Calcific Tendinopathy of the Shoulder: Difference between revisions

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== Search Strategy  ==
&nbsp;


<u>Pubmed</u>,&nbsp;<u>Science Direct</u>, <u>Cochrane Library</u>, <u>Medline</u>
== Introduction ==
[[File:Dense calcification of the supraspinatus.jpeg|thumb|Calcification of the supraspinatus]]
Calcific tendinopathy (CT) of the shoulder is a common, painful condition identified by the existence of calcium deposits in the rotator cuff tendons.<ref name=":2">Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthopedic research and reviews. 2018;10:63.Available:https://www.dovepress.com/calcific-tendinopathy-of-the-shoulder-clinical-perspectives-into-the-m-peer-reviewed-fulltext-article-ORR (accessed 12.1.2023)</ref> It usually results in shoulder pain with decreased range of motion. Diagnosis is made by shoulder x-rays, with visible signs of calcium deposits overlying the rotator cuff insertion.Treatment consists of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Those who fail conservative treatment may choose to have arthroscopic decompression of the calcium deposits.<ref name=":1">Orthobullets [https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis Calcific Tendonitis]Available:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)</ref>


"calcific tendonitis” “diagnosis” “treatment” “evaluation”<br>  
== Epidemiology ==
Usually occurs in middle-aged patients between the ages of 30 and 60, with a slight preference for females.<ref name=":0">Radiopedia [https://radiopaedia.org/articles/calcific-tendinitis?lang=gb Calcific Tendinitis] Available: https://radiopaedia.org/articles/calcific-tendinitis?lang=gb<nowiki/>(accessed 12.1.2023)</ref>


"calcific tendonitis of the shoulder" "calcific tendinitis examination"
== Pathogenesis ==
 
Current theories indicate that CT may be the result of a cell-mediated process in which calcium deposition occur followed by their spontaneous resorption. However, in a few cases, this self-healing process is disrupted, causing symptoms. Literature now is showing that biological and genetic factors may underlie CTs genesis.. These new finding may explain why most of the therapies currently in use provide partially satisfactory outcomes.<ref name=":2" />
== Definition/Description  ==
 
Calcific tendonitis, or "calcium hydroxyapatite crystal deposition disease”<ref name="Wainner" />, refers to the deposition of calcium—predominantly hydroxyapatite—in a tendon, most often in those of the rotator cuff. May be secondary to a local decrease in oxygen tension resulting in fibrocartilaginous metaplasia and resulting calcification.<ref name="Serafini">Serafini G, Sconfienza L, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial. Radiology [serial online]. July 2009;252(1):157-164. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 20, 2011.</ref><br>
 
== Epidemiology/Etiology  ==
 
'''Etiology is still unclear.'''
 
<u>Possible Causes<ref name="Wainner" /><ref name="Cacchio">Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.</ref></u>:
 
*Hypovasculariation, but has been removed from both poorly and well-vascularized tissues.
*Compression&nbsp;
*Metabolic factors  
*Mesodermal defects&nbsp; &nbsp;
*Local degenerative and proliferative changes
 
<u>Unlikely Causes<ref name="Wainner" /></u>:
 
*Infection and Trauma
*No abnormalities found in blood or urine analyses.
 
<br>Calcific tendonitis occurs in 2.5%–7.5% of healthy shoulders in adults<ref name="Serafini" />, and 39-62% of those being seen in medical centers for shoulder pain<ref name="Wainner" />. It's more commonly seen in women (70% of cases) and most frequently during the 5th decade of life, but has been seen in a 3 year-old and a 72 year-old.<ref name="Serafini" /><ref name="Wainner" />. Right shoulder is more frequently affected but no evidence to support prediscposing factors.<ref name="Wainner" /><sup></sup>
 
<u>Common locations</u>:&nbsp;<ref name="Serafini" />
 
*The supraspinatus tendon (80% of cases): critical zone -&nbsp;''Most Common''
*Infraspinatus tendon (15% of cases): lower 1/3
*subscapularis tendon (5%of cases): pre-insertional fibers
 
The consistency of the &nbsp;calcium deposit seems to be correlated with pain severity, not the size.&nbsp;<ref name="Wainner" />&nbsp;
 
*Asymptomatic:&nbsp;appear granular or cheesy,&nbsp;and have sharply defined, circumscribed borders.
*Symptomatic:&nbsp;enlarge, liquify, and have less well-defined borders.<br>&nbsp; &nbsp; &nbsp; &nbsp; "dry powder", "chalk-like", "semi-liquid toothpaste", "milky" and "creamy"<br>


