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Effect of extracorporeal shock wave therapy and ultrasound-guided percutaneous lavage in reducing the pain of rotator cuff calcific tendinopathy; an updated systematic review and meta-analysis
⁎Corresponding author: Amin Karami. aminkarami1370@gmail.com
⁎⁎Corresponding author: Bijan Forogh. forogh.b@iums.ac.ir
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous lavage (UGPL or barbotage) are among those used to treat the pain of rotator cuff calcific tendinopathy (RCCT). This meta-analysis was done to review the effect ESWT and UGPL in reducing the pain of RCCT.
A comprehensive search was done based on the PRISMA. PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar were reviewed for articles published by Feb 1, 2024, on ESWT vs. UGPL. The main keywords searched are as follows: “rotator cuff calcific tendinopathy”, “tendinitis”, " ESWT”, " ultrasound-guided percutaneous lavage”, " RCCT ″, " UGPL”, " extracorporeal shock wave therapy” and titles or abstracts may contain one or a mix of these elements. This study was registered at PROSPERO with code” CRD42022385068”. STATA version 13 was applied to analyze.
In general, 779 patients from 22 studies were analyzed. The mean age was 51.85 ± 3.41 years. The patients were referred after 18.69 months of suffering from tendinopathy symptoms. Right-sided and supraspinatus locations were affected more. ESWT has been effective in a decrease of calcium deposit (−1.70 SMD after 1 week for ESWT, −0.96 SMD after 12 weeks for ESWT and −1.20 SMD after 12 weeks UPGL). ESWT has been effective in decreasing VAS by −4.32 SMD after 1 week while UPGL showed −0.23 SMD reductions in VAS After 1 week but in time >1 week, UPGL showed better effect by more reduction in VAS. ESWT has been effective in an increase of CMS by 1.60 SMD after 4–6 weeks, by 1.79 SMD after 12 weeks, by 2.44 SMD after 24 weeks, and 2.53 SMD after 48 weeks.
Based on the results, ultrasound-guided lavage is more effective in reducing pain than ESWT, and this effect becomes more evident in the long term. In terms of CMS score, over time, the efficiency of ESWT becomes more visible. In long-term follow-up, UPGL had a better effect on the calcium deposit reduction.
Keywords
Pain
Rotator cuff calcific tendinopathy
Ultrasound-guided percutaneous lavage
Extracorporeal shock wave therapy
1 Introduction
Rotator cuff calcific tendinopathy (RCCT) is a common cause of shoulder pain. This condition is identified by the existence of calcium carbonate hydroxyapatite crystals in rotator cuff tendons. The prevalence of calcific tendonitis is higher in both the general population (2.7–7.8 %) and people with shoulder pain (8–40 %).1,2 In the RCCT, there is a greater involvement of the supraspinatus tendon. Individuals usually affected by calcific tendonitis are typically between the ages of 30 and 60, with women having a 1.5 times higher likelihood of being affected than males.1 Patients who have the RCCT often feel pain in the deltoid area related to their activities, leading to low range of motion and experiencing pain at night along with varying levels of functional impairment. Even though RCCT is typically viewed as a condition that improves on its own over time, the symptoms can still be intense and persist in the long term.2–4
The precise cause is not yet fully understood, but the leading explanation is linked to a dynamic and cell-mediated response process. This process is categorized into three specific phases: pre-calcific, calcific (including the formation, resting, and absorption phases), and post-calcification stage.5
During the absorption phase, the symptoms usually deteriorate. Those in this stage have the best chance of recovering without undergoing surgery.6 The main treatment choices include rest, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and sub-acromial corticosteroid injection (SAI).6–8
Invasive techniques are available when initial treatment fails. Ultrasound-guided percutaneous lavage (UGPL or barbotage) and Extracorporeal shockwave therapy (ESWT) are common approach used in the treatment of refractory cases that can be considered as an alternative to surgical treatment.7,9 These therapies are characterized by being minimally invasive, cost-effective, and relatively simple to carry out, with minimal side effects. Previous research has demonstrated promising outcomes.10–12
In the PubMed database, there are 9 systematic reviews so far on the treatment of rotator cuff calcific tendonitis, the most recent of which is from 2020, and the extracted articles are up to 2018. The research in this particular field is lacking in high quality. Without further research with high quality in this field, it is not possible to inform people about the best treatment option. Therefore, we decided to investigate non-surgical treatments including ESWT and UGPL to treat rotator cuff calcific tendonitis.
