Do you treat shoulder impingement diff. with evidence of calcific tendonitis (Full Version)

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Kaden -> Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 1:33:26 PM)

I have been getting a lot of referrals very focused on calcium depositis as the source of the problem.  MDs asking for US and ionto with acetic acid to "break up" the deposits.

I have not found much supportive literature to support the use of either of those modalities.

My question is two fold:

1) Do you treat this population any different than the typical impigement/tendinosis patient

2)  Do you use either US or ionto with acetic on this population.





bonez -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 2:20:11 PM)

Back in November I posted about glut med calcification and shill linked a New England journal of medicine study to calcific tendonitis of the shoulder treated with US. I've copied below I think







 
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I would try high intensity ultrasound (it isnt really high, still within therapeutic realm) at 2.5 w/cm2, replicating the study showing benefit for calcific tendinitis in the shoulder, from the New England Journal of Medicine.
Here is the abstract
ABSTRACT
Background and Methods
Although ultrasound therapy
is used to treat calcific tendinitis of the shoulder,
its efficacy has not been rigorously evaluated. We
conducted a randomized, double-blind comparison of
ultrasonography and sham insonation in patients with
symptomatic calcific tendinitis verified by radiography.
Patients were assigned to receive 24 15-minute
sessions of either pulsed ultrasound (frequency, 0.89
MHz; intensity, 2.5 W per square centimeter; pulsed
mode, 1:4) or an indistinguishable sham treatment to
the area over the calcification. The first 15 treatments
were given daily (five times per week), and the remainder
were given three times a week for three weeks.
Randomization was conducted according to shoulders
rather than patients, so a patient with bilateral
tendinitis might receive either or both therapies.
Results
We enrolled 63 consecutive patients (70
shoulders). Fifty-four patients (61 shoulders) completed
the study. There were 32 shoulders in the ultrasound-
treatment group and 29 in the sham-treatment
group. After six weeks of treatment, calcium
deposits had resolved in six shoulders (19 percent)
in the ultrasound-treatment group and decreased by
at least 50 percent in nine shoulders (28 percent), as
compared with respective values of zero and three
(10 percent) in the sham-treatment group (P=0.003).
At the nine-month follow-up visit, calcium deposits
had resolved in 13 shoulders (42 percent) in the ultrasound-
treatment group and improved in 7 shoulders
(23 percent), as compared with respective values
of 2 (8 percent) and 3 (12 percent) in the sham-treatment
group (P=0.002). At the end of treatment, patients
who had received ultrasound treatment had
greater decreases in pain and greater improvements
in the quality of life than those who had received
sham treatment; at nine months, the differences between
the groups were no longer significant.
Conclusions
In patients with symptomatic calcific
tendinitis of the shoulder, ultrasound treatment helps
resolve calcifications and is associated with shortterm
clinical improvement. (N Engl J Med 1999;340:
1533-8.)
 
 
Good Luck
 
Steve



Kaden -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 2:42:01 PM)

Thanks.  I have seen that article.  I assume the mechanism is one of vibration properties breaking up the deposit.  One would have to think that many of these would need to be in infancy stages to work.  Once they begin to significantly calcify into more bone like in nature I doubt US would work.

I have the article but have yet to read other than abstract - I will take a closer look.

My only big problem with the article at a glance - and US studies in general is the parameters.  How many of us would use US for 15 minutes for up to 24 sessions.



USAPT -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 2:55:06 PM)

Kaden,
We all know that to the extent of finding an answer, you will have articles saying yes and no AA and US helps with obvious variables such as freq and duration. I located an article using both:

http://web.ebscohost.com.ahecproxy.ncahec.net/ehost/pdf?vid=5&hid=108&sid=155b91f4-7709-466a-8364-9f00d426e1ab%40sessionmgr104

Insurance issues aside, I don't have the time, nor would I make it, to perform US or ionto 24 to 40 times as represented in the article. 

