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    Appendix

    The following table outlines the studies that are considered potentially relevant to the IP overview but were not included in the summary of the key evidence. It is by no means an exhaustive list of potentially relevant studies.

    Case series with fewer than 30 patients have been excluded. Systematic reviews that were published before 2010 have also been excluded.

    Additional papers identified

    Article

    Number of patients/ follow up

    Direction of conclusions

    Reasons for non-inclusion in summary of key evidence section

    Al-Abbad H, Allen S, Morris S et al. (2020) The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression. BMC Musculoskeletal Disorders.21: 275

    Systematic review and meta-analysis

    n=27 studies

    Shockwave therapy altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of shockwave therapy dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review.

    Mixed indications; review focuses on changes in imaging.

    Albert J-D, Meadeb J, Guggenbuhl P et al. (2007) High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a randomised trial. The Journal of Bone and Joint Surgery 89: 335–41

    RCT (high versus low energy ESWT)

    n=80

    Follow up: mean 110 days

    High-energy shock-wave therapy statistically significantly improves symptoms in refractory calcifying tendinitis of the shoulder after 3 months of follow up, but the calcific deposit remains unchanged in size in most patients.

    Included in systematic review (Surace 2020).

    Arirachakaran A, Boonard M, Yamaphai S et al. (2017) Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs. European Journal of Orthopaedic Surgery & Traumatology 27: 381– 90

    Systematic review and network meta-analysis

    n=7 studies

    The network meta-analysis suggested that combined ultrasound-guided needling and subacromial corticosteroid injection significantly decreased shoulder pain VAS, improved Constant-Murley Score and decreased the size of calcium deposits, while also lowering risks of adverse events when compared to barbotage plus ESWT, ESWT and subacromial corticosteroid injection; therefore, the evidence points to ultrasound-guided needling as being the treatment of choice for nonsurgical options of treatment in calcific tendinitis of the shoulder.

    A systematic review with a more recent search date is included.

    Avancini-Dobrovic V, Frlan-Vrgoc L, Stamenkovic D et al. (2011) Radial extracorporeal shock wave therapy in the treatment of shoulder calcific tendinitis. Collegium Antropologicum 35: 221–5

    Case series

    n=30

    Follow up: 6 months

    Radial ESWT applied to shoulder calcific lesions of the rotator cuff resulted in pain relief, increase in the range of motion and increase in the muscular strength. As shown by X-ray, these results were followed by the decrease in the size of the rotator cuff calcifications.

    Small case series.

    Bannuru RR, Flavin NE, Vaysbrot E et al. (2014) High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: a systematic review. Annals of Internal Medicine 160: 542–9

    Systematic review

    n=28 studies

    Twenty RCTs compared ESWT energy levels and placebo and consistently showed that high-energy ESWT was better than placebo in decreasing pain and improving function and resorption of calcifications in calcific tendinitis.

    A more recent systematic review is included.

    Bechay J, Lawrence C, Namdari S (2020) Calcific tendinopathy of the rotator cuff: a review of operative versus nonoperative management. The Physician and Sports Medicine 48: 241–46

    Review

    Conservative management should be the first line of treatment for symptomatic calcific tendinopathy. If this fails, ESWT or Ultrasound-guided percutaneous irrigation is often effective and should be the next step in treatment.

    No meta-analysis.

    Cacchio A, Paoloni M, Barile A et al. (2006) Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical Therapy 86: 672–82

    RCT (high versus low dose RSWT)

    n=90

    Follow up: 6 months

    The results suggest that using RSWT to manage calcific tendinitis of the shoulder is safe and effective, leading to a statistically significant reduction in pain and improvement of shoulder function after 4 weeks, without adverse effects.

    Included in systematic review (Surace 2020).

    Carlisi E, Lisi C, Dall'angelo A et al. (2018) Focused extracorporeal shock wave therapy combined with supervised eccentric training for supraspinatus calcific tendinopathy. European Journal of Physical and Rehabilitation Medicine 54: 41–7

    Non-randomised comparative study

    n=22

    Follow up: 9 weeks

    Our study confirmed that focused ESWT is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Adding a supervised eccentric training, focused on the abductor muscles, was useful to improve maximum isometric abduction strength, but appeared to give no advantage in the short-term outcome of shock wave therapy.

    Study focused on effect of supervised eccentric training as an adjunct to ESWT.

