All right. My name is Mary Grace Castro. I'm one of the sports medicine fellows at Northwell based at North Shore University Hospital. Today I'm going to be talking about calcific tendinopathy of the shoulder. This talk was inspired by one of patients that we had seen recently in clinic, a patient who presented acutely with calcific tendinopathy. We had initially offered to do a barbiturage, but ultimately the patient wasn't able to tolerate it. She ended up getting just a steroid injection. This brought me to one of these articles, which looked at is ultrasound-guided lavage an effective intervention for rotator cuff calcific tendinopathy, a systematic review with a meta-analysis of randomized control trials. This was published in 2019 in the BMJ Open Sport and Exercise Medicine Journal. Just for a little bit of background, I'm going to be referring to this process as calcific tendinopathy. But in the literature, there are several different terms that are used to describe this entity. Rotator cuff calcific tendinopathy, it's a common shoulder disorder which leads to pain and dysfunction. It's characterized by the formation of deposits of calcium crystals in one or more of the rotator cuff tendons. The etiology is actually unknown, and experts have shown that it's not due to trauma or overuse and it can rarely be part of a systemic disease. It can be associated with diabetes, thyroid disorder, kidney stones. There's also a question if there could be a genetic predisposition to this disease, especially because there's been reports of a lot of bilateral occurrences of the disorder. The pathophysiology is controversial. There used to be a thought that this was related to age-related tendon degeneration, but there's been several findings that don't support this, including it being found in a relatively young peak incidence, there being spontaneous healing, and it can occur in healthy untraumatized tissue. In 1997, Utoff and Lower, they described the disease as progressing through four distinct phases with correlating clinical and pathologic findings, and this is pretty widely accepted. In the first phase, which is the formative phase, you have fibrocartilaginous transformation of a tendon, and then you have calcification of that transformed tissue, and the calcification can increase in size during this phase. During the resting phase, the calcific deposit is going to be stable in size, and you can possibly have pain and mechanical symptoms during this phase. During the resorptive phase, this is the painful phase for most patients is when you have an inflammatory response. You'll have neovascularization around the calcific deposit, and macrophages and giant cells will absorb the calcification, and you can also have some extension into the subacromial verso, which can be very painful. In the post-calcific phase, you have the calcification is resorbed, and fibroblasts reconstitute the normal collagen structure of the tendon. This is present about 3-10 percent of the general population, and 7-17 percent of patients with shoulder pain will be found to have calcific tendinopathy. Half of them are going to be asymptomatic, and it can be seen in up to 40 percent bilaterally. It's most commonly seen in females in the fourth, sixth decades of life, and it can be associated with diabetes, thyroid disorders, estrogen metabolism, and nephrolithiasis. Although we often think that it's related to manual labor and athletic activities, it's actually been shown that they're not more commonly affected versus patients that are sedentary. It's typically going to affect the supraspinatus more than infraspinatus and less commonly the subscapularis and the teres minor. Patients are going to present with pain to the top and lateral parts of their shoulder. They'll have increased night pain. They will not rely on the affected shoulder. They might have pain with overhead movements, and this can present either acutely or chronically. On exam, the patient will have pain with active abduction and they could have decreased abduction, range of motion secondary to this pain, scapular dyskinesias, and if the patient's able to tolerate passive movement, it should be unaffected, and they'll have positive impingement test. For diagnostic imaging, you're typically going to need at least an x-ray plus or minus an ultrasound to really exclude other causes of subacromial pain. MRI or CT is definitely unnecessary, but if you happen to obtain those tests for other reasons, then these are just the various look of how you would see it. On x-ray, it's useful to actually characterize the stage of the calcification. In the resting phase, the calcification will look more homogeneous and have well-defined borders versus in the resorptive phase, it can look a little bit more cloud-like and have more ill-defined borders. In an insertional tendinopathy, you may see a fine line at the insertional point of the tendon usually proximal to the greater tubercle. It's useful to get an internal rotation and external rotation views because if the calcification is located in the infraspinatus or the subscapularis, it can actually be blocked by the positioning of the humeral head. On ultrasound, it's also useful to help characterize the staging. In the resting