== Localisation ==
<sup></sup>
*Supraspinatus tendon (80% of cases): critical zone -&nbsp;''Most Common''
*Infraspinatus tendon (15% of cases): lower 1/3
*Subscapularis tendon (5%of cases): pre-insertional fibers<ref name="Serafini">Serafini G, Sconfienza L, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial. Radiology [serial online]. July 2009;252(1):157-164. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 20, 2011.</ref>
{{#ev:youtube|ycphj08OJt0}}
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


<u>Clinical presentation varies.<ref name="Cacchio" /></u><br>
The chief patient complaints to expect in calcific tendinopathy are:


Calcific tendonitis is a self-limiting condition.<ref name="Serafini" />&nbsp;Symptoms may last several days or become chronic; there is no clear prediction of disease course.&nbsp;Time required for symptoms to disappear is typically too long for patient’s QoL.<ref name="Cacchio" />  
* Night pain, causing loss of sleep.<sup><ref name="Ebenbichler">Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.</ref>,&nbsp;<ref name="Gimblett">Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.</ref>,&nbsp;<ref name="Alexander">Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy.  2010; vol 90 (1): 14-25.</ref>,&nbsp;<ref name="Wainner" />.</sup>
* Constant dull ache<sup><ref name="Wainner" /></sup>.
* Pain increases considerably with AROM<sup><ref name="Wainner" /></sup>.
* Decrease in ROM, or complaint of stiffness&nbsp;<sup><ref name="Fusaro">Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.</ref>,&nbsp;<ref name="Alexander" />,&nbsp;<ref name="Wainner" /></sup>.  
* Radiating pain up into the suboccipital region, or down into the fingers<ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Wainner" />.<br>The condition goes through 4 stage, see table below.


The typical clinical manifestation is a sub-acute, low-grade shoulder pain that increases at night (50% of patients), with restricted range-of-motion.<ref name="Serafini" /><br>
{| width="400" cellspacing="1" cellpadding="1" border="1"
 
<br>
 
{| width="400" border="1" cellpadding="1" cellspacing="1"
|-
|-
! scope="col" colspan="2" bgcolor="#33cc00" | Stages<ref name="Wainner" />
! colspan="2" scope="col" bgcolor="#33cc00" | Stages<ref name="Wainner">Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic &amp; Sports Physical Therapy [serial online]. March 1998;27(3):231-237. ( LOE 4 )</ref>
|-
|-
| align="center" bgcolor="#66ff66" | Stage Name  
| bgcolor="#66ff66" align="center" | Stage Name
| align="center" bgcolor="#66ff66" | Presentation
| bgcolor="#66ff66" align="center" | Presentation
|-
|-
| &nbsp;Chronic (Silent)<br>&nbsp;Phase  
|&nbsp;Chronic (Silent)<br>&nbsp;Phase
|  
|  
*Presence of the calcific deposit&nbsp;<br>is asymptomatic and may be so for years.
*Presence of the calcific deposit&nbsp;<br>is asymptomatic and may be so for years.
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|-
|-
|  
|  
Mechanical Phase&nbsp;  
Mechanical Phase&nbsp;


|  
|  
*Tendon impingement being a prominent finding  
*Tendon impingement being a prominent finding
*Pain of less severe nature than the acute phase
*Pain of less severe nature than the acute phase


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== Differential Diagnosis  ==
== Differential Diagnosis  ==


&nbsp;<u>Pathologies which present similiar to Calcific Tendonitis of the Shoulder:</u><br>
* Incidental calcification: found in 2.5-20% of 'normal' healthy shoulders.
 
* Degenerative calcification: found tendons with tear history; generally smaller; slightly older individuals
*[[Rotator Cuff Tears]]
* Loose bodies: associated chondral defect; associated secondary osteoarthritis<ref name=":0" />
*[[Gout|Gout<ref name="Gimblett">Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.</ref>]]<br>


== Outcome Measures  ==
== Outcome Measures  ==
*[https://www.physio-pedia.com/Visual_Analogue_Scale VAS Pain scale]<ref name="Cacchio">Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.( LOE 1b )</ref><br>
*[[DASH Outcome Measure]]


<u>Outcome measures to track treatment efficacy:</u>
== Medical Management    ==
Nonoperative