    Carulli C, Tonelli F, Innocenti M et al. (2016) Effectiveness of extracorporeal shockwave therapy in three major tendon diseases.

    Journal of Orthopaedics and Traumatology 17: 15–20

    Case series

    n=311 (129 calcific tendonitis of the shoulder)

    Follow up: 1 year

    There were statistically significant results at follow-up regarding the mean numeric rating scale score (from 6.25 to 0.2) and the Constant Murley Score (from 66.7 to 79.4) for calcific tendonitis of the shoulder.

    Mixed indications.

    Charrin, J E; Noel, E R (2001) Shockwave therapy under ultrasonographic guidance in rotator cuff calcific tendinitis. Joint Bone Spine 68: 241–4

    Case series

    n=32

    Follow up: 24 weeks

    Improvements in the pain and self-questionnaire scores were noted in 37% of patients after 12 weeks and 55% after 24 weeks. Plain radiographs were changed in 27% of patients after 12 weeks (with complete clearance of the calcific deposits in 7%) and in 24% of patients after 24 weeks (complete clearance in 17%).

    Small case series.

    Coletti N, Schiavetti S, Giusto F et al. (2008) Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. Journal of Orthopaedics and Traumatology 9: 179–85

    Non-randomised comparative study

    n=46

    Follow up: 24 months

    Shock wave therapy is equivalent to arthroscopy, and so shock wave therapy should be preferred because of its non-invasiveness.

    More recent studies with more patients or longer follow up are included.

    Cosentino R, De Stefano R, Selvi E et al. (2003) Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study. Annals of the Rheumatic Diseases 62: 248–50

    RCT (ESWT versus sham)

    n=70

    Follow up: 6 months

    Because of its good tolerance, safety, and clinical radiological response, ESWT can be considered as an alternative treatment for chronic calcific tendinitis of the shoulder.

    Included in systematic review (Surace 2020).

    De Boer FA, Mocking F, Van Kampen PM et al. (2017) Ultrasound guided needling vs radial shockwave therapy in calcific tendinitis of the shoulder: a prospective randomized trial. Journal of Orthopaedics 14: 466–69

    RCT (RSWT versus ultrasound-guided needling)

    n=25

    Follow up: 12 months

    Compared to RSWT, ultrasound-guided needling resulted in lower pain and faster resorption of calcifications after 6 weeks. No statistically significant differences were found after 1 year.

    Included in systematic review (Surace 2020).

    Del Castillo-Gonzalez F, Ramos-Alvarez JJ, Rodriguez-Fabian G et al. (2016) Extracorporeal shockwaves versus ultrasound-guided percutaneous lavage for the treatment of rotator cuff calcific tendinopathy: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine 52: 145–51

    RCT

    (ESWT versus ultrasound-guided lavage)

    n=243

    Follow up: 12 months

    Pain and the amount of calcification were statistically significantly reduced by both techniques at 3, 6 and 12 months (p<0.001 for each), but statistically significantly more so by ultrasound guided percutaneous lavage (p<0.001).

    Included in systematic review (Surace 2020).

    Duymaz T, Sindel D (2019) Comparison of radial extracorporeal shock wave therapy and traditional physiotherapy in rotator cuff calcific tendinitis treatment. Archives of Rheumatology 34: 281–87

    RCT (radial ESWT plus physiotherapy versus physiotherapy alone)

    n=80

    Follow up: end of treatment

    Although all parameters of the patients in both groups improved, patients in the radial ESWT group had a statistically significant improvement in pain, range of movement and QuickDash scores (p<0.001, p<0.001, and p<0.001, respectively).

    Included in systematic review (Surace 2020).

    Engebretsen K, Grotle M, Bautz-Holter E et al. (2009) Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study.

    BMJ 339: b3360

    RCT (radial ESWT versus supervised exercise)

    n=104

    Follow up: 12 months

    A treatment effect in favour of supervised exercises at 6, 12, and 18 weeks was found. The adjusted treatment effect was -8.4 (95% CI -16.5 to -0.6) points. A statistically significantly higher proportion of patients in the supervised exercises group improved (odds ratio 3.2, 95% CI 1.3 to 7.8). More patients in the shockwave treatment group had additional treatment between 12 and 18 weeks (odds ratio 5.5, 95% CI 1.3 to 26.4).

    Included in systematic review (Surace 2020).