phase, you'll see a hyper-echoic lesion with an acoustic shadowing and it looks a bit arc-shaped versus in the resorptive phase, it's no longer arc-shaped and it can look fluffy, fragmented, or punctuated. If you use Doppler, you can see increased vascularity around the deposits. There's also a classification system that is based on the percentage of calcium that you can use with ultrasound. Type 1, again, it looks more well-defined with acoustic shadowing versus type 2, there's more of a mild acoustic shadowing. Type 3, the calcification is more iso-echoic where the tendon doesn't have acoustic shadowing versus in type 1 and type 2, it looks more hyper-echoic. For management, generally, most patients will have a benign course and will respond well to oral anti-inflammatories or analgesics. If they have very severe pain or if there's some evidence of inflammation on ultrasound, then you can consider giving a glucocorticoid injection. In terms of physical therapy, you'll focus on upper body posture and restoring scapulothoracic and glenohumeral strength and function. But there isn't a really widely accepted way to go about it. It's something that you can just try and see with each patient. For initial therapy, most patients will respond after three months of conservative treatment. Negative prognostic factors include if their deposits are bilateral, if it's a large deposit, which can be defined as something greater than 1,500 millimeters cubed, if it's located near the anterior portion of the acromion, or if there's subacromial extension of deposits. For therapies for refractory cases, you can consider extracorporeal shock wave therapy, ESWT, and ultrasound-guided lavage and needling or barbiturage. These are two of the most commonly used therapies and what's typically studied. The last resort would be surgery. ESWT, so this is basically using acoustic waves to fragment calcific deposits in the rotator cuff. This can be a bit of a painful procedure, so you can consider using local anesthesia or some oral anesthetics. There isn't a standardized protocol, so a lot of different protocols have been described in the literature using different doses, durations, and intervals, but they seem to have better effects when you're using a medium or a high dose. Ultrasound-guided lavage, so this has gained a lot of popularity the last two decades as second-line treatment and it involves breaking up and aspirating the calcific deposit. It's been shown that the actual amount of calcium removed doesn't really affect the outcome and there will be a decrease in the size regardless of how much you initially aspirate. This is typically done with a glucocorticoid injection. This brings us back to the article I selected for today. The authors at this point, they noticed that there was a lot of studies looking at ultrasound-guided lavage, but it was unclear whether this intervention was more beneficial versus what was the conventional interventions. Also, they had noticed that in a lot of the studies that the way that they define ultrasound-guided lavage wasn't well-defined in a lot of studies, so they would group if patients were treated with just fragmentation versus if there was an actual lavage procedure performed. The purpose of their study was to update the available evidence on the efficacy of ultrasound-guided lavage in adults with rotator cuff calcific tendinopathy. The authors, they did a literature search up to April 2018, and they used four bibliographic databases which are listed and they looked up terms that were related to the shoulder, rotator cuff, tendinopathy, calcified needling, and irrigation. Their inclusion criteria, they had six. They needed the calcific tendinopathy to be confirmed either by x-ray or ultrasound, and the intervention had to include ultrasound-guided lavage, so not just fragmentation. This has to be done either with a steroid or alone or with some other intervention. The intervention has to be compared either to placebo or another intervention. The study had to have at least one outcome measured related to pain function, health-related quality of life, return to work, satisfaction, global rating of change, or to calcification size. It had to be a randomized controlled trial that was published in either English or French. They excluded any studies if the patients had any full thickness rotator cuff tears, if there was any post-surgical condition, or if there were any other concomitant shoulder, upper limb, or neck disorder. They assessed the RCTs via the Cochrane Risk of Bias Tool, which we'll look up a little bit later. They perform either meta-analyses and or qualitative synthesis of the evidence. For the results, the three out of the nine randomized controlled trials met eligibility criteria, and figure 1, it just shows a schematic of how they did their literature search. If you look using the words that they were looking, they started off with almost 4,000 studies, and ultimately they had nine, but then only three met eligibility criteria. This table 1 is characteristics of looking at the three different studies that they used. It just described the participant, what intervention they did, how many patients they had, the outcome, the follow-up times, and what their results