*VAS Pain scale<ref name="Cacchio" />
# NSAIDs, physical therapy, stretching & strengthening, steroid injections
*UCLA Shoulder Rating Scale<ref name="Cacchio" /><br>
# [[Tendinopathy Treatment Adjuncts|Extracorporeal shock-wave therapy as an adjunct treatment]]. Most useful in refractory calcific tendonitis in the formative and resting phases
*[[DASH Outcome Measure]]<br>
# Ultrasound-guided needle lavage vs. needle barbotage (needle to break up calcium deposit)
*Radiology/MRI changes<ref name="Case Studies">Takahashi M, Ogawa K. Calcific tendinitis of the rotator cuff showing a contracted state of abduction: a report of four cases. Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons. January 1997;6(1):72-76.</ref>


<br>
Operative: surgical decompression of calcium deposit.<ref name=":1" />


== Examination  ==
== Physiotherapy ==
Physiotherapy techniques include


As Calcific tendinitis is a soft tissue injury that can only be conclusively diagnosed via imaging, it is important to rule out other shoulder pathologies. In regards to imaging, a minimum of 2 views of the suspected tendon area to rule out avulsion fractures and rule in calcific tendinitis are required. It is recommend that the initial images include the anteroposterior view in neutral, internal, and external rotation<sup><ref name="Gimblett">Gimblett PA , Saville J , Ebrall P.  A conservative management protocol for calcific tendinitis of the shoulder. Journal of Manipulative &amp; Physiological Therapeutics 1999; vol 22(9): 622-627</ref></sup>. Imaging will provide definitive proof of calcific buildup thru what appear to be “bone spurs”.&nbsp; An ultrasound image of the area is also advised, as this will rule out or rule in any differential diagnoses of soft tissue injuries such as a rotator cuff tear&nbsp;<sup><ref name="Rapp">Rapp S M. With few advances in calcific tendinitis treatment, diagnosing it becomes critical.  Orthopedics Today. 2008; 70.</ref></sup>.&nbsp; 20-46.4&nbsp;% of all cases are bilateral in nature, so all images and examinations should be conducted in a bilateral fashion <sup><ref name="Fusaro">Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.</ref>,&nbsp;<ref name="Gimblett" /></sup>. Only 35% of cases are symptomatic, so bilateral imaging and examination can detect calcified deposits in an asymptomatic shoulder, if one side is already experiencing calcific tendinitis. This can help to guide treatment and decrease possible patient expenses and future visits.<br>
* Range of motion exercises to avoid articular stiffness
* Strength exercises to restore normal shoulder/scapular mechanics.  
* [[Scapular Dyskinesia|Scapular dyskinesia]] can cause subacromial impingement and a rehabilitation program that addresses this issue has been shown to reduce shoulder pain<ref name=":2" />. See link for detail.


Since imaging is the only way to diagnose calcific tendinitis, physical examinations will be seek to more-so rule out a condition than to rule in a condition. The examination findings are based on patient history and clinical findings. In regards to history, calcific tendinitis occurs most frequently in the fourth and fifth decades but has been reported in a 3 year old and as late as 72 year old <sup><ref name="Fusaro" />,&nbsp;<ref name="Wainner">Wainner R S, Hasz M. Management of Acute Calcific Tendinitis of the Shoulder. JOSPT 1998; vol 27 (3): 231-237.</ref></sup>. In most reports, females are more commonly affected than males. And regardless of handedness, the right side has a higher incidence of occurrence<sup><ref name="Wainner" /></sup>. Several systemic diseases are associated with an increased risk of calcification, such as gout, hypercalcemia of any cause, and various rheumatic diseases<ref name="Ebenbichler">Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.</ref>,&nbsp;<ref name="Gimblett" />.
See [[Therapeutic Exercise for the Shoulder]]


The chief patient complaints to expect in calcific tendinitis are:<br>1.) Night pain, causing loss of sleep (rule out cancer!)<sup><ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Alexander">Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.</ref>,&nbsp;<ref name="Wainner" /></sup><br>2.) Constant dull ache<sup><ref name="Wainner" /></sup>.<br>3.) Pain increases considerably with AROM<sup><ref name="Wainner" /></sup> (rule out fracture!).<br>4.) Decrease in ROM, or complaint of stiffness&nbsp;<sup><ref name="Fusaro" />,&nbsp;<ref name="Alexander" />,&nbsp;<ref name="Wainner" /></sup>.<br>5.) Radiating pain up into the suboccipital region, or down into the fingers<ref name="Ebenbichler" />,&nbsp;<ref name="Gimblett" />,&nbsp;<ref name="Wainner" />.
There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendinopathy.  See above link.<ref>Lee SY<sup>1</sup>, Cheng B, Grimmer-Somers K.  
The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. ( LOE 2a )
</ref> But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.<ref>Humeral head osteonecrosis after extracorporeal shock-wave treatment for rotator cuff tendinopathy. A case report.
Liu HM, Chao CM, Hsieh JY, Jiang CC
J Bone Joint Surg Am. 2006 Jun; 88(6):1353-6. ( LOE 4 )
</ref><ref>Osteonecrosis of the humeral head after extracorporeal shock-wave lithotripsy.
Durst HB, Blatter G, Kuster MS
J Bone Joint Surg Br. 2002 Jul; 84(5):744-6. ( LOE 4 )
</ref>See [[Tendinopathy Treatment Adjuncts]]


• Observation-check bilaterally for swelling, atrophy or scapular movement that will indicate compensation for decreased humeral movement.
== References  ==


• Palpation-attention to any swelling, temperature difference, point tenderness. Most specifically, the supraspinatus tendon, as it is the most commonly affected<sup><ref name="Gimblett" /></sup>. The infraspinatus, teres minor, subscapularis, and biceps tendons are also involved and follow in incidence in the aforementioned order<sup><ref name="Wainner" /></sup>.
<references />  
 
• Neuro and cervical screen may indicated as N&amp;T, or radiating pn may be present.
 
• AROM and PROM-pain and decreased ranges may be present in any, or all planes (depending on tendon(s) involved).&nbsp; Observe end feel, may be empty 2˚ to pain.
 
• MMT’s-may demonstrate decrease from contralateral side or be limited by pn.
 
== Medical Management <br>  ==
 
add text here <br>
 
== Physical Therapy Management <br>  ==
 
add text here <br>
 
== Key Research  ==
 
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
== Resources <br>  ==


add appropriate resources here <br>
&nbsp;


== Clinical Bottom Line  ==
[[Category:Texas_State_University_EBP_Project]]
 
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
Calcific tendinitis is a comparatively common disease with an incidence between 2.7 and 7.5% and minority of cases are symptomatic<sup>3</sup>. Its unknown etiology and impact on quality of life and function are just two reasons it requires further research. A thorough physical examination and patient history review can help to distinguish it from other pathologies of&nbsp; with a similar presentation. Current best evidence suggests that ……….
[[Category:Shoulder]]  
 
[[Category:Conditions]]  
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
[[Category:Conditions]]
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]  
<div class="researchbox">
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
 
see [[Adding References|adding references tutorial]].
 
<references />


[[Category:Texas_State_University_EBP_Project]]
[[Category:Shoulder - Conditions]]
[[Category:Sports Medicine]]
[[Category:Tendinopathy]]

Latest revision as of 09:53, 12 January 2023

Original Editors Mary Harris, Tom Lawlor, Patrick Bales, Misty Hillin, Rick Wetherald as part of the Texas Evidence Based Practice Project.

Top Contributors - Mary Harris, Thomas Lawlor, Karina Leahy, Rick Wetherald, Patrick Bales, Admin, Lucinda hampton, Fasuba Ayobami, Kim Jackson, Tony Lowe, Wanda van Niekerk, 127.0.0.1, Anthony Mertens, Naomi O'Reilly and WikiSysop

 

Introduction[edit | edit source]

Calcification of the supraspinatus

Calcific tendinopathy (CT) of the shoulder is a common, painful condition identified by the existence of calcium deposits in the rotator cuff tendons.[1] It usually results in shoulder pain with decreased range of motion. Diagnosis is made by shoulder x-rays, with visible signs of calcium deposits overlying the rotator cuff insertion.Treatment consists of NSAIDs, physical therapy, corticosteroid injections and ultrasound-guided needle lavage. Those who fail conservative treatment may choose to have arthroscopic decompression of the calcium deposits.[2]

Epidemiology[edit | edit source]

Usually occurs in middle-aged patients between the ages of 30 and 60, with a slight preference for females.[3]

Pathogenesis[edit | edit source]

Current theories indicate that CT may be the result of a cell-mediated process in which calcium deposition occur followed by their spontaneous resorption. However, in a few cases, this self-healing process is disrupted, causing symptoms. Literature now is showing that biological and genetic factors may underlie CTs genesis.. These new finding may explain why most of the therapies currently in use provide partially satisfactory outcomes.[1]

Localisation[edit | edit source]

  • Supraspinatus tendon (80% of cases): critical zone - Most Common
  • Infraspinatus tendon (15% of cases): lower 1/3
  • Subscapularis tendon (5%of cases): pre-insertional fibers[4]

Characteristics/Clinical Presentation[edit | edit source]

The chief patient complaints to expect in calcific tendinopathy are:

  • Night pain, causing loss of sleep.[5], [6], [7], [8].
  • Constant dull ache[8].
  • Pain increases considerably with AROM[8].
  • Decrease in ROM, or complaint of stiffness [9], [7], [8].
  • Radiating pain up into the suboccipital region, or down into the fingers[5], [6], [8].
    The condition goes through 4 stage, see table below.
Stages[8]
Stage Name Presentation
 Chronic (Silent)
 Phase
  • Presence of the calcific deposit 
    is asymptomatic and may be so for years.

Acute Painful Phase

  • Severe pain, disability, and
    frequently nocturnal discomfort.

Mechanical Phase 

  • Tendon impingement being a prominent finding
  • Pain of less severe nature than the acute phase

Differential Diagnosis[edit | edit source]

  • Incidental calcification: found in 2.5-20% of 'normal' healthy shoulders.
  • Degenerative calcification: found tendons with tear history; generally smaller; slightly older individuals
  • Loose bodies: associated chondral defect; associated secondary osteoarthritis[3]

Outcome Measures[edit | edit source]

Medical Management[edit | edit source]

Nonoperative

  1. NSAIDs, physical therapy, stretching & strengthening, steroid injections
  2. Extracorporeal shock-wave therapy as an adjunct treatment. Most useful in refractory calcific tendonitis in the formative and resting phases
  3. Ultrasound-guided needle lavage vs. needle barbotage (needle to break up calcium deposit)

Operative: surgical decompression of calcium deposit.[2]

Physiotherapy[edit | edit source]

Physiotherapy techniques include

  • Range of motion exercises to avoid articular stiffness
  • Strength exercises to restore normal shoulder/scapular mechanics.
  • Scapular dyskinesia can cause subacromial impingement and a rehabilitation program that addresses this issue has been shown to reduce shoulder pain[1]. See link for detail.

See Therapeutic Exercise for the Shoulder

There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) as a potentially effective treatment of calcific tendinopathy. See above link.[11] But ECSW is not free from complications, that included transient bone marrow edema and even reported cases of humeral head necrosis.[12][13]See Tendinopathy Treatment Adjuncts

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthopedic research and reviews. 2018;10:63.Available:https://www.dovepress.com/calcific-tendinopathy-of-the-shoulder-clinical-perspectives-into-the-m-peer-reviewed-fulltext-article-ORR (accessed 12.1.2023)
  2. ↑ 2.0 2.1 Orthobullets Calcific TendonitisAvailable:https://www.orthobullets.com/shoulder-and-elbow/3042/calcific-tendonitis (accessed 12.1.2023)
  3. ↑ 3.0 3.1 Radiopedia Calcific Tendinitis Available: https://radiopaedia.org/articles/calcific-tendinitis?lang=gb(accessed 12.1.2023)
  4. ↑ Serafini G, Sconfienza L, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial. Radiology [serial online]. July 2009;252(1):157-164. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 20, 2011.
  5. ↑ 5.0 5.1 Ebenbichler G R. et. al. Ultrasound therapy for calcific tendinitis of the shoulder. New England Journal of Medicine. 1999; Vol 340 (20): 1533-1538.
  6. ↑ 6.0 6.1 Gimblett P, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. Journal Of Manipulative And Physiological Therapeutics [serial online]. November 1999;22(9):622-627.
  7. ↑ 7.0 7.1 Alexander L D., et. al. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. 2010; vol 90 (1): 14-25.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Wainner R, Hasz M. Management of acute calcific tendinitis of the shoulder. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. March 1998;27(3):231-237. ( LOE 4 )
  9. ↑ Fusaro I, et. al. Functional results in calcific tendinitis of the shoulder treated with rehabilitation after ultrasonic-guided approach. Musculoskeletal Surgery. 2011 (95): S31–S36.
  10. ↑ Cacchio A, Paoloni M, Spacca G, et al. Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy [serial online]. May 2006;86(5):672-682.( LOE 1b )
  11. ↑ Lee SY1, Cheng B, Grimmer-Somers K. The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. ( LOE 2a )
  12. ↑ Humeral head osteonecrosis after extracorporeal shock-wave treatment for rotator cuff tendinopathy. A case report. Liu HM, Chao CM, Hsieh JY, Jiang CC J Bone Joint Surg Am. 2006 Jun; 88(6):1353-6. ( LOE 4 )
  13. ↑ Osteonecrosis of the humeral head after extracorporeal shock-wave lithotripsy. Durst HB, Blatter G, Kuster MS J Bone Joint Surg Br. 2002 Jul; 84(5):744-6. ( LOE 4 )

 

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