHS Trust

Leeds, England, UK

References

1. Rompe JD, Burger R, Hopf C, Eysel P. J Shoulder Elbow Surg. 1998;7:505-9.

2. Re LP Jr, Karzel RP. Orthop Clin North Am. 1993;24:125-32.

3. Goutallier D, Duparc F, Postel JM, Bernageau J, Allain J. Rev Rhum Engl Ed. 1996;63:349-57.

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