were. Basically, we're looking at adults with chronic rotator cuff calcific tendinopathy, which they define as at least three to six-month duration. It was either confirmed by x-ray or ultrasound, and the average age was around 49-53 years old. In two of the trials, the participants had already failed a conservative treatment, which they didn't really define whether it was just physical therapy versus NSAIDs, or if there was glucocorticoid use as well. For the intervention, one of the RCTs, they used ultrasound-guided LAVAGE with steroid injection versus just a steroid injection alone. Two of the other RCTs, they use ultrasound-guided LAVAGE with a steroid versus shockwave therapy. The two RCTs used different types of shockwave therapy. The first one used radial shockwave therapy for four sessions and the second one used ESWT times eight sessions. Radial shockwave therapy is actually a little bit different from ESWT. It's generally going to be lower amplitude, it's supposed to be less painful, but also has less penetration versus ESWT. It's used for more superficial structures versus ESWT would target more deeper structures. The outcome measures they looked at were pain assessment using a visual analog scale or numerical rating scale, a self-reported function, so they used a few different questionnaires including the Oxford Children's Score, the Western Ontario Rotator Cuff Questionnaire, and the Disability of the Shoulder, Arm, and Hand Questionnaire, and it was a DASH. They also looked at the Constant Murley Score, which is a composite functional measure looking at pain function, strength, and range of motion. One of the studies also looked at reduction in calcification size. This next slide just shows an example of what the Oxford Children's Score, like the kind of questions that they used, and the CMS is on the right, so it has two subjective measures of pain and ADLs versus the range of motion and strength were acquired by the provider, and this is square of 100. The risk of bias appraisal was done using the Cochrane Risk of Bias tool, which you can see it. Looking at the three different studies on the left, the authors, two of the authors would give a rating of either a low risk of bias, which is seen in green, an unclear risk of bias in yellow, and a high risk of bias in red, and it looks at different biases. If you look on the right, it's the collective risk of bias as a percentage. The selection bias of selecting the participants had a low risk of bias, but in general, the performance detection and attrition bias had a high risk of bias for most of these studies and selective reporting. The reporting bias was mostly low risk. So the first result, so they looked at the efficacy of ultrasound guided lavage with the steroid versus the shockwave therapy. So in terms of pain, they found that lavage significantly decreased pain versus shockwave therapy in both the short-term and the long-term. The mean difference, so out of 10 points, decreased about negative 1.84, negative 1.96, which for the mean, this was above the mean difference, above the minimally clinically important difference, MCID, of 1.4 for shoulder pain. And the MCID is just a patient-derived score, which is basically the lowest score for which the patient perceives as some sort of benefit or some sort of improvement. And for the same thing for versus shockwave therapy in terms of, and this is just, oh, sorry. This is a graphical representation of what we just discussed. Looking at force plots, if you look, so the top plot is looking at the short-term, the bottom is looking at the long-term, and both of the measures are showing in favor of the ultrasound guided lavage, which was approximately like a difference of negative two in terms of the pain. And then they looked at function, and they also found that the ultrasound guided lavage significantly improved function versus shockwave therapy. And this, they judged based on the CMS score, which was improved at six weeks, and the magnitude of difference was within the MCID for CMS. And the last thing was for calcification size versus shockwave therapy. So both actually showed significant reductions in size over time, but the ultrasound guided lavage had more significant decrease at three and six and 12 months. All right, and then looking now at ultrasound guided lavage with a steroid versus just the steroid alone, both groups did improve in function, and, but the lavage improved CMS and the work score more at 12 months. There was no difference in the dashboard. And calcification size was significantly decreased in the lavage group at 12 months, but at 60 months, there wasn't a significant difference. So some adverse effects in treatment crossover and loss to follow-up. So for the first, so there were no serious adverse effects in any of the trials. In the BORADL trial, so there was actually some patients that changed their treatment plans during to consistent pain. Some of the patients from the shockwave group changed their treatment plan due to pain. And the Data Safety Monitoring Board actually stopped enrollment after six weeks because there was just a higher pain in the shockwave group, which is kind of interesting because in this study, they use the radio shockwave therapy, which