2 Methods and materials
2.1 Design and settings
A comprehensive search was conducted following the guidelines of PRISMA.13 PubMed, Web of Science, Scopus, Cochrane Library, Google Scholar and were all examined for articles released by Feb 1, 2024, regarding ESWT versus UGPL. The search primarily focused on keywords such as “rotator cuff calcific tendinopathy”, “tendinitis”, “ESWT”, “ultrasound-guided percutaneous lavage”, “RCCT”, “UGPL”, " extracorporeal shock wave therapy”, or a mix of them in the titles or abstracts. Two authors independently evaluated the papers' eligibility following the PRISMA guidelines. Additionally, the references of the articles are manually checked for any other relevant papers, and any duplicate studies are eliminated. This particular study has been registered on PROSPERO under the code “CRD42022385068".
2.2 Search strategy for PubMed
((rotator cuff calcific tendinopathy [Title/Abstract] OR rotator cuff calcific tendinopathy [MeSH Terms] OR shoulder [Title] OR rotator cuff [Title/Abstract] OR tendinitis [Title/Abstract]) AND ((extracorporeal shock wave therapy [MeSH Terms] OR extracorporeal shock wave therapy [Title/Abstract] OR ultrasound-guided percutaneous lavage [MeSH Terms] OR ultrasound-guided percutaneous lavage [Title/Abstract]))
2.3 Link
https://pubmed.ncbi.nlm.nih.gov/?term=+%28%28rotator+cuff+calcific+tendinopathy+%5BTitle%2FAbstract%5D+OR+rotator+cuff+calcific+tendinopathy+%5BMeSH+Terms%5D+OR+shoulder+%5BTitle%5D+OR+rotator+cuff+%5BTitle%2FAbstract%5D+OR+tendinitis+%5BTitle%2FAbstract%5D%29+AND+%28%28extracorporeal+shock+wave+therapy+%5BMeSH+Terms%5D+OR+extracorporeal+shock+wave+therapy+%5BTitle%2FAbstract%5D+OR+ultrasound-guided+percutaneous+lavage+%5BMeSH+Terms%5D+OR+ultrasound-guided+percutaneous+lavage+%5BTitle%2FAbstract%5D%29%29.
2.4 PICO structure
P = patients with rotator cuff calcific tendonitis, I = ultrasound-guided percutaneous lavage, C = shock wave therapy, O = pain (VAS score).
2.5 Eligibility criteria
The inclusion criteria encompassed studies involving patients with RCCT undergoing ESWT and UGPL, as well as those designed as prospective randomized controlled trials (RCTs). The exclusion criteria involved case reports, animal studies, and observational studies containing inaccurate pain assessments.
2.6 Quality assessment
The study assessed the quality of the trials by examining the risk of bias through the Cochrane Handbook. Each trial was classified into unclear, low, or high risk categories based on factors like random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and biases.14 Two authors independently assessed each article, with a third reviewer joining when needed.
2.7 Statistical issue
The impact of ESWT and UGPL was evaluated by determining the standardized mean difference (SMD), referred to Cohen's D, on postoperative pain. Calculation of SMD involved the mean difference and standard deviations (SD) before and after the procedure. I2 was applied to interpret the heterogeneity. The random‐effects model was employed for the continuous outcome being studied, along with a random or fixed-effects meta‐analysis to estimate the main index, the pooled SMD. A forest plot visually represented the pooled SMD. Examination for publication bias was conducted through Begg's tests, and Hozos' methods were utilized to determine the mean and standard deviation.15 The analysis was carried out using STATA version 13.
