Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously

The purpose of this study was to investigate the association of endocrine disease with calcific tendinitis and the effects that such disease has on its natural history. A retrospective observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Seventy-three (71.6 %) female, 29 (28.4 %) male. Compared with population prevalences, significant levels of endocrine disorders were found in our study cohort. Sixty-six patients (81 shoulders, 62 female (93.9 %), 4 male (6.1 %), mean age 50.3 years) with associated endocrine disease were compared with 36 patients (44 shoulders, 11 female (30.6 %), 25 male (69.4 %), mean age 52.4 years) without endocrine disease. The endocrine cohort were significantly younger than the non-endocrine cohort when symptoms started (mean 40.9 years and 46.9 years respectively, p=0.0026), had significantly longer natural histories (mean 79.7 months compared with 47.1 months, p=0.0015) and a significantly higher proportion underwent operative treatment (46.9 % compared with 22.7 %, p=0.0014). Disorders of thyroid and oestrogen metabolism may contribute to calcific tendinitis aetiology. Classifying calcific tendinitis into Type I idiopathic and Type II secondary or endocrine-related aids prognosis and management

There is debate regarding the most appropriate treatment of calcific tendinitis. Minimally-invasive techniques with image-guided needling of the deposits have been developed to provide an alternative solution. We present the results of fluoroscopically-guided barbotage in 100 patients. One hundred patients with acute or chronic shoulder pain, visible on plane radiographs or ultrasound scan, were referred from the Orthopaedic Department for barbotage over a six-year period. This study is a retrospective review of the results of barbotage in these patients, using a patient-based questionnaire. Forty three patients ultimately required arthroscopy of their painful shoulder. However, at surgery, the calcific deposits were noted to have dispersed in the majority of these patients. In addition there was often a long symptom-free period between the initial barbotage and recurrence of pain. In many cases the nature of their symptoms had changed and at arthroscopy signs of impingement or rotator cuff tears were common. Barbotage eliminated the need for more invasive surgery in over half of the patients in this study. It should be considered in all patients with calcific tendinitis refractory to non-operative treatment

Calcific tendinitis of the shoulder is a common cause of shoulder pain and is usually treated conservatively initially. We evaluated the ultrasound-guided needling procedure for calcium deposits in the rotator cuff. Between 2002 and 2003 eight men and 18 women (mean age 49 years) with calcific tendinitis of the shoulder were treated this way. The mean duration of symptoms was 29 months. Before the procedure, the skin and subacromial bursa were infiltrated with local anaesthetic. The calcium deposit was perforated and aspirated when possible. With saline, a lavage was done to wash out the calcium. Eleven patients (42.3%) had marked improvement in pain and needed no further treatment. Four patients required a reneedling procedure, and four patients needed repeated subacromial injections during the absorption phase of the calcium. In six patients arthroscopic calcium removal was needed. The mean visual analogue pain score during the procedure was 2.63. There were no complications. The ultrasound-guided needling procedure is an effective and well-tolerated method of treatment of calcific tendinitis of the shoulder and in 77% of our cases there was no need for surgical removal. Where there is incomplete dissolution, the procedure can be repeated

The aim of the study was to evaluate changes in clinical results after extracorporeal shock wave therapy (ESWT) on calcified lesions of the shoulder. 963 patients with calcifying tendinitis were treated with high energy shock waves. The mean energy flux density was 0. 28 mJ/mm2. To evaluate the effect we used the visual analogue scale (VAS) and the Roles-Maudsley-score to analyse the effect on activity of daily living, and pain perception. ESWT was indicated after non operative treatment failed. At 12 months after ESWT, 73. 6% of patients reported excellent and good results, 26% scored satisfactory and poor, using the Roles-Maudsley-Score. The positive effect of the ESWT on pain perception after 12 months was statistically significant (p< 0. 001). The difference between pain perception before and after ESWT persisted in the follow up interval. No decrease was shown after 2 years. In all cases no severe side effects were observed except small petechial haemorrhages. High energy shock wave therapy is indicated to treat calcifying tendinitis which is resistant to any other non-operative treatment. The decrease in pain perception persists over a period of more than two years. Absence of side effects and its effectiveness suggest that ESWT is indicated prior to surgical intervention

Aim To evaluate the functional results of rotator cuff function and integrity after arthroscopic excision of calcium and decompression with a minimum follow up of two years. Methods Between 2002 and 2004, sixty consecutive patients with calcific tendinitis underwent arthroscopic excision of calcium and subacromial decompression. Their average age was 51 years (range 28 to 78). The male to female ratio was 2:3. All patients were retrospectively reviewed by an independent observer. Functional outcome was assessed objectively by Constant scoring system and subjectively by Oxford Shoulder Questionnaire. The integrity of the rotator cuff was assessed by ultrasound scan. (Sonosite). Operative technique After arthroscopic subacromial decompression, all calcific deposits were excised with an arthroscopic rotating blade. The resultant cuff defect was left to heal and no cuff repair was performed. Other intra-articular pathology including SLAP lesions were treated at the same time. Postoperatively, early mobilization of the shoulder was encouraged. Results The mean Constant score at follow-up was 82 (range 63 to 100). Fifty-four patients (90%) had good or excellent results and six patients (10%) had a fair score. Ultrasound assessment showed intact rotator cuff with no residual defect in forty-three patients, partial thickness tears in twelve, and small full thickness tears in three. Two patients had recurrence of calcium. Only four of the fifteen patients who had ultrasound evidence of rotator cuff tear were symptomatic. Conclusion Arthroscopic excision of calcium and subacromial decompression is an effective method of pain relief in calcific tendinitis of the shoulder. 75% of the rotator cuff appeared to have healed after two years. Of the remaining 25% patients who had a defect in their supraspinatus tendon, only 6% remain symptomatic