is supposed to be less painful versus ESWT. In the Del Custio-Gonzalez et al study, about 31% of the patients from the shockwave group didn't actually complete the study. And in that study, they didn't really describe why this happened. So that one, they actually had to complete eight sessions. So whether it was just due to patient compliance or if the patients were actually just feeling better or if they just couldn't tolerate the procedure, it's just not described in the study at all. And in the last trial, the Witten et al, some of the patients in the lavage group actually underwent a second lavage or surgery. And some of the patients in the steroid group also ended up getting lavage or surgery. So there were several limitations obviously in this study. So it was very small sample size and there was a high risk of bias in two of the three articles. And there was an absence of comparison with a conservative treatment involving physical therapy. And as we kind of just discussed in the last slide, there were a lot of patients that ended up being lost to follow up, especially in the shockwave therapy group. So what conclusions they made were low quality evidence that ultrasound guided lavage with a steroid might be more effective than shockwave therapy, improving pain and function in rotator cuff calcific tendinopathy. And adding an ultrasound guided lavage to a steroid may improve function at 12 months. So in terms of like how this would change our management, I think all of the trials they show that actually both therapies are effective. It doesn't really discuss as much, but in shockwave therapy versus placebo, both studies have shown that there is an improvement. So I think it's really ultimately gonna be up to what the provider has available to them, what they're comfortable with, what the patient preferences. You could talk to them about having a lavage because it may have a better outcome if it's minimally invasive, but versus the shockwave therapy, if that's also a good option, but it seems to be a bit more painful actually for the ESWT. And just to go a little bit into the technique for ultrasound guided lavage. So there's, again, not an established protocol for this, and there's different techniques that people use. The schematic on the left is just showing you can actually use two different syringes, one to puncture the calcification and lavage, and the other one is to aspirate the calcification. I think a lot of people are comfortable just using one needle, and you can have the patient lying in supine and have their hand palm up under the opposite buttocks to kind of open up the space and numb up the area with a local anesthetic with a small gauge needle up to and around the calcification, and then taking a larger needle, such as the 18 gauge, directly puncturing the calcification and aspirating a few times. People use different techniques, whether you do a single puncture versus if you redirect is going to be provider dependent. There's different anecdotal evidence, but afterwards you can follow this up with a corticosteroid injection into the subacromial bursa or with Swerdoll. And for patients that don't respond to conservative treatment or shockwave therapy or Barbitage, there are surgical options such as calcification removal, acromioplasty, or a combination of both of these techniques. There are other different techniques that are also being studied, such as just dry needling and PRP, which still need more studies to support those. And these are my references. Thank you. Do you guys have any questions? Yeah, great job. No, I thought it was really good. Really good. Amazing review. Yeah, yeah, yeah. No ahs, no ums. No, it was very, very good. It flowed very nicely. Did have a couple of questions and kind of just remarks. Sure. So I think it's great how you commented about the importance of adding the corticosteroid injection afterwards with this and sometimes even spontaneously that the crystals can go into the SCSD bursa and cause an acute inflammation of pain. So especially after the procedure in order to decrease the risk of this, it's always great to add that corticosteroid. And it seems like they just looked at lavage and corticosteroid versus corticosteroid alone. But also I think it would be interesting to see a direct comparison between the lavage and the needle, or that lavage. Right. But just based on the actual pathophys, I think it'd probably be much better just to get the crystal out of there. Right. I think from some of my readings, some people just recommend it. And if you're visualizing the calcification and barbiturates has good results that you might as well try to aspirate it if it's possible, but there are times when if the calcification is really hard, that it's just not possible. And some people just describe just fragmenting it because you're unable to get anything back and it can take a little bit of patience as well. Yeah, that's great. I think just one thing that occurs to me is like, how consistent were they with anesthetic use with the shockwave therapy? Right. And follow up with that, like they don't really mention too much. Right. People had a lot more pain afterwards. Plus it was a different technique, like you said. Yeah. What would the