-Jason



Shill -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 4:40:45 PM)

I would tell you to replicate the study to the best of your ability, as the results were pretty good.  I have actually done this, and we did about 20 visits.  My patient happened to work in the same hospital I did, so convenience was a huge factor. We would adjust the home program every week or every other week, and just do the US exclusively for the other visits.  I agree that 20 visits seems like a lot, but the ends justify the means, and while it may not fall nicely within a small number of visits, my argument is so what?  The number of times you see someone for this many visits is very small, the exception, not the norm.  By the way, if you do US for 15 minutes, make sure you have had your coffee.  It is so mind numbingly boring, both you and the patient will drift off.......zzzzzzzzz...  that said, boring treatments that bring good outcomes are fine with me.



ginger -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 7:37:01 PM)

I have to cast my mind back more than eighteen years now to a time when I used US in the way described here. Back to a time when shoulder pain problems were still mostly a mystery. As is apparently true for most doctors of medicine and the researchers who came up with this twenty ultrasound treatment doozy. As my hands on skill improved, so did my outcomes. As I directed my attentions away from the shoulder , to the vertebral spine, outcomes took a sharp turn for the better.
The notion of "calcific tendonitis" is just as risible as similar notions that drive doctors and others to take thousands of x-rays of spines. This in the mistaken belief that degenerative changes are the driver for painful spinal episodes there.
It is largely up to us to dispell these erroneous beliefs , by remaining alert to the prospect of neuralgic events, of protective behaviours and of disorderly conduct leading to pain. It is these areas that management of and resolution of shoulder problems need a shake up. I am still shocked and dismayed when I know that the kind of nonsense that i was taught at university about shoulder pain , is still being taught as orthodox and usefull . Like those put forward in this article.



PTupdate.com -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 9:22:34 PM)

Well, Army PT returns (Brenner) and now ginger is back as well.   All we need is a good fight between Dorko and SJ and we'll have the yesteryears

I have not read the full article, but doubt that the US somehow breaks up the deposits.....US isn't lithotripsy.  I am not sure acetic acid ionto would work either.....the basis for use on heterotropic ossification is one of lowering the pH of the surrounding tissues, where soft callous bone that has not yet hardened becomes soluble...something it's not at regular tissue pH.  I dont' think it works on solidified/calcified bone...otherwise we'd be dissolving someones femur as we work on that quad mass

Perhaps ginger reminds us to look elsewhere.....how do we even know that those little stones are causing  a persons pain?   Maybe I have a few in my cuff tendon, and don't feel a thing.  It may be the only radiographic abnormality seen, and thus gets the finger pointed at it.  The pain could be other local tissue dysfunction, joint mechanic dysfunction, or as ginger will tell us, an L5 problem requiring continuous mobilizations.

If the US truly does somehow change the calcification process, and really is the cause of pain relief, these cases may be the ones to use the Richmar AutoSound on.



TexasOrtho -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 9:54:16 PM)

Ginger and John.  Very solid posts.  I am equally unconvinced that US acts as lithotripsy as John puts it.  I have a hard time performing anything as monotonous as US for 15 minutes even if it were effective.  This would be a good CAT project:  What is the strength of evidence supporting the use of therapeutic ultrasound in managing calcific tendonitis?

I also agree with Ginger's point that radiographic findings to not equate to clinical presentation (although I had to look up the word 'risible').[:)]  I need to go back and review some literature I dug up on this a few years back.  I recall it not changing my management strategies enourmously between tendonopathy and calcific tendonitis.  I have found (anecdotally of course) that the prognoses to be similar with or without a calcific event present.



ginger -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 6, 2008 10:13:53 PM)

Rod, risible,  as in " do you find this wisible?, Biggus Dickus , thwow this man woughly to the gwound"



bonez -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 2:07:37 AM)

