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Table 2 Imaging outcome measures for rotator cuff calcifying tendinitis

From: The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

Author (year) SWT type Comparator Imaging outcome Follow-up
Period Baseline - F/U
Mean ± SD
P value
Within group Between group
Albert (2007) [20] High SWT Low SWT The radiological aspects of calcifications (i.e. type, size and location) were determined through lateral and anteroposterior shoulder views in neutral, external and internal rotation. Changes were graded as no resorption, partial resorption and total or subtotal resorption (over 80% reduction of calcified surface on anteroposterior view) 3 months High: 6(15%) had total or subtotal resorption. 3(7.5%) had partial resorption
Low: 2(5%) had total or subtotal resorption. 5(12.5%) had partial resorption
NR NR
Cacchio (2006) [21] R-SWT Placebo The radiological aspects of calcifications (i.e. type, size and location) were determined through lateral and anteroposterior shoulder views in 45 degrees of external and internal rotation were acquired. Type of calcification was evaluated according to the Gartner and Simons classification. A caliper that evaluated calcification length (in millimeters) was used for size measurement. 1 week 39(86.6%) had total resorption, 6(13.4%) had partial resorption, while the control group, no complete disappearance of calcifications was observed.
The mean Calcium deposits diameter (mm) pre-SWT was 21.3 ± 7.5, post-SWT was 0.85 ± 1.2. In contrast, pre-sham was 19.7 ± 8.3, post-sham was 18.85.8 ± 6.4.
< 0.00 < 0.00
Charrin (2001) [22] F-SWT None Calcific deposit appearance was assessed on a plain radiograph in neutral rotation 3,6,12,24 weeks After 12 weeks, 2/30 had total resorption. 5 deposits had partial resorption.
After 24 weeks, 5/29 had total resorption and 2 deposits had partial resorption
NR NA
Cosentino (2003) [23] F-SWT Placebo Variations in the dimension of the calcification were evaluated by anteroposterior views. Modification of the calcification (a reduction of size of > 2 mm) was indicated as disintegration; the total disappearance was indicated as dissolution. 1 month 11(31%) had total resorption, 14(40%) had partial resorption. Calcification remained unchanged in the control group < 0.001 NR
Daecke (2002) [24] F-SWT 1 vs 2 sessions Anteroposterior radiograph in internal and external rotation was obtained to show obvious changes in the shape and structure (disintegration) or complete resorption of the calcification 3,6 months, 4 years 30% in group A and 52% in group B had partial or total resorption after 3 months, 47 and 77% after 6 months and 93% for both groups at 4 years NR < 0.046 at 6 months
DeBoer (2017) [25] R-SWT Ultrasound Needling (UN) Scoring of calcification deposits was assessed through the Gartner Classification of Calcific Tendinitis. 6 weeks 1/14 (7%) in the R-SWT group had total resorption vs 5/11 (45.5%) in UN group NR 0.029
DelCastillo-Gonzalez (2016) [26] F-SWT Ultrasound-guided percutaneous lavage (UGPL) Calcification size measurement was assessed by ultrasound imaging. 3,6,12 months 55.6% had total resorption by 12 months in the SWT group vs 86.78% in the UGPL group.
The mean Calcium deposits diameter (mm) pre-SWT was 10.53 ± 5.29, post-SWT was 4.67 ± 6.08 after 12 months. In contrast, pre-UGPL was 12.075 ± 4.85, post-UGPL was 1.56 ± 2.79.
< 0.01 < 0.01
Farr (2011) [27] F-SWT Low SWT Radiological difference of the calcific deposit was rated as improvement, unchanged or worsening 6,12 weeks 58% improved in group A compared to 69% in group B after 12 weeks.
5 in group A, and 4 in group B had total resorption
NR NR
Gerdesmeyer (2003) [28] F-SWT Low SWT and placebo The radiological aspects of calcifications (i.e. type, size and location) were determined through anteroposterior shoulder views in 45 degrees of external and internal rotation. 3,6,12 months High: 60% had total resorption within 6 months and 86% after 12 months. Low: 21% had total resorption within 6 months and 37% after 12 months. Placebo: 11% had total resorption within 6 months and 25% after 12 months.
Calcific deposit size (mm2) mean change from baseline after 12 months was − 162.2 (95%CI − 204 to −120) in the High-SWT group, − 91.5 (95%CI − 148 to − 35.1) low-SWT group and − 46.8 (95%CI −74.3 to −19.3) in the placebo group
NR group 1 vs 3 P < 0.01, group 2 vs 3 P = 0.1, group 1 vs 2 p = 0.04
Hsu (2008) [29] F-SWT Placebo An anteroposterior radiograph with the arm in neutral rotation was obtained. The calcific deposits were categorized according to morphology and size (the longest length of the calcium deposit). Scoring of calcification deposits was assessed through the Gartner Classification of Calcific Tendinitis 6 weeks, 3,6,12 months 7(21.2%) had total resorption, 11(36.6%) had partial resorption. In the control group, none had total resorption and 2(15.3%) had partial resorption.
The mean Calcium deposits diameter (mm) pre-SWT was 11.9 ± 5.4 (3.4–23.5), post-SWT was 5.5 ± 6.3 (0–18.7). In contrast, pre-sham was 10.5 ± 6.4 (2.5–20.4), post-sham was 9.8 ± 5.9 (2.3–21).
