Is Extracorporeal Shockwave Therapy Effective Even in The Treatment of Partial Rotator Cuff Tear
Is Extracorporeal Shockwave Therapy Effective Even in The Treatment of Partial Rotator Cuff Tear
Is Extracorporeal Shockwave Therapy Effective Even in The Treatment of Partial Rotator Cuff Tear
2, 709-714 (2020)
Orthopaedics Unit, Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty
1
of Medicine and Surgery, Aldo Moro University of Bari, General Hospital, Bari, Italy; 2Rehabilitation
Unit, Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine
and Surgery, Aldo Moro University of Bari, General Hospital, Bari, Italy; 3Hygiene Unit, Department of
Biomedical Science and Human Oncology, Aldo Moro University of Bari, General Hospital, Bari, Italy
Corresponding Author:
Dr Angela Notarnicola,
Orthopaedics Unit, Department of Basic Medical Science, 0393-974X (2020)
Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, Copyright © by BIOLIFE, s.a.s.
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709 DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF
INTEREST RELEVANT TO THIS ARTICLE.
710 A. NOTARNICOLA ET AL.
those variables that have been shown to be associated to the pain during the study period. No patient reported
the respective outcome in simple linear regression. The adverse effects. No statistically significant differences
correlation coefficient was indicated calculating 95% CI were observed between groups for anthropometric
and the Student’s t-test. For all tests a value of p <0.05 variables of weight (mean value: 71.6±10.5 kg; t=0.4;
was considered significant. p=0.697), height (mean value: 162.2±8.6 cm; t =0.2; p
=0.82) and BMI (mean value: 27.3±4.0 kg/cm2; t=0.3;
RESULTS p=0.773). Three patients (10%) were tobacco smokers
and there were no statistically significant differences
The sample of the study was made up of thirty in the distribution of smokers per group (X2=0.4;
subjects, of whom 15 (50%) belonged to the ESWT p=1.000). On average, patients had experienced
group and the remaining 15 (50%) to the exercise symptoms for 12.6±8.2 months (range=2.0-24.0)
group. Twenty (66.7%) patients were female and prior to enrollment, and no statistically significant
there were no statistically significant differences in the differences were observed between groups (t=1.4;
distribution of females per group (X2=0.0; p=1.000); p=0.186). No statistically significant differences were
the mean age of the group was 65.2±8.7 years (range = observed in the distribution of right limb patients
45-81) and no statistically significant differences were affected by right shoulder injury(p> 0.05). ANOVA
observed in the comparison of the mean age between analysis for repeated measurements showed that
groups (t = 0.2; p=0.807). No drop-out occurred. All there was a statistically significant difference in the
patients reported that they did not use drugs to manage comparison between variable times (T0-T1) of the
Fig. 1. The sonographic images of a 71 year-old female showing the tear of the rotator cuff tendon at T0. The tear size
is 5.5 mm on the longitudinal axis, 3 mm on the transversal axis (a) and 6.4 mm on the antero-posterior axis (b). Three
months after ESWT the tear size in the same patient is 5.4 on the longitudinal axis, 0.74 mm on the transversal axis (c)
and and 4.7 mm on the antero-posterior axis (d).
712 A. NOTARNICOLA ET AL.
T0
7.41.4 7.50.8 7.41.1
Pain (VAS)
(5.0 – 10.0) (5.0 – 8.0) (5.0 – 10.0)
2.70.7 3.30.7 3.00.8
MMT
(1.0 – 4.0) (2.0 – 5.0) (1.0 – 5.0)
32.214.2 31.611.3 31.912.6
ASES
(8.4 – 51.6) (18.3 – 54.9) (8.4 – 54.9)
Lenght of lesion
6.31.5 6.41.9 6.41.7
( longitudinal axis)
(3.2 – 8.9) (3.2 – 10.7) (3.2 – 10.7)
(mm)
Length of lesion
5.21.5 5.51.8 5.41.6
( transversal axis)
(3.5 – 7.8) (2.6 – 9.1) (2.6 – 9.1)
(mm)
Lenght of lesion
2.90.8 2.90.8 2.90.8
(antero-posterior
(1.5 – 4.3) (1.5 – 4.5) (1.5 – 4.5)
axis) (mm)
T1
3.92.2 6.91.2 5.42.3
Pain (VAS)
(1.0 – 8.0) (4.0 – 8.0) (1.0 – 8.0)
3.31.1 3.10.6 3.20.9
MMT
(1.0 – 5.0) (2.0 – 5.0) (1.0 – 5.0)
54.921.8 35.312.4 45.120.1
ASES
(28.3 – 93.3) (18.3 – 54.9) (18.3 – 93.3)
Lenght of lesion
5.32.4 6.21.8 5.82.1
( longitudinal axis)
(2.0 – 10.0) (3.5 – 10.6) (2.0 – 10.6)
(mm)
Length of lesion
4.12.1 5.43.4 4.72.9
( transversal axis)
(1.5 – 8.9) (1.2 – 16.7) (1.2 – 16.7)
(mm)
Lenght of lesion
1.90.9 2.51.0 2.21.0
(antero-posterior
(0.5 – 3.1) (0.7 – 4.5) (0.5 – 4.5)
axis) (mm)
(T0:
(T0: at enrollment;
at enrollment; T1:T1:
afterafter 3 months)
3 months) (data(data are expressed
are expressed as +/-
as mean mean +/- standard
standard deviation
deviation and
and range).
range).
VAS value (F=17.4; p=0.000), of the ASES value interaction between time and group for VAS value
(F=19.7; p=0.000) and of the size of the lesion (on (F=7.0; p=0.013), for MMT value (F=6.5, p=0.016),
longitudinal axis: F=5.5, p=0.027; on a transverse for ASES value (F=9.6, p=0.005, Table I) and for the
axis: F=9.5, p=0.005; on an antero-posterior axis: size of the lesion on the antero-posterior axis (F=4.2;
F=22.9; p =0.000) (Table I). There was a significant p=0.049). Simple linear regression analysis showed
difference between groups for the VAS value (F=6.7, a statistically significant link between VAS value at
p=0.016). T1 and group (coefficient = -0.7; 95% CI = -1.0 -
A significant difference was observed in the -0,4; t=4.7; p=0.000). The MMT value at T1 had a
Journal of Biological Regulators & Homeostatic Agents
713
statistically significant association with the MMT the greater susceptibility of the tissue.
value at T0 (coef.=0.5; 95% CI=0.1-0.9; t =2.8; p = We hypothesize that an important role of
0.009). The ASES value at T1 was associated both shock waves in the treatment of tendon lesions
with the ASES value to T0 (coef. = 0.8; 95% CI=0.2 is the anti-oedema and anti-inflammatory effect,
-1.3; t = 2.9; p = 0.008) and with group (coefficient = which could slow the progression of degeneration
6.5; 95% CI = 6.4-32.9; t =3.0; p = 0