Aims: The roentgenologic morphology of symptomatic calcified deposits of the rotator cuff can be classified according Gärtner (1993, Z Orthop Ihre Grenzgebiete 131: 461–469). This classification influences therapeutic procedures and prognosis of clinical outcome in these patients. In the present study intraoberserver-reproducibility and interobserver-reliability of Gärtner’s classification were tested. Methods: Plane radiographs of 100 patients with calcifications of the supraspinatus tendon were classified according the criteria of Gärtner by six independent observers twice within four months. Intrao-berserver-reproducibility and interobserver-reliability were calculated by means of Cohen’s-kappa-index. Results: Kappa-values of intraoberserver-reproducibility had a mean of 0.4208 (SD 0.1299), kappavalues of interobserver-reliability were 0.490 for the first and 0.474 for the second classification. Conclusions: Determination of intraoberserverreproducibility gave insufficient to satisfactory results, interobserver-reliability was sufficient. The clinical use of Gärtner’s classification to plan therapeutic procedures or to determine clinical prognosis in patients with calcifying tendinitis can be recommended only with limitations

The purpose of this study was to assess the clinical outcome of two non-invasive techniques used in the treatment of calcific tendinitis of the shoulder. Over the eight month period April 2000 to November 2000 sixty patients who were referred to this hospital with symptomatic calcific tendonitis were treated either with extracorporeal shockwave therapy (ESWT) using the Storz Medical Minilith (Storz Medical AG, Kreuzlingen, Germany) or by barbotage (needle puncture, aspiration and lavage under ultrasound control). All the patients had a long history of shoulder pain (average 42 months), caused by a radiographically evident calcific deposit, that had been unresponsive to conservative treatment including physiotherapy, steroid injections and non-steroidal anti-inflammatory tablets. 15 patients were treated with ESWT and 45 with ultrasound guided barbotage. The patients undergoing ESWT had the application head positioned under real time ultrasound or flouroscopic control. Patients had from one to three treatments with up to 2,500 shocks per treatment at incremental energy levels from 0.1 to 0.2 mJ/ mm2. Patients undergoing real time ultrasound guided barbotage had a single treatment. Clinical outcome was evaluated after a three month period with a postal questionnaire. Thirty-two of 45 patients (71%) in the barbotage group had a marked reduction in symptoms at three months compared to nine out of 15 (64%) of the ESWT group. Shockwave therapy (ESWT) and ultrasound guided barbotage are simple non invasive outpatient procedures which are effective in 64% to 71% of patients. These simple outpatient techniques should be considered for chronic pain due to calcific deposits that have been unresponsive to conservative treatments, and surgery reserved for those who fail to benefit

Purpose: We present the results of subacromial decompression and repair of the rotator cuff through a minimal deltoid-on approach. Material and Method: Eighty-seven patients with longstanding shoulder pain were evaluated in two years (1999–2000) in our department. In sixty -eight of them symptoms were due to impigment syndrome. Eight patients with follow up time less than six months were excluded from this study, twenty were treated conservatively and the remaining forty (22 female, 18 male, mean age 50.3) underwent surgery. Three x-ray views were obtained in all patients, i.e. standard AP, true AP, and subacromial space projection. MRI was also obtained in all patients. MRI revealed calcific tendinitis in fifteen patients, osteophytes of the acromioclavicular joint in thirteen, a hooked (type III) acromion in ten and partial tear of the supraspinatus tendon in nineteen. In five of them there was also a partial tear of the infraspinatus. Finally, seven patients were suffering of a full thickness tear of the supraspinatus tendon. All patients were operated through a minimal deltoid-on approach. Acromioplasty and coracoacromial ligament dissection was performed in all. In patients with osteoarthritis of the acromioclavicular joint, osteophytes were carefully removed. Calcific deposits were also removed in all patients. In eighteen patients tears of the rotator cuff were detected and repaired using bone anchors. Results: All patients were examined six months postoperatively. Results were evaluated with CONSTANT SCORE and with a questionnaire for patient’s satisfaction. Thirty-seven patients were very satisfied with the result and three were satisfied. As for Constant score, pain improved at an average of 7.8 points, daily activities by 5.4, and range of movement by 4.2 points. Results were evaluated by the examiner as excellent in thirty-six patients (90%) and very good in four patients. Conclusion: Deltoid-on approach, in patients with impingement syndrome of the shoulder provides adequate exposure for the surgical repair with minimal trauma and a very low rate of complications

The February 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: whether we should replace fractured shoulders; the limited evidence for shoulder fractures; cuffs and early physio; matrix proteins and cuff tears; long-term SLAP tear outcomes; suture anchors; recurrent Bankart repairs; and acromial morphology and calcific tendonitis.

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.