< 0.01 < 0.01
Jakobeit (2002) [30] F-SWT None Diagnostic ultrasonography and radiography were used to classify the calcareous deposits in 5 categories according to their morphological appearance and size. 4 weeks 57/80 (71.25%) had total resorption. 16/80 (20%) had partial resorption NR NA
Kim (2014) [31] F-SWT Ultrasound Needling Radiographic evaluations were performed by standard shoulder anteroposterior radiographs in neutral, internal, and external rotation together with axillary and supraspinatus outlet views to determine the size, morphology, and location of the calcific deposits. Resorption of the calcific deposit was graded as none, partial, or complete. 6 weeks, 3,6,12 months The mean Calcium deposits diameter (mm) pre-SWT was 11 ± 1 (4.9–19.3), post-SWT was 5.6 ± 0.8. In contrast, pre-US needling was 14.8 ± 1.7 (6.6–31), post-US needling was 0.45 ± 0.3.
In the SWT group, 42.6% had total resorption, 16.7% had partial resorption. In the US needling group 72.2% had total resorption and 11.1% had partial resorption.
< 0.05 =0.001
Kransy (2005) [32] F-SWT Ultrasound Needling combined with SWT Anteroposterior radiographs were taken in internal and external rotation together with axial and supraspinatus-outlet views to determine the size, morphology and location of the calcific deposits. 4.1 ± 0.5 In the SWT only group, 13(32.5%) had total resorption, 14 (35%) had partial resorption. In the US needling combined with SWT group 24(60%) had total resorption and 10 (25%) had partial resorption. NS =0.024
Loew (1999) [33] F-SWT Low SWT and control Radiographs included an anteroposterior view in internal and external rotation and a supraspinatus outlet view. Effective treatment was recorded when the calcification had completely disappeared or showed obvious resorption with inhomogeneity and reduction in size 3,6 months There was total resorption in 4/20 in group 1, 11/20 in group 2, 12/20 in group 3, in contrast to 2/20 in the control group Group 1 = 0.37
Group 2, 3 < 0.01
NR
Lowe (1995) [34] F-SWT None Radiological assessment of the calcification was made in three different planes. 6,12 weeks After 12 weeks, changes were seen in 12 patients; 7 showed a total resorption of the calcium deposits NR NA
Moretti (2005) [35] F-SWT None Radiographs in anteroposterior of shoulder, acromial outlet view and sonography were evaluated to study the type of calcium deposit according to DePalma criteria 1,6 months 29/54 (54%) had total resorption and 19/54 (35) had partial resorption after 1 month. These findings appeared unvaried at 6 months follow-up NR NA
Pan (2003) [36] F-SWT TENS High-resolution ultrasonography (HRUS) was used for imaging measurements. The morphology of calcific plaque of the shoulder on HRUS was classified into 4 types: (1) arc-shaped (echogenic arc with clear shadowing), (2) fragmented (at least 2 separated echogenic plaques with or without shadowing) or punctuated (tiny calcific spots without shadowing), (3) nodular (echogenic nodule without shadowing), and (4) cystic types (bold echogenic wall with echo-free content) 2,4,12 weeks The mean of difference in Calcium deposits diameter (mm) in the SWT group was 4.39 ± 3.76 after 12 weeks. In contrast, the TENS group was 1.65 ± 2.83.
16/33(48.5%) changed in the type of calcification In the SWT group while 3/29 (10.3) in the TENS group.
< 0.01 0.002
Pigozzi (2000) [37] F-SWT None Radiological assessment of anteroposterior, internal and external rotation and trans-glenoid projection was performed 1 month 7/19 (37%) had reduction or fragmentation of the calcium deposit NR NA
Pleiner (2004) [38] F-SWT Placebo Anteriorposterior, axial and outlet-view images were used. Changes calcifications were assessed using the Gartner scale in which a score of 1: indicates no change or a worsening, a score of 2: a decrease of at least 50% in the area and density of the calcification, and a score of 3: complete remission of the calcification 3,7 months 6/31 (19.4%) had total resorption and 6/31 (19.4%) had partial resorption in the SWT group, in contrast to 2/26 (7.7%) had total resorption and 2/26 (7.7%) had partial resorption in the control group after 7 months NR =0.07
Rompe (1995) [39] F-SWT None On radiographs, any sign of disintegration was rated as success 6,24 weeks 4/40 (10%) had total resorption and 17/40 (42.5%) had partial resorption after 6 weeks.
After 24 weeks, 6/40 (15%) had total resorption and 19/40 (47.5%) had partial resorption
NR NA
Rompe (2001) [40] F-SWT Surgical extirpation On the anteroposterior radiological views, resorption was graded as none, partial, or complete. 12 months 47% had total resorption and 33% had partial resorption in the SWT group. In the surgical group, 85% had total resorption and 15% had partial resorption. There was no significant difference regarding the radio-morphologic features NR < 0.01
Sabeti-Aschraf (2005) [41] F-SWT Navigation vs feedback No change in the radiographs was graded as 4, a 3 indicated slight alteration of the calcium deposit, reduction in deposit size and radiographic density was graded as 2, and a 1 was given if the calcium deposit was no longer evident 3 months 6/25 (24%) had total resorption and 7/25 (28%) had extensive resorption in the navigation group, in contrast to 1/25 (4%) had total resorption and 5/25 (20%) had partial resorption in the feedback group NR 0.041
Tornese (2011) [42] F-SWT Neutral vs hyperextended internal rotation arm position Changes between pre- and post-treatment radiographs were graded as no resorption, partial resorption and total or subtotal resorption (> 80% reduction in calcified surface on anteroposterior view) 3 months 12/18 (66.7%) had total resorption in the hyperextended internal rotation group, in contrast to 6/17 (35.3%) in the neutral position group NR < 0.05
  1. F-SWT focused SWT, R-SWT radial SWT, NR not reported, NS not significant, NA not applicable