    Farr S, Sevelda F, Mader P et al. (2011) Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder. Knee Surgery, Sports Traumatology, Arthroscopy 19: 2085–9

    RCT (single high-dose ESWT versus 2 treatments of low-dose ESWT)

    n=30

    Follow up: 12 weeks

    This pilot study indicates that a single high-level ESWT may be as effective as 2 applications of a lower-dosed ESWT for calcifying tendinitis.

    Included in systematic review (Surace 2020).

    Frassanito P, Cavalieri C, Maestri R et al. (2018) Effectiveness of Extracorporeal Shock Wave Therapy and kinesio taping in calcific tendinopathy of the shoulder: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine 54: 333–40

    RCT

    n=42

    Follow up: 12 weeks

    Kinesio taping associated with ESWT seems to improve the recovery in rotator cuff calcific tendinopathy with a faster therapeutic response compared to ESWT only.

    Study assesses effect of kinesio taping as an adjunct to ESWT.

    Gerdesmeyer L, Wagenpfeil S, Haake M et al. (2003) Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA 290: 2573–80

    RCT (high-energy ESWT versus low-energy ESWT versus sham therapy)

    n=144

    Follow up: 12 months

    Both high-energy and low-energy ESWT appeared to provide a beneficial effect on shoulder function, as well as on self-rated pain and diminished size of calcifications, compared with placebo. Furthermore, high-energy ESWT appeared to be superior to low-energy ESWT.

    Included in systematic review (Surace 2020).

    Haake M, Deike B, Thon A et al. (2002) Exact focusing of extracorporeal shock wave therapy for calcifying tendinopathy. Clinical Orthopaedics and Related Research 397: 323–31

    RCT (ESWT focused on the origin of supraspinatus tendon versus ESWT focused on the calcific deposit)

    n=50

    Follow up: 1 year

    Statistical analyses showed a significant superiority of extracorporeal shock wave application at the calcified area in the primary end point (Constant and Murley score). Therefore, exact fluoroscopic focusing of ESWT at the calcific deposit for treatment of calcifying tendinopathy of the supraspinatus muscle is recommended.

    Included in systematic review (Surace 2020).

    Haake M, Wirth T, Rautmann M (2001) Extracorporeal shock wave therapy vs surgical treatment in calcifying tendinitis and non calcifying tendinitis of the supraspinatus muscle. European Journal of Orthopaedic Surgery and Traumatology 11: 21–24

    Non-randomised comparative study

    n=60

    Follow up: 3 months

    ESWT appears to be an effective and relatively inexpensive treatment for supraspinatus muscle tendinitis and should be considered before surgical treatment is employed.

    Studies with more patients or longer follow up are included.

    Hawk C, Minkalis AL, Khorsan R et al. (2017) Systematic review of nondrug, nonsurgical treatment of shoulder conditions. Journal of Manipulative and Physiological Therapeutics 40: 293–319

    Systematic review

    n=25 systematic reviews and 44 RCTs

    Moderate evidence supported ESWT for calcific tendinitis rotator cuff associated disorders.

    A more recent systematic review is included.

    Hearnden A, Desai A, Karmegam A et al. (2009) Extracorporeal shock wave therapy in chronic calcific tendonitis of the shoulder--is it effective? Acta Orthopaedica Belgica 75: 25–31

    RCT (ESWT versus placebo)

    n=20

    Follow up: 6 months

    This study confirms that ESWT is effective in treating chronic calcific tendonitis when compared with a placebo group. However, it was not as successful as previously claimed; half the patients did not have a satisfactory outcome and needed surgical excision. Patients found the procedure painful, which has not been previously alluded to.

    Included in systematic review (Surace 2020).

    Hsu C-J, Wang D-Y, Tseng K-F et al. (2008) Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Journal of Shoulder and Elbow Surgery 17: 55–9

    RCT (ESWT versus sham treatment)

    n=46

    Follow up: 12 months

    ESWT shows promise for pain relief and functional restoration of calcific tendinitis with negligible complications.

    Included in systematic review (Surace 2020).

    Huisstede BMA, Gebremariam L, van der Sande R et al. (2011) Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis--a systematic review. Manual Therapy 16: 419–33

    Systematic review

    n=17 RCTs

    Only high-ESWT is effective for treating calcific rotator cuff tendinosis.

    A more recent systematic review is included.