A couple of additional thoughts. What is new on the ecswt front wrt. calcium disolution?
Secondly i personally have battled with calcification at an old surgical site that was suspected to irritate an adjacent bursa. The kitchen sink was thrown at it with minimal resolution. So the question arose is it the calcification.
It is really handy to be the the lab rat and still get to think sometimes. My friendly ortho and I broached ths very question. Our plan of attack was two pronged. First since this lay close to surrounding bone was it metabolically active. second was it a symptom generator.
What we did was run a bone scan to determine bone activity and rule out pseudoarthrosis with the adjacent bone. Once that was cleared I was blinded to a choice of long lasting freezing and an interventional radiologist guided freezing to the surface beside the affected bursa. We pre determined that i the freezing had any affect positively at the injection time the radiologist would also inject some steroid.
I was left to record when the freezing affect quit and if it allowed normal function. Well I can confirm that marcaine does wear off at 12 hours as the relief was phenomenal until the freezing wore off.
So from my own experience there can be a correlation between symptoms and calcified tendon.
An additional note was functional improvement was also present while frozen. Glut med activation was always proportionally tough based pain levels. During the injection period Single leg weight bear was much improved without the excessive pelvic shift seen before injection



ginger -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 3:53:14 AM)

with respect to your experiences with steroids and freezing bonez, , indroducing pain and inflammation releiving effects local to the pain site will relieve pain and inflammation regardless of cause. A referred pain event can be temporarily nullified with good targeting of steroids , anaesthesia etc. By doing so, unfortunately, this does not prove it to be either a local or a referred event. Mostly because in the process of reducing inflammation , it is nerves that are reduced to an insensitive state. The brain will then continue to map out the disposition of pain , or lack therof ,according to the ability( or lack therof )  of the nerves local to the site referred to, untill such time as the effect has worn off. Which explains why so many shoulders resist long term amelioration when injections provide only short term results.



PTupdate.com -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 7:53:09 AM)

Agree with ginger....in part

True that steroid injections can and often will reduce or temporarily eliminate pain at a referral site.  Neurogenic inflammation has been documented in the literature, and the situation of a new distal problem can occur.  Lumbar radiculopathy creating the appearance of trochanteric bursitis is one that comes to mind......the injection often helps, but only for a few days or weeks, and then symptoms return.

As far as shoulder pain believe relieved by injection, only to return, is more often a case of re-agitation.  People have an underlying condition, it becomes inflamed, the injection calms that down, and the patient resorts back to the behavior or movement dysfunction that created it in the first place....and boom, they're back in the hole again.  BUT, we need to keep in the back of our heads that these cases too could be a referral pattern, and examine/evaluate accordingly (C4 loves to mimic AC joint dysfunction-----throw in the person being an avid lifter, and some osteolysis of the distal clavicle, and everybody ignores the neck)



Shill -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 8:20:23 AM)

Hey guys, before you get too convinced about your being unconvinced that the US could end up changing the size of the calcific deposit, read the NEJM study, because it actually did.  Ginger, welcome back.  I see that you remain unconvinced that other pathologies could actually exist outside the realm of the facet.  Calcific tendonitis (or should it be called calcific tendinosus?) has characteristics that are different than other tendinopathies. (burning like pain, with non radicular symptoms for one). The supraspinatus is a common spot for it, based on the circulatory challenges to its insertion as the arm hangs at rest.  Lack of adequate circulation during healing is one of the theories behind the glitch that allows bony tissue to be deposited rather than tendinous as things try to right themselves.  Its funny to me (or is it sad?) that in the face of a relatively decent study, smart people still ignore the outcomes because it takes a lot of visits, or uses a modality, or takes them back to 18 years ago.  Insert Adam Sandler right here, with a big "You think you are better than me?"  (the study is saying this, not me).

FYI Ginge - Adam Sandler is an American comedian of juvenile nature most of the time.  I mean, he is no Kevin Bloody Wilson, but juvenile nonetheless.



ginger -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 8:37:53 AM)

hey shill , my son loves adam shandler. so no problem . I;m not as familiar with his "work ' but I seem to recall a golfing film where he would almost run to the ball and give it an almighty whacking. Kinda like what I do though I have had nowhere near as much success.  One day.



PTupdate.com -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 8:53:04 AM)

Shill...you're right, I do need to read the entire article.  Abstract is appealing.  If anybody has the full deal, let me know.