comparison be like if you did steroids with the shockwave therapy? Because you are breaking it up. Maybe you can cause an inflammatory cascade as well. Right. But, you know, can they have higher functional scores or do they just tolerate it better at the very least if they introduce steroids and anesthetic? So I know for a fact that some offices, they just, they don't necessarily use anesthetic when they're doing shockwave therapy. Oh, right. It'd be interesting if that was like mentioned in the comparison, you know, and would it affect the results? Right. Yeah. The studies were not very clear about that. And the reasons why those patients dropped out or just never followed was unclear as well. I mean, it could have been for that reason versus, or maybe they just had improvement and just there's no way of knowing. It's good that they mentioned the long-term functionality scores. There's like some variability of like the results of each modality because of that. So around 16 months? Yeah. That's a long period of time. Yeah. So is there a standard number of treatments for shockwave? No. So even- Is that like all over the place? Just like sort of like PRP and Prolo? Exactly. Yeah. The best advice I've seen on the listserv is like there is some Korean, I think, society, some of the music in English, they print out a booklet about all the, it's utility and then indications for different things. And like try to, they try to follow those guidelines. It's some society that's focused on using shockwave therapy for multiple things. And I think just kind of my general approach for the acute and sub-acute phase, trialing that conservative therapy, plus or minus the steroid injection, plus or minus referral for shockwave therapy. But for those chronic cases, I think I really would kind of have that discussion regarding lavage, the benefits and risks with the patient, just to prevent them from having the residual pain and hopefully decrease their percentage of patients going on to require arthroscopic procedures as well. Anecdotally, the patients that we've done barbatage or lavage on, they haven't come back. Yeah. And were they always presenting acutely or are those for like chronic cases as well? Sort of like half and half for acute. If someone's initially tried, you know, initial, it's like, I say, S-E-V-E-R-S-A injection and then, okay, come back in a second. It's not helping. And then they'd be back at, you know, two or three weeks a month and then you can do it. It's interesting what happened with that WIT study. So many, some people went on to have rows and shoulders. Some people had to escalate their treatment and then someone had to do a second lavage. Yeah. I wonder like how frequently across the board that happens that people have to go in again to do it or that, you know, I understand the steroid itself not working enough and graduating into more modalities, but the complication rate for that small pool, I'm like, oh, that's interesting. Yeah. I mean, it's unclear. I think if there's, depending on the calcification size, it's like reasonable to do a second lavage depending on the size, or I don't know if it based on those patients were just had a more extensive disease versus, I don't know, it's normal. Yeah. I think kind of how you mentioned with like the calcification size, something that they didn't mention in the three RCTs is that they have the different locations of where some locations are more symptomatic, like the bursal-sided calcifications versus if it's intertendedness or articular-sided, then you're going to usually be less symptomatic and of course smaller. Right. So that could have definitely been, you know, the refractory issues and maybe those need the second lavage. I know it's like, okay, there is technically a void. Yeah. Does this stuff need to be followed up with PRP or something like that? Yeah. Right? PRP a little bit, I think. Not in this article. Not in this article, but it didn't seem to have significant advantage over a corticosteroid injection. So with like the cost of it, it just didn't make sense to recommend it. Yeah. I don't see, you know, face value. I don't see how PRP would help, you know, a calcified bursitis or tendonopathy. I'm just wondering if there's the void matter, if their functionality is preserved and they don't have complications later on that they're completely tearing off as if it's a native society. And where's the function? And where's the activity of the patient, you know? That makes me curious. You know, it's not really the athletic that come with it. It's sort of like, just like you say, these sedentary 40, 50 year old, you know, patients that are coming in. Yeah. It's actually like a point of contention with surgeons too about the indication if they go in surgically, whether they need to repair what they left over. And it seems like maybe if it's about a centimeter, they recommend it, but it's not. Okay. But that's still something that they- So like 10 X, you would just go in there and just, you know, just suck the thing out and you'd be done. Great, awesome. All right, thanks everyone.

3rd Edition, CASE 51

3rd Edition

Shoulder

calcific tendinopathy

rotator cuff

ultrasound-guided lavage

shoulder pain

treatment methods

systemic diseases