EVALUATING TREATMENT OPTIONS FOR TREATMENT EVALUATING EVALUATING TREATMENT OPTIONS FOR CALCIFIC TENDINITIS OF THE ROTATOR CUFF CALCIFIC TENDINITIS CALCIFIC OF THE ROTATOR CUFF OF THE ROTATOR JAN LOUWERENS JAN Jan Louwerens EVALUATING TREATMENT OPTIONS FOR CALCIFIC TENDINITIS OF THE ROTATOR CUFF Jan Louwerens EVALUATING TREATMENT OPTIONS FOR CALCIFIC TENDINITIS Evaluating treatmentOF THE options ROTATOR for calcific tendinitis CUFF of the rotator cuff ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. ir. K.I.J. Maex COLOFON ISBN: 978-94-6421-031-6 Cover: John den Exter & Annemieke Louwerens ten overstaan van een door het College voor Promoties ingestelde commissie, Lay-out: Birgit Vredenburg, persoonlijkproefschrift.nl in het openbaar te verdedigen in de Agnietenkapel Illustrations: Jessie van Hattum op vrijdag 6 november 2020, te 13.00 uur Printed by Ipskamp Printing | proefschriften.net The printing of this thesis was financially supported by: Wetenschapsbureau Spaarne Gasthuis, Nederlandse Orthopaedische Vereniging, Nederlandse Vereniging voor door Arthroscopie, Wetenschapsfonds Amsterdam Medisch Centrum, Richard Wolf GmbH, Maatschap Orthopedie Spaarne Gasthuis, Coral, Orthis, Link & Lima Nederland, Kaptein Orthopedie, Nederlandse Vereniging voor Musculoskeletale Shockwave Therapie, Oudshoorn Orthopedie, Enraf Nonius, Verheul & Weerman Fysiopraktijken and Jan Karel Gerard Louwerens Chipsoft geboren te Rotterdam Copyright © 2020 Jan Karel Gerard Louwerens. All rights are reserved. No part of this thesis may be reproduced or transmitted in any form or by any means without the prior permission in writing of the author. 3 PROMOTIECOMMISSIE TABLE OF CONTENTS Promotores: prof. dr. B.J. van Royen Vrije Universiteit Amsterdam Chapter 1 General introduction and thesis outline 7 prof. dr. D. Eygendaal AMC-UvA Part 1: Epidemiological and radiological evaluation of calcific tendinitis of the rotator cuff Copromotores: dr. A. van Noort Spaarne Gasthuis dr. M.P.J. van den Bekerom OLVG Chapter 2 Prevalence of calcific deposits within the rotator cuff tendons in adults with and without 27 subacromial pain syndrome: clinical and radiologic analysis of 1219 patients Overige leden: prof. dr. J.L. Tol AMC-UvA Chapter 3 Radiographic assessment of calcifying tendinitis of the rotator cuff: an inter- and 43 intraobserver study prof. dr. M. Maas AMC-UvA dr. P.P.F.M. Kuijer AMC-UvA Part 2: Exploring minimally invasive treatment options prof. dr. R.L. Diercks Rijksuniversiteit Groningen Chapter 4 Evidence for minimally invasive therapies in the management of chronic calcific 59 prof. dr. G.J. Kleinrensink Erasmus Universiteit Rotterdam tendinopathy of the rotator cuff. A systematic review and meta-analysis dr. M. Reijnierse LUMC Chapter 5 The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound- 87 guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: a systematic review Faculteit der Geneeskunde Part 3: Evaluating the effectiveness of high-energy ESWT versus ultrasound-guided needling Chapter 6 Comparing ultrasound-guided needling combined with a subacromial corticosteroid 113 injection versus high-energy extracorporeal shockwave therapy for calcific tendinitis of the rotator cuff: a randomized controlled trial Chapter 7 The impact of minimally invasive treatment for rotator cuff calcific tendinitis on self- 137 reported work ability and sick leave Chapter 8 Quantifying the minimal and substantial clinical benefit of the Constant-Murley score 153 and the Disabilities of the Arm Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff Chapter 9 General discussion, clinical implications and future perspectives 171 Chapter 10 Summary 189 Appendix Treatment flowchart (Dutch) 197 Nederlandse samenvatting 200 PhD portfolio 208 List of publications 210 Dankwoord 212 About the author 216 1 General introduction and thesis outline CHAPTER 1 GENERAL INTRODUCTION AND THESIS OUTLINE GENERAL INTRODUCTION 1 CALCIFIC TENDINITIS OF THE ROTATOR CUFF Calcific tendinitis of the rotator cuff is a condition characterised by the deposition of hydroxyapatite crystals in tendons.1 It is frequently encountered in the rotator cuff tendons.2 The rotator cuff is a complex of four muscles and their tendons that act as important stabilizers of the glenohumeral joint and provide strength during abduction and rotation (figure 1). Rotator cuff calcific tendinitis (RCCT) is an important source of nontraumatic shoulder pain.3 It is generally considered to be a self-limiting disease with spontaneous improvement of symptoms over time. However, in some individuals symptoms can be prolonged and intense. Its estimated prevalence in the population ranges from 2.7% to 20%.2,4,5 