A few hypotheticals:  Let's say everything here is valid and true, and that pulsed US at these values does indeed reduce the size of the calcific deposits, and relieves the symptoms as well.  Do we begin performing this treatment as detailed in the study, knowing that it becomes a money loser?  After all, Medicare reimburses for US somewhere around $13 in my area, so 20 minutes of treatment (setup time, clean up time,etc) becomes a wash.  Is it worth it to take that loss to provide what a patient really needs?  Is it OK to take this loss in hopes that it will solidify a relationship with a physician?  Would it be more beneficial to purchase the Richmar and not bill for the treatment? (since US is a constant attendance modality, I am not sure it's legal to strap that thing on and go tend to other business and still bill for it)



SJBird55 -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 11:15:24 AM)

The question isn't whether to do US or not... the question is, is US as described in the study the best, most effective and most efficient option?  IF you have outcome numbers for this particular population and you aren't using US and you are achieving reasonable outcomes (whatever reasonable is ;) ) in less than 20 visits AND being paid at a higher rate than US, then does it really matter that US is an option?

The other question I have to put it into perspective, how often do we really, really know that a patient has calcific tendonitis/tendonosus? And then, with anything calcific, that calcific change just didn't happen overnight - why all of a sudden is it a problem?  How many people have non-symptomatic calcific tendonitis/tendonosus?

I will admit, most patients that attend services with me walk in the door with "shoulder pain."  That's it.  Radiographs for the shoulder aren't as frequently done in my area as radiographs for "low back pain."

What does "burning like" pain indicate?  I think Ginger is on track with thinking about the brain and nerves.  When there is a burning sensation for an orthopaedic complaint, I begin to think the nervous system is sensitized for some reason.  I agree with both Ginger and Duffy - more than just the shoulder proper should be addressed.



Shill -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 12:39:35 PM)

SJ
I dont disagree with that.  My point is just when one does get a case of calcific tendinitis confirmed with radiographs, MRI, when one has the luxury of those, thats we really probably dont need to look elsewhere.  I doubt anyone does, or at least I hope no one would too often, unless of course the symptoms simply are nowhere in the ballpark.  We cant be the group that disregards all findings and expects to be respected.  That said, without expensive confirming tests, Im not sure there is a good way to differentiate between calcific tendinitis and other tendinitis/osis.  But honestly I would not dust off the ultrasound for a non-confirmed case of this.

Duffy,
thats actually a good idea with a strap on device.  (stop snickering).  The strap on US type thingy that someone could use at home to treat a calcific deposit/tendinitis.  Certainly makes things a bit more realistic than trying it in the clinic, especially with the woeful reimbursement you mention.



TexasOrtho -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 12:45:02 PM)

I think this would be a good CAT project for my current student.  I'll get her right on it! [;)] Shill.  I'm not convinced burning shoulder pain is pathomnemonic for a symptomatic calcific event. I am sure it exists and this study found some positive results.  This gives it some merit over pure conjecture that it helps reduce the size of the deposit.

However do we have a connection between the size of the deposit and the course or prognosis of the disease?  What are the outcomes for calcific tendonitis managed in other ways?  I think these are questions that would add strength to an opinion on one side or the other.

Ginger, brilliant Life of Brian reference.  I'll send you a beer down under if you can name Bikus' wife's name (google not allowed).



TexasOrtho -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 12:46:25 PM)

Shill we must have posted at the same time.  Good points.  Did you really say strap-on?  I need a shower.



bonez -> RE: Do you treat shoulder impingement diff. with evidence of calcific tendonitis (May 7, 2008 2:16:22 PM)

While as a Chiropractor I too have to agree with Ginger my experience is a little different. My facet joints do quite well ,the pain is not burning and is actually quite sharp when performing certain movements that involve glut med. there is slight mobility of the calcification and movement palpation with the right pressure triggers symptom replication.
What was missed was us not trying the second half of the experiment which was injection to the same spot with hypertonic saliene or some other irritant to provoke the symptom response.
I completely agree that the steroid use is not the optimal strategy long term but I don't relish having 1/3 of glut med's tendon being resected either. That was why I asked if the experience with ecswt showed promise. My ortho buddy and I suspect that since the mass is too corticated it is unlikely to disolve.



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