    Ioppolo F, Tattoli M, Di Sante L et al. (2013) Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation 94: 1699– 706

    Systematic review

    n=6 studies

    There was a clinical improvement with a pooled total resorption ratio of 27.2 (95% CI, 7.2 to 102.7) and a pooled partial resorption ratio of 16.2 (95% CI, 3.3 to 79.0). Shockwave therapy increases shoulder function, reduces pain, and is effective in dissolving calcifications. These results were maintained over the following 6 months.

    A more recent systematic review is included.

    Ioppolo F, Tattoli M, Di Sante L et al. (2012) Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis: a randomized clinical trial comparing two different energy levels. Physical Therapy 92: 1376–85

    RCT (high-energy ESWT versus low-energy ESWT)

    n=46

    Follow up: 12 months

    In ESWT for supraspinatus calcifying tendinitis, an energy level of 0.20 mJ/mm2 appears to be more effective than an energy level of 0.10 mJ/mm2 in pain relief and functional improvement.

    Included in systematic review (Surace 2020).

    Jakobeit C, Winiarski B, Jakobeit S et al. (2002) Ultrasound-guided, high-energy extracorporeal - shock-wave treatment of symptomatic calcareous tendinopathy of the shoulder. ANZ Journal of Surgery 72: 496–500

    Case series

    n=80

    68 patients (85%) had complete freedom from symptoms or only had minimal residual symptoms when stressing their shoulder joint. The calcification in 57 (71%) patients was completely resorbed after treatment and partially resorbed in 16 patients (20%). Complete resorption of the calcareous deposits led to freedom from symptoms.

    Studies that were more recent, had more patients or longer follow up were included.

    Kim EK, Kwak KI (2016) Effect of extracorporeal shock wave therapy on the shoulder joint functional status of patients with calcific tendinitis. Journal of Physical Therapy Science 28: 2522–24

    RCT

    n=40

    The treatment group showed a more significant decrease in pain at 2, 6, and 12 weeks compared to the control group (p<0.05).

    Treatment included transcutaneous electrical nerve stimulation as well as ESWT.

    Kim SJ, Lee HJ, Kim YV et al. (2014) Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound guided needling and extracorporeal shock wave therapy. Journal of Shoulder and Elbow Surgery 23:1640–46

    RCT (ESWT versus ultrasound-guided needling)

    n=62

    Follow up: mean 23 months

    Both treatment modalities for calcific tendinitis improved clinical outcomes and eliminated calcium deposits. Ultrasound-guided needling treatment, however, was more effective in function restoration and pain relief in the short term.

    Included in systematic review (Surace 2020).

    Kolk A, Yang KG, Tamminga R et al. (2013) Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis. A prospective randomised double-blind placebo-controlled multicentre trial. Bone & Joint Journal 95: 1521–6

    RCT (radial ESWT versus placebo)

    n=82

    Follow up: 6 months

    A VAS score for pain, a Constant-Murley score and a simple shoulder test score statistically significantly improved in both groups at 3 and 6 months compared with baseline (all p≤0.012). The scores were similar in both groups.

    Low-dose radial ESWT does not appear to reduce pain or improve function in patients with chronic rotator cuff tendinitis compared with placebo treatment.

    Included in systematic review (Surace 2020).

    Krasny C, Enenkel M, Aigner N et al. (2005) Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. The Journal of Bone and Joint Surgery 87: 501–7

    RCT

    n=80

    Follow up: mean 4 months

    Ultrasound-guided needling in combination with high-energy shock-wave therapy is more effective than shock-wave therapy alone in patients with symptomatic calcific tendonitis, giving significantly higher rates of elimination of the calcium deposits, better clinical results and reduction in the need for surgery.

    Study assessed the effect of combining ultrasound-guided needling with ESWT.

    Kvalvaag E, Brox JI, Engebretsen KB et al. (2017) Effectiveness of radial extracorporeal shock wave therapy (rESWT) when combined with supervised exercises in patients with subacromial shoulder pain: a double-masked, randomized, sham-controlled trial. The American Journal of Sports Medicine 45: 2547– 54

    RCT (supervised exercises plus radial ESWT versus supervised exercises plus sham radial ESWT)

    n=143

    Follow up: 24 weeks

    At 24 weeks, participants in both groups had improved (p<0.001) in SPADI score compared with baseline, but there were no differences between the groups (mean difference 0.7; 95% CI, -6.9 to 8.3; p=0.76). Prespecified subgroup analysis of patients with calcification in rotator cuff showed that the radial ESWT group had a greater improvement in SPADI score after 24 weeks (mean difference -12.8, 95% CI -24.8 to ‑0.8, p=0.018).

