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Rotator cuff tendinopathy is one of the commonest causes of shoulder pain, mostly affecting the supraspinatus tendon. It is a common disabling condition that affects females more than males with predominance in the 3rd to 5th decades of life.
Supraspinatus tendinopathy is a degenerative condition termed as angiofibroblastic hyperplasia with a secondary neurogenic inflammatory component outside the tendon in the surrounding tissues, occurring with microtrauma mostly due to ischemia and release of inflammatory mediators.
Calcific supraspinatus tendinopathy is believed to occur in 3 stages; pre-calcific stage, calcific stage which is subdivided into: formative phase, resting phase and resorptive phase and the post-calcific phase. Non-calcific supraspinatus tendinopathy is considered as the pre-calcific stage by some authors.
Shoulder pain in the deltoid region is the presenting symptom, with worsening at night or after overhead activities with functional impairment. It leads to deltoid muscle wasting, decreasing the shoulder range of motion, decreasing shoulder girdle muscle power. Complications of supraspinatus tendinopathy includes subacromial impingement syndrome and microtears of the tendons that may progress to partial tears and in rare cases complete tears occur.
Investigations include X-ray, MRI and MSUS are done to confirm the diagnosis and to exclude other causes that mimic the clinical picture. MSUS is used for both diagnosis and in some cases treatment guidance.
Various treatments are used starting with oral and topical NSAIDs, physical therapy modalities; TENS, iontophoresis, therapeutic ultrasound, phonophoresis, LASER and ESWT. In chronic severe cases, minimal invasive techniques are used as subacromial corticosteroid injection, PRP injection, prolotherapy, US guided needling and lavage and dry needling. Surgical intervention is used as the last line of treatment in resistant severe cases.
Subacromial corticosteroid injections are the most widely used treatment in case of chronic rotator cuff tendinopathy. It is injected either blind or ultrasound guided. Different forms and dosages are available with the long acting corticosteroids are the most effective as triamcinolone 40 mg. There is a debate on its long term effects.
ESWT is a non-invasive modality used in treatment of tendinopathy. It depends on directing sound waves of high peak pressure to the targeted tissue. It has two types; radial and focused shock wave therapy. Its short term effects include pain relief and anti-inflammatory effect. Its long term effects include tissue healing and destruction of calcifications.
The aim of this study was to compare the short term effect of radial shockwave therapy versus ultrasound guided subacromial steroid injection in calcific and non-calcific chronic supraspinatus tendinpathy.
The study included 30 patients diagnosed with supraspinatus tendinopathy. They are 6 males and 24 females. Their age was between 32 and 60 years old. The duration of their symptoms was between 4 to 12 months.
The patients were assessed by full baseline clinical examination with focus on; the VAS, tenderness score, active shoulder range of motion and muscle power. MSUS was done to confirm the diagnosis of calcific or non-calcific tendinopathy and to detect subacromial subdeltoid bursitis and associated tendinopathies.
Four patients were diagnosed with calcific supraspinatus tendinopathy, fifteen patients had subacromial subdeltoid bursitis and six patients had associated bicipital tendinopathy.
The patients were divided into two groups; group I received a single subacromial ultrasound guided triamcinolone 40 mg and lidocaine injection, and group II received 4 sessions of radial shockwave therapy.
At 6 weeks follow up, both groups underwent clinical examination of the shoulder with recording the VAS.
There was no statistically significant difference between both groups at initial assessment of VAS, being 6.6+1.12 (in group I) and 6.86+1.18 (in group II). After treatment, group I showed highly significant improvement in VAS being 1.47+0.91. Also, group II showed highly significant improvement being 1.73+1.28. On comparing both groups regarding post-treatment, there was no significant difference with P>0.05 indicating both groups giving matched results.
There was no statistical significant difference between both groups at initial assessment of muscle wasting, observed in 2 patients in group I and 1 patient in group II. At follow up, a significant improvement was seen in both groups. But on comparing both groups there was no statistical difference (P <0.05).
There was no significant difference at initial assessment of both groups regarding the tenderness score being 6.67% for 1, 80 % for 2 and 13.3% for 3 in group I and0in group II; 20% for 1, 53.3% for 2 and 26.7% for 3. At follow up, no significant change was observed in group I being; 26.7% for 0, 60% for 1 and 13.3% for 2 in group I while a significant change was observed in group II; 33.3% for 0, 46.7% for 1 and 20% for 2. On comparing both groups, there was no significant difference (P-value >0.05).
There was no significant difference in both groups at initial assessment of both groups regarding muscle power. At follow up, there was no significant change in both groups and on comparing both groups there was no significant difference (P- value >0.05).
There was no significant difference in both groups at initial assessment of both groups regarding active shoulder range of motion. At follow up there was a significant change in both groups (P-value <0.05). On comparing both groups there was no significant difference (P-value >0.05)