3 Results
In this review, 779 patients from 22 studies were analyzed (Fig. 1). The mean age was 51.85 ± 3.41 years. Approximately, patients were referred after 18.69 months of suffering from tendinopathy symptoms. Right-sided is affected more. As this review declared 85 % (N = 186) of affected tendon was related to supraspinatus following by infraspinatus location (13 %, n = 27) (Fig. 2). Characteristics of final studies are shown in Table 1.
| Author, year | N | Age, year | Affected side (right/left) | Intervention | Duration of symptoms, months |
| Gerdesmeyer et al., 200316 | 48 | 51.6 ± 8.5 | 28/20 | ESWT (High energy ESWT) | 42.6 |
| Gerdesmeyer et al., 200316 | 48 | 47.3 ± 8.5 | 28/20 | ESWT (Low energy ESWT) | 42.8 |
| Cosentino et al., 200317 | 35 | – | – | ESWT | – |
| Krasny et al., 200518 | 40 | 49.4 | 13/27 | ESWT | 30.5 |
| Cacchio et al., 200619 | 45 | 56.1 ± 21.98 | 27/18 | ESWT | 14 |
| Hsu et al., 200820 | 33 | 55.4 | 30/3 | ESWT | 2.3 |
| de Witte et al., 201321 | 23 | 53.7 ± 7.3 | 16/7 | UGPL | – |
| Kim et al., 201422 | 29 | 57.4 | – | ESWT | – |
| Kim et al., 201422 | 25 | 57.4 | – | UGPL | – |
| De Boer et al., 201723 | 14 | 53 | – | ESWT | – |
| De Boer et al., 201723 | 11 | 53 | – | UGPL | – |
| Castillo-Gonzalez et al., 201611 | 80 | 49 ± 7 | – | ESWT | – |
| Castillo-Gonzalez et al., 201611 | 121 | 49 ± 7 | – | UGPL | – |
| Zhu et al., 200824 | 41 | 52.3 | 29/12 | UGPL | 11 |
| Li et al., 202125 | 22 | 50.6 ± 5.2 | 18/4 | ESWT (FSWT) | 3.5 |
| Li et al., 202125 | 22 | 53.4 ± 6.7 | 20/2 | ESWT (RSWT) | 3.5 |
| Al-Khair et l., 202126 | 15 | 50.53 ± 6.78 | 10/15 | ESWT (FSWT) | 8.07 |
| Al-Khair et l., 202126 | 15 | 53.47 ± 10.04 | 9/6 | ESWT (RSWT) | 8.93 |
| Al-Khair et l., 202126 | 15 | 48.80 ± 11.02 | 8/7 | ESWT (CSWT) | 10.27 |
| Louwerens et al., 202027 | 41 | 51.6 ± 9.4 | – | ESWT | 41 |
| Louwerens et al., 202027 | 41 | 52.7 ± 8.7 | – | UGPL | 36 |
| Zamzam et al., 201928 | 15 | 43.26 ± 7.58 | 10/5 | ESWT | 7.26 |
3.1 Effect of ESWT/UGPL procedure on calcium deposit
According to Fig. 3, ESWT has been effective in decrease of calcium deposit by −1.70 SMD after 1 week. Also, ESWT decreased calcium deposit by −0.96 SMD after 12 weeks and UPGL decreased it by −1.53 SMD after 12 weeks. In long-term follow up, UPGL had better effect on the calcium deposit reduction (Fig. 4).
3.2 Effect of ESWT/UGPL procedure on VAS
According to Figs. 5–9, ESWT has been effective in decrease of VAS by −4.32 SMD after 1 week while UPGL showed up to −0.23 SMD reductions in VAS After 1 week (Fig. 5). This value was −1.05 and −1.11 SMD for ESWT and UPGL procedures 4–6 weeks after intervention (Fig. 6). The value was −1.61 and −2.16 SMD for ESWT and UPGL procedures 12 weeks after intervention (Fig. 7), and −3.14 and −3.98 SMD 6 months after ESWT and UPGL, respectively (Fig. 8). At 1 year follow up, VAS decreased by −4.91 SMD for UPGL and −3.05 SMD for ESWT groups (Fig. 9). UPGL had better effect on the VAS reduction especially in long-term evaluation.
3.3 Effect of ESWT procedure on CMS
According to Figs. 10–12, ESWT has been effective in increase of CMS by 1.60 SMD after 4–6 weeks (Fig. 10), by 1.79 SMD after 12 weeks (Fig. 11), by 2.44 SMD after 24 weeks (Fig. 12), and 2.53 SMD after 48 weeks (Fig. 13). ESWT works better over time in which the highest increase of CMS was observed at 48 weeks follow up.