    Included in systematic review (Surace 2020).

    Lanza E, Piccoli F, Intrieri C et al. (2021) US-guided percutaneous irrigation of calcific tendinopathy of the rotator cuff in patients with or without previous external shockwave therapy. La Radiologia Medica 126: 117–23

    Cohort study

    n=70

    Follow up: mean 14 months

    Previous unsuccessful ESWT did not affect the outcome of ultrasound guided percutaneous irrigation of calcific tendinopathy.

    The intervention was ultrasound guided percutaneous irrigation in patients with or without previous ESWT.

    Lee S-Y, Cheng B, Grimmer-Somers K (2011) The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis. Journal of Shoulder and Elbow Surgery 20: 845–54

    Systematic review

    n=9 studies

    Because of variable treatment parameters (such as dosage), this review was unable to provide clear guidance of the dose-effect of the midterm effectiveness of ESWT. Studies of better methodologic design using standardised treatment protocols and studies with longer follow-up are needed.

    A more recent systematic review is included.

    Loew M, Daecke W Kusnierczak D et al. (1999) Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. The Journal of Bone and Joint Surgery 81: 863–7

    RCT (no treatment versus single session low-dose ESWT versus single session high-dose ESWT versus dual session high-dose ESWT)

    n=80 (part A), 115 (part B)

    Follow up: 6 months

    The results showed energy-dependent success, with relief of pain ranging from 5% in the control group up to 58% after 2 high-energy sessions.

    Included in systematic review (Surace 2020).

    Lorbach O, Kusma M, Pape D et al. (2008) Influence of deposit stage and failed ESWT on the surgical results of arthroscopic treatment of calcifying tendonitis of the shoulder. Knee Surgery, Sports Traumatology 16: 516–21

    Case series

    n=50 (24 had ESWT)

    The type of calcific deposit and the preoperative treatment of the shoulder with ESWT did not have any significant impact on the postoperative results of arthroscopic surgery.

    Study focuses on the effect of having unsuccessful ESWT before arthroscopic treatment.

    Louwerens JKG, Veltman ES, van Noort A et al. (2016) The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: a systematic review. Arthroscopy: the Journal of Arthroscopic & Related surgery 32: 165–75

    Systematic review

    n=22 studies

    Patients can achieve good to excellent clinical outcomes after high-energy ESWT, ultrasound-guided needling, and arthroscopy for calcific tendinopathy of the shoulder.

    A more recent systematic review is included (Surace 2020).

    Louwerens JKG, Sierevelt IN, van Noort A et al. (2014) Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery 23: 1240–9

    Systematic review

    n=20 studies

    High-energy extracorporeal shockwave therapy is the most thoroughly investigated minimally invasive treatment option in the short-term to midterm and has proven to be a safe and effective treatment.

    A more recent systematic review that includes the same relevant studies is included (Surace 2020).

    Maier M, Staupendahl D, Duerr HR et al. (1999) Castor oil decreases pain during extracorporeal shock wave application. Archives of Orthopaedic and Trauma Surgery 119: 423–7

    Case series

    n=60

    Castor oil had an advantage over ultrasound jelly and vaseline in all indications used with regard to application pain. The positive effect of castor oil can be explained by its cavitation-free quality.

    Mixed indications; study focuses on the use of castor oil to decrease pain during treatment.

    Maier M, Stabler A, Lienemann A et al. (2000) Shockwave application in calcifying tendinitis of the shoulder--prediction of outcome by imaging. Archives of Orthopaedic and Trauma Surgery 120: 493–98

    Case series

    n=62

    Follow up: mean 18 months

    The results suggest that in patients with chronic calcifying tendinitis, the absence of contrast enhancement, especially around the deposit, is a strong predictive parameter of a positive clinical outcome of ESWT.

    Small case series.

    Malliaropoulos N, Thompson D, Meke M et al. (2017) Individualised radial extracorporeal shock wave therapy (rESWT) for symptomatic calcific shoulder tendinopathy: a retrospective clinical study. BMC Musculoskeletal Disorders 18: 513

    Case series

    n=67

    Follow up: 1 year

    One-year success rate was estimated at 92% and 1-year recurrence rate was 7%.

    In this retrospective study an individualised rESWT protocol resulted in a high success rate with low number of recurrences.

    Small case series.