The condition typically affects patients between 30 to 60 years of age, and women are more frequently affected than men.5,6 Based on imaging studies, the supraspinatus tendon is affected in approximately 80%, the infraspinatus tendon in 15%, and the subscapularis tendon in 5%.7 In up to 10% of patients, the pathology appears bilateral.2,8 PATHOPHYSIOLOGY In calcific tendinitis, hydroxyapatite crystals deposits in the substance of a tendon (figure 2 & 3). The condition can affect any tendon at its insertion. Although calcific deposits are most frequently seen around the shoulder and in the Achilles tendon, they have also been described in other tissues such as the rectus femoris muscles or intra-osseous locations.9–11 Radiographic and infrared spectrometry identified the consistency of the material as calcium carbonate apatite12 and in more detail, two different types of carbonate apatite were identified, according to the position of the carbonate ions in the hydroxyapatite.13 While macroscopically the material is frequently described as either a toothpaste like fluid or a mass of sandy material, there are conflicting reports in the literature whether there is also a chemical compositional change in the different phases of the disease.1,14,15 The presence of calcific deposits in the rotator cuff tendons is known under many names: calcific tendinitis, calcifying tendinopathy, tendinosis calcarea, calcareous tendinitis, calcific periarthritis and periarticular apatite deposit.16 Some terms try to emphasize the extra-articular location of the calcium deposit while others mention the compound found in the calcification or the fact that there is a distinction between an inflammation or non-inflammatory degeneration of the tendon.17 Painter18 was the Figure 1. Anatomy of the rotator cuff. Netter illustration used with permission of Elsevier Inc. first to describe the radiographic findings in 1907. A few years before Harrington and All rights reserved. www.netterimages.com Codman performed the first reported operative removal of a calcific deposit.19 8 9 CHAPTER 1 GENERAL INTRODUCTION AND THESIS OUTLINE The precise pathogenetic mechanism of RCCT remains debated. In 1930, Codman19 1. Pre-calcific stage:tendon transformation in fibrocartilaginous tissue in less vascular hypothesized that the formation of calcification was preceded by a degenerative areas of the tendon, which acts as a substrate for calcium deposition. 1 process of the tendon. In 1938 Sandstrom20 stated that local ischemia and vascular 2. Calcific stage: actual calcium deposition in the tendon. It is composed of the changes caused necrosis of the tendon which was the first step in the deposition of formative, resting and resorptive phase. In the formative phase the matrix calcific material. Bishop21 thought repetitive minor trauma could induce micro tears vesicles unite to become calcific deposits that are separated by fibrocartilage in the tendon tissue, hyaline degeneration and deposition of calcium. Bosworth21 or fibrocollagenous tissue. This process is mediated by the chondrocytes of the supported this theory in his classic study among 6061 volunteers. In 1997, the most fibrocartilaginous metaplasia. The resting phase is noticeably dormant, with a lack advocated theory by Uhthoff and Loehr was published, suggesting the occurrence of a of inflammation or vascular infiltration. The resorptive phase begins after a variable cell-mediated reactive calcifying process that is preceded by initial cartilage metaplasia.7 time period and correlates with the appearance of thin walled vascular channels, Uhthoff divided the pathogenesis of RCCT in three stages (figure 4.): as well as macrophages phagocytosis of the calcium deposit. This phase is also characterized by oedema and increased intratendinous pressure with possible extravasation of calcium crystals in the subacromial bursa or greater tubercle. 3. Post-calcific stage:following resorption, fibroblasts and granulation tissue appear in the previous site of the deposits. This process usually ends with complete healing of the involved tendon and can take several months. Figure 2. Antero-posterior radiograph of the left shoulder showing a calcific deposit in the Figure 3. Corresponding illustration highlighting all relevant anatomical structures. supraspinatus tendon. 10 11 CHAPTER 1 GENERAL INTRODUCTION AND THESIS OUTLINE CLINICAL PRESENTATION The clinical presentation of patients with RCCT is variable. Patients generally experience 1 Since the paper from Uhthoff in the late 90s, Rui et al.22,23 developed an alternative pain that is similar to the clinical presentation of subacromial pain syndrome. The active theory