3.3.1 Publication bias
The analysis results indicated that bias publication had no effect to make negative findings, as presented by the symmetry in funnel plot of Fig. 14 (Egger's test: t = −0.40, P = 0.700, 95 % CI: −22.769-16.043).
4 Discussion
Zhang et al. compared three treatments for rotator cuff calcific tendonitis, a shoulder pain condition. They analyzed data from eight clinical trials involving over 600 patients. The treatments were NSAIDs, ESWT and UGPL The study found that UGPL was more effective than ESWT at reducing pain and clearing calcium deposits after one year. Importantly, there weren't more complications with UGPL compared to ESWT. This suggests UGPL may be a better option for treating rotator cuff calcific tendonitis, particularly for pain relief and removing calcium deposits.12
Researchers (Wu et al., 2017) investigated treatments for RCCT, a shoulder pain condition, after less intensive treatments haven't worked. Their study showed that three therapies were effective in reducing pain and preventing calcium deposits from getting worse: ESWT, High-energy focused shockwave therapy (H-FSW), Ultrasound-guided needling (UGN). Out of these, H-FSW provided the best improvement in patients' ability to use their shoulders normally. This suggests that doctors should consider UGN, shockwave therapy, and especially H-FSW as an alternative treatments for chronic calcific tendinitis when initial conservative measures haven't been successful.29
A study by Simpson et al. investigated treatments for RCCT, a shoulder pain condition. They found moderate evidence that H-FSW is more effective than low-energy therapy in improving pain and function after 3–6 months. Additionally, they found moderate evidence that percutaneous ultrasound-guided intervention may be more beneficial than medium/high-energy shockwave treatment in reducing pain and improving calcium deposit appearance over a one-year period.30
A study by Lafrance et al. compared ultrasound-guided lavage to shockwave therapy for shoulder pain caused by calcium deposits. They found that ultrasound-guided lavage resulted in significantly more pain relief than shockwave therapy, with an average reduction of nearly 2 points on a 10-point scale in the short/long-term. The study also showed that adding UGPL to a corticosteroid injection further improved pain relief in the long term.31
Arirachakaran et al., in 2016 conducted as a network meta-analysis and showed that ESWT significantly improves VAS compared to placebo. UGPL plus ESWT significantly improved VAS and decreased calcium deposit size compared to ESWT alone. Combined ultrasound-guided needling and sub-acromial corticosteroid injection significantly reduces shoulder pain and VAS, and reduces the size of calcium deposits, while reducing the risks and side effects compared to UGPL. ESWT and sub-acromial corticosteroid injection also reduce the VAS. The evidence shows that UGPL is the choice for the non-surgical treatment in rotator cuff calcific tendonitis.10 Our study was in line with the dominant results of the studies, so that we only had access to the studies that had been done on ESWT patients in the CMS review, and these effects were better over time, so that the CMS scores increased with increasing follow-ups. In terms of the pain score, lavage under ultrasound guidance showed a better result, although the effects of ESWT are more visible for the first week after the intervention, but it is less lasting. Calcium deposits also decreased significantly after ESWT procedure. In the third month after the intervention, the reduction of calcium deposits was more in patients who underwent UPGL.
5 Conclusion
According to the results, ultrasound-guided lavage proves to be superior to ESWT in terms of effectiveness in reducing pain, and this effect becomes more evident in the long term. In terms of the CMS score, the efficiency of the ESWT becomes more and more visible over time. In the long-term follow-up, UPGL had a better effect on reducing calcium deposits.
Ethical approval
This study didn't involve individual participants. Only data from previously published, ethically conducted studies was used.
Human and animal rights
This is a systematic review, and thus, nohuman or animal was included in the study.
Funding
This research was done without any specific grant funding.
Informed consent
This is a systematic review, and thus, no individual participant was included in the study.
Guardian/patient's consent
This study is secondary study with primary data so the unit of this research is the number of studies and has no need to Guardian/Patient's consent that is why this is meta-analysis.
CRediT authorship contribution statement
Bijan Forogh: Conceptualization, Methodology, Software. Amin Karami: Data curation, Writing – original draft. Masoumeh Bagherzadeh Cham: Visualization, Investigation, Supervision, Writing – review & editing.
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