    Mangone G, Veliaj A, Viliani T et al. (2010) Radial extracorporeal shock-wave therapy in rotator cuff calcific tendinosis. Clinical Cases in Mineral and Bone Metabolism 7: 91–96

    Non-randomised comparative study

    n=62

    Follow up: 3 months

    Patients who had high power laser therapy had good clinical results but returned to original syndrome 1 month after treatment. Radial ESWT gave improvement after treatment extended in time (3 months) in terms of pain and recover of functionality with a limited number of applications.

    Small study with short follow up.

    Moretti B, Garofalo R, Genco S et al. (2005) Medium-energy shock wave therapy in the treatment of rotator cuff calcifying tendinitis. Knee Surgery, Sports Traumatology, Arthroscopy 13: 405–10

    Case series

    n=54

    Follow up: 6 months

    38 (70%) patients reported satisfactory functional results. Radiographs and sonographs showed a disappearance of calcium deposit in 29 patients (54%) and in 19 patients (35%) it appeared to be reduced more than a half. A correlation was found between residual calcium deposit and the clinical outcome, but some patients showed a reduced pain without modification of calcium deposit.

    Small case series.

    Moya D, Ramon S, Schaden W et al. (2018) The role of extracorporeal shockwave treatment in musculoskeletal disorders. Journal of Bone and Joint Surgery 100: 251–63

    Review

    Given its efficacy in pain reduction and functional outcomes, resorption rate, safety, non-invasiveness, reduced recovery time, and cost-effectiveness, the authors consider that high-energy focused ESWT is the treatment of choice in calcifying tendinopathy of the shoulder when conservative treatment has failed.

    No meta-analysis. A more recent review is included.

    Moya D, Ramon S, Guiloff L et al. (2015) Current knowledge on evidence-based shockwave treatments for shoulder pathology. International Journal of Surgery 24: 171–8

    Review

    There is evidence to support the use of shockwaves in certain shoulder pathologies. Its efficiency, safety and non-invasiveness justify its choice over surgical procedures in rotator cuff calcifications.

    No meta-analysis. A more recent review is included.

    Notarnicola A, Moretti L, Maccagnano G et al. (2016) Tendonitis of the rotator cuff treated with extracorporeal shock wave therapy: radiographic monitoring to identify prognostic factors for disintegration. Journal of Biological Regulators and Homeostatic Agents 30: 1195–202

    Case series

    n=174 shoulders

    Follow up: 3 months

    Calcification disappeared in 37% of shoulders, reduced in size in 22% and there was no change in 41%. The calcifications that disappeared were large according to Bosworth (p=0.004). The probability of disappearance of calcification increased with increasing age (p=0.011), for medium calcifications according to Bosworth (p=0.001), and calcifications of type A according to Mole (p=0.043).

    Study focuses on effect of ESWT on calcification, assessed by imaging.

    Pan P-J, Chou C-L, Chiou H-J et al. (2003) Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Archives of Physical Medicine and Rehabilitation 84: 988–93

    RCT (ESWT versus trans-cutaneous electrical nerve stimulation)

    n=60

    Follow up: 12 weeks

    In both groups, Constant score and VAS improved significantly at 2-, 4-, and 12-week follow-ups (p<0.05), and the size of calcium deposits decreased significantly at the 4- and 12-week follow-ups. Moreover, the arc-shaped calcific plaques of the rotator cuff were markedly meliorated with ESWT.

    Included in systematic review (Surace 2020).

    Perlick L, Luring C, Bathis H et al. (2003) Efficacy of extracorporal shock-wave treatment for calcific tendinitis of the shoulder: experimental and clinical results. Journal of Orthopaedic Science 8: 777–83

    RCT (low-dose ESWT versus high-dose ESWT)

    n=80

    Follow up: 1 year

    Based on experimental and clinical results it is evident that disintegration of calcific deposits is dose dependent. Because of the time that elapses until changes became evident on the radiographs, an instant and sole mechanical effect on the calcific deposits is unlikely. Therefore, a combined mechanical and cellular mechanism for absorption of the calcific deposits must be presumed.

    Included in systematic review (Surace 2020).

    Peters J, Luboldt W, Schwarz W et al. (2004) Extracorporeal shock wave therapy in calcific tendinitis of the shoulder. Skeletal Radiology 33: 712–8

    RCT (low-dose ESWT versus high-dose ESWT versus sham ESWT)

    n=90

    Follow up: 6 months

    ESWT in calcific tendinitis of the shoulder is effective. It does not have serious side effects at an energy level of 0.44 mJ/mm2.

    Included in systematic review (Surace 2020).

    Pigozzi F, Giombini A, Parisi A et al. (2000) The application of shock-waves therapy in the treatment of resistant chronic painful shoulder. A clinical experience. The Journal of Sports Medicine and Physical Fitness 40: 356–61

    Case series

    n=72

    Follow up: 1 month

    53% of patients had excellent results, 14% good, 13% fair and 20% poor. In the group with calcifying tendinitis, there was a reduction in 37% and no change in 63%.

    Small case series with mixed indications.

    Pleiner J, Crevenna R, Langenberger H et al. (2004) Extracorporeal shockwave treatment is effective in calcific tendonitis of the shoulder. A randomized controlled trial. Wiener klinische Wochenschrift 116: 536–41

    RCT (ESWT versus placebo)

    n=43

    Follow up: 7 months

    As applied, ESWT with an energy flux density of 0.28 mJ/mm2 led to a statistically significantly greater improvement in shoulder function and a slightly higher, nonsignificant, rate of >50% disintegration of calcific deposits compared with the control group. However, this did not result in reduction of pain.

    Included in systematic review (Surace 2020).

    Rebuzzi E, Coletti N, Schiavetti S et al. (2008) Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. J Orthop Traumatol 9: 179–85

    Non-randomised comparative study

    n=46

    Follow up: 2 years

    Shock wave therapy was equivalent to arthroscopy, and so shock wave therapy should be preferred because of its non-invasiveness.

    Small, non-randomised study.

    Rompe JD, Burger R, Hopf C et al. (1998) Shoulder function after extracorporal shock wave therapy for calcific tendinitis. Journal of Shoulder and Elbow Surgery 7: 505–9

    RCT (low-dose ESWT versus high-dose ESWT)

    n=100

    Follow up: 24 weeks

    After 24 weeks, 52% of the patients in group 1 (low dose) rated the results of treatment as good or excellent, compared with 68% in group 2 (high dose; p<0.01). No improvement was reported by 24% versus 10%, respectively, at the 24-week follow-up.

    Included in systematic review (Surace 2020).

    Rompe JD, Rumler F, Hopf C et al. (1995) Extracorporal shock wave therapy for calcifying tendinitis of the shoulder. Clinical Orthopaedics and Related Research 321: 196–201

    Case series

    n=40

    Follow up: 24 weeks

    Partial or complete disintegration of the deposit was observed in 63% of patients. Statistical analysis showed significant improvement both of subjective and objective criteria. According to the Constant score, 60% of patients had normal values, and 73% had no or only occasional discomfort. Only 6 patients (15%) reported no improvement.

    Small case series.

    Sabeti M, Dorotka R, Goll A et al. (2007) A comparison of two different treatments with navigated extracorporeal shock-wave therapy for calcifying tendinitis - a randomized controlled trial. Wiener klinische Wochenschrift 119: 124–8

    RCT (low-dose ESWT versus high-dose ESWT)

    n=47

    Follow up: 12 weeks

    Navigated shock-wave therapy significantly improves pain and shoulder function. Patients obtained nearly equal results after 3 low-energy or 2 middle-energy sessions of shock-wave treatment.

    Included in systematic review (Surace 2020).

    Sabeti-Aschraf M, Dorotka R, Goll A et al. (2005) Extracorporeal shock wave therapy in the treatment of calcific tendinitis of the rotator cuff. The American Journal of Sports Medicine 33: 1365–8

    RCT (palpation-guided ESWT versus image-guided ESWT)

    n=50

    Follow up: 12 weeks

    Both groups had statistically significant improvements in the Constant and Murley score and the VAS after 12 weeks. The results from the navigation group were statistically significantly superior to those of the feedback group. In the navigation group, 6 calcium deposits disappeared and 9 altered, compared to 1 disappearance and 12 alterations in the feedback group. There were no severe complications.

    Included in systematic review (Surace 2020).

    Simpson M, Pizzari T, Cook T et al. (2020) Effectiveness of non-surgical interventions for rotator cuff calcific tendinopathy: A systematic review. Journal of Rehabilitation Medicine 52: jrm00119

    Systematic review

    n=18 articles

    There was moderate evidence for the benefit of high energy ESWT over low energy ESWT for pain and function between 3 and 6 months follow up, and benefit over placebo for improved function at up to 6 months follow up. There was moderate evidence for the benefit of ultrasound-guided percutaneous intervention over medium or high-energy ESWT for reduced pain and calcific morphology when followed up over a 1-year period. Methodological concerns preclude definitive recommendations.

