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By Sally Beattie, MS, RN, CS, GNP
Summary—Painful calcification in shoulder tendons has traditionally been managed by the administration of anti-inflammatory agents and rest, followed as needed by range-of-motion exercise to maintain joint function. Empirical observations suggest that ultrasound therapy may provide another option for this disorder. To confirm its efficacy, researchers in Vienna conducted a randomized, double-blind comparison of ultrasonography and sham sound-wave application in patients with symptomatic calcific tendinitis verified by radiography.1
At the end of six weeks of ultrasound treatment, calcifications in 47% of the treated shoulders were improved or resolved as compared with only 10% improvement and 0% resolution in shoulders given the sham treatment. The nine-month follow-up revealed 65% of the ultrasound-treated shoulders improved, while only 20% of the sham treated subjects reported improvement or resolution.
However, the increase in improvement between the six-week and nine-month follow-up was not statistically significant. The study suggests ultrasound therapy provides short-term clinical improvement, but further investigation is needed before it becomes widely used in this clinical setting.
Painful and debilitating, calcific tendinitis of the shoulder is a self-limiting reactive calcification of the rotator-cuff tendons. It commonly affects individuals between 30 and 60 years of age, women slightly more than men, and workers in sedentary jobs more often than those who perform manual work. Current treatments aimed at removal of these deposits such as surgery and percutaneous needle aspiration reduce pain and restore shoulder function in some, but not all, patients.2
Empirical observations following the use of shock-wave therapy for similar types of musculoskeletal disorders show promising results. However, the clinical efficacy of ultrasound therapy for treating calcific tendinitis of the shoulder has not been confirmed.
To address this issue, researchers in Vienna conducted a randomized double-blind comparison of ultrasound and indistinguishable sham insonation in patients who had symptomatic calcific tendinitis verified by radiography.1
Patients with a radiographically established diagnosis of calcific tendinitis were invited to participate in a randomized, double-blind comparison of ultrasound and sham insonation. Inclusion criteria included:
• idiopathic calcific tendinitis type 1 (appearing circumscribed and dense on radiography;
• or type 2 (dense or circumscribed appearance);
• diameter of calcification exceeding 5.0 mm;
• mild-to-moderate pain present for more than four weeks;
• or restricted range of motion of affected shoulder or shoulders.
Patients with type 3 calcific tendinitis (translucent or cloudy appearance without clear circumscription) were excluded because that type often resolves spontaneously.
Additional exclusion criteria were:
• a systemic disease such as gout, some rheumatic diseases, or hypercalcemia, which are associated with an increased risk of calcification;
• previous surgery, percutaneous needle aspiration, ultrasound, or shock-wave therapy;
• injection of glucocorticoids in the shoulder within three months preceding the study;
• or regularly used analgesic or anti-inflammatory drugs for the relief of pain.
Investigators recruited 63 patients with 70 involved shoulders; 54 subjects (61 involved shoulders) completed the study.
Randomization to ultrasound (n=32) or sham (n=29) treatment was conducted according to shoulders rather than patients. A therapist not involved in treatment handed out the assignments in sealed envelopes and also switched the ultrasonic generator to active or sham mode. Neither patient nor therapist actually applying the treatment was aware of the treatment assignment.
Subjects received 24 treatments administered for 15 minutes per session at a frequency of 0.89 MHz using an intensity of 2.5 W per square centimeter, to the area over the calcification. The first 15 treatments were given daily (five times per week) for three weeks, and the remaining nine were given three times a week for three weeks. Patients could take an analgesic drug for occasional pain relief, but nonsteroidal or steroidal anti-inflammatory preparations were not allowed.
The primary outcome measure was change from baseline in the calcium deposits shown on radiography. X-rays were assessed independently by two radiologists not involved in the study. Secondary outcomes included changes from baseline in subjective and objective measures of pain and function assessed using the 100-point Constant Score3 and the pain score developed by Binder.4 The Constant Score provides an overall assessment of the shoulder with respect to degree of pain, ability to perform normal tasks of daily living, and the active range of motion and power of the shoulder. The pain score developed by Binder focuses exclusively on subjective symptoms including pain, pain on resisted movement, and pain on active abduction. Radiography and clinical examinations were performed immediately before the first and after the last treatment session and nine months following baseline evaluation.
After six weeks of treatment, calcium deposits had resolved in 19% (six shoulders) of the ultrasound treatment group and had decreased by at least 50% in 28% (nine shoulders), compared with respective values of zero and 10% (three shoulders) in the sham treatment group (P=0.003). At nine months follow-up, deposits had resolved in 42% (13 shoulders) and improved in 23% (seven shoulders) of the ultrasound treatment group, compared with 8% (two shoulders) and 12% (three shoulders), respectively, in the sham group.
At the end of therapy, the ultrasound group had significantly greater decreases in pain and function. Although further improvements were noted in both groups, the differences were no longer significant at nine months. These results confirmed preliminary data5 supporting the association between ultrasound therapy for resolving calcifications and providing short-term clinical improvements for patients with symptomatic calcific tendinitis of the shoulder. There were no reported adverse effects associated with this study; however, a few patients with calcific tendinitis and minimal shoulder pain experienced a transient increase in shoulder pain shortly after the onset of ultrasound treatment.1
Implications for Practice
Calcification of the shoulder tendons initially may be asymptomatic or associated with varying degrees of pain at rest or with movement, especially abduction. A "catching" sensation with movement may be experienced, as well as nocturnal discomfort. As the condition progresses, patients may complain of constant severe pain and restriction of movement that typically lasts about two weeks and may be accompanied by fever and malaise. An elevated erythrocyte sedimentation rate and neutrophilia may be present. Differential diagnosis includes joint sepsis and gout. The pain and some restriction of movement may last several months.
The current standard treatment for calcific tendinitis is administration of nonsteroidal anti-inflammatory drugs.1 A single subacromial injection of a local anesthetic sometimes provides temporary relief. During the acute phase, patients may need to rest the affected arm in a sling.2 Once pain is controlled, function may be maintained through exercises to extend the range of motion and strengthen the rotator cuff.2 Extracorporeal shock-wave therapy may be effective in reducing calcification and stimulating healing of soft tissue.2 Clinicians need to be aware that a potential side effect of high-intensity ultrasound is local tissue damage if the heat is excessive.
This study did not compare these therapies with the use of ultrasound in clinical or economic terms. Nor did it establish characteristics of patients who are likely to have a positive response. Thus, its potential benefit remains unknown. Until these issues are clarified, routine use of ultrasound for calcific tendinitis of the shoulder is not recommended but should be reserved for patients with severe symptoms and used with other treatments.2 v
1. Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999;340:1533-1538.
2. Speed CA, Hazleman BL. Calcific tendinitis of the shoulder (editorial). N Engl J Med 1999;340:1582-1584.
3. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-164.
4. Binder A, Parr G, Hazleman B, et al. Pulsed electromagnetic field therapy of persistent rotator cuff tendinitis: a double-blind controlled assessment. Lancet 1984;1:695-698.
5. Ebenbichler GR, Resch KL, Graninger WB. Resolution of calcium deposits after therapeutic ultrasound of the shoulder. J Rheumatol 1997;24:235-236.