High-energy shockwave therapy effective in treating shoulder calcific tendinitis

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1. In calcific tendinitis of the shoulder, high-energy extracorporeal shockwave therapy (ESWT) is associated with improvement shoulder function, pain and calcification. 

2. The effects of ESWT in noncalcific tendinitis and low energy ESWT in calcific tendinitis are inconclusive. 

Evidence Rating Level: 1 (Excellent)       

Study Rundown: Rotator cuff tendinitis is one of the most common causes of shoulder pain. Cases refractory to conservative therapies can be considered for surgical intervention. However, especially in cases of calcific tendinitis, there has been interest in ESWT (extra-corporal shockwave therapy) as a non-invasive alternative to surgery.  The efficacy of ESWT has been studied at various energy flux densities (EFD) to placebo in numerous clinical studies from Europe and Taiwan. This systematic review of 28 randomized control trials (RCTs) showed that high energy ESWT (EFD ≥0.28 mJ/mm2) was associated with improvements in shoulder function, pain and calcifications in calcific tendinitis when compared to placebo.  However, similar improvements were not associated with low energy ESWT (EFD <0.28 mJ/mm2).  Moreover, the effects of ESWT on noncalcific tendinitis were found to be inconclusive. Major limitation of this systematic review is the heterogeneity of the trials, including inconsistencies in the EFD categories and the variability in the patient populations used in each study.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Shock Wave Therapy for Calcific Tendinitis of the Shoulder A Prospective Clinical Study with Two-Year Follow-up

In-Depth [systematic review]: This systematic review included 28 RCTs comparing high (EFD ≥0.28 mJ/mm2) and low-energy (<0.28 mJ/mm2) ESWT to placebo for treatment of calcific and non-calcific shoulder tendinitis. The 28 trials included 1745 patients with a mean age of 51 years, 3-12 months minimum duration of symptoms and on average 58% were women. Most of the trials were conducted in Europe, except for the 2 from Taiwan. The trials included in the study were generally of low quality and were highly heterogeneous. Sample sizes varied from 20-144 patients.  Only 6 trials were double0blinded, 3 trials had dropout rates >20%, intention to treat was used in only 14 studies and 14 different devices were used across the cohort of 28 included trials.  In the studies on calcific tendinitis, high energy ESWT significantly improved shoulder pain and function, compared to placebo. High energy ESWT proved significantly better than low energy ESWT at improving shoulder function and reducing calcification, but not at reducing pain.  The evidence regarding low energy ESWT and use of ESWT in non-calcific tendinitis was inconclusive.

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