    Review includes a range of interventions.

    A systematic review with a more recent search date is included.

    Speed C (2014) A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. British Journal of Sports Medicine 48: 1538–42

    Systematic review

    n=23 studies

    There is evidence that focused ESWT is effective in the treatment of plantar fasciitis, calcific tendinitis, and that radial pulse therapy is effective in plantar fasciitis. Where benefit is seen in focused ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. There is low level evidence for lack of benefit of low-dose focused ESWT and radial pulse therapy in non-calcific rotator cuff disease and mixed evidence in lateral epicondylitis.

    Review included mixed indications.

    A more recent systematic review is included.

    Tornese D, Mattei E, Bandi M et al. (2011) Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: a randomized study. Clinical Rehabilitation 25: 731–9

    RCT (ESWT neutral position technique versus ESWT with hyper-extended internal rotation technique)

    n=35

    Follow up: 3 months

    Positioning the shoulder in hyperextension and internal rotation during extracorporeal shock wave therapy seems to be a useful technique to achieve resorption of calcific deposits.

    Included in systematic review (Surace 2020).

    Verstraelen FU, In den Kleef NJHM, Jansen L et al. (2014) High-energy versus low-energy extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: which is superior? A meta-analysis. Clinical Orthopaedics and Related Research 472: 2816–25

    Systematic review

    n=5 RCTs

    All 5 RCTs showed greater improvement in functional outcome (Constant-Murley score) in patients who had high-energy ESWT compared with patients who had low-energy ESWT at 3 and 6 months. The 3-month mean difference was 9.9 (95% CI, 9.0 to 10.7, p<0.001; 6-month data could not be pooled). Furthermore, high-energy ESWT more often resulted in complete resorption of the deposits at 3 months. The corresponding odds ratio was 3.4 (95% CI, 1.4 to 8.6) and p=0.009 (6-month data could not be pooled).

    Review focuses on comparison on high and low-energy ESWT.

    A more recent systematic review is included, which includes the same studies.

    Wang C-J, Yang KD, Wang F-S et al. (2003) Shock wave therapy for calcific tendinitis of the shoulder: a prospective clinical study with two-year follow-up. The American Journal of Sports Medicine 31: 425–30

    Non-randomised comparative study (ESWT versus sham)

    n=43

    Follow up: 24 to 30 months (study group)

    The overall results in the study group were 61% excellent (20/33 shoulders), 30% good (10), 3% fair (1), and 6% poor (2), and those of the control group were 17% fair (1/6 shoulders) and 83% poor (5). The symptom recurrence rate in the study group was 7%. Dissolution of calcium deposits was complete in 58% of the study group, partial in 15%, and unchanged in 27%. Fragmentation was seen in 17% of the control group patients; in 83% deposits were unchanged. There was no recurrence of calcium deposits.

    Small, non-randomised study.

    Wu Y-C, Tsai W-C, Tu Y-K et al. (2017) Comparative effectiveness of nonoperative treatments for chronic calcific tendinitis of the shoulder: a systematic review and network meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation 98: 1678–92

    Systematic review and network meta-analysis

    n=14 studies

    The present network meta-analysis demonstrates that ultrasound-guided needling, radial ESWT, and high-energy focused ESWT alleviate pain and achieve complete resolution of calcium deposition. Compared with low-energy focused ESWT, transcutaneous electrical nerve stimulation, and ultrasound therapy, high-energy focused ESWT is the best therapy for providing functional recovery. Physicians should consider ultrasound-guided needling, radial ESWT, and high-energy focused ESWT as alternative effective therapies for chronic calcific tendinitis of the shoulder when initial conservative treatment fails.

    A more recent systematic review is included, which has the same studies on ESWT.

    Zoellner J, Nafe B, Rompe JD (2001) Shock wave therapy versus conventional surgery in the treatment of calcifying tendinitis of the shoulder. Clinical Orthopaedics and Related Research 387: 72–82

    Non-randomised comparative study

    n=79

    Follow up: 2 years

    Surgery was superior compared with high-energy shock wave therapy for patients with homogenous deposits. For patients with inhomogenous deposits, high-energy ESWT was equivalent to surgery and should be given priority because of its non-invasiveness.

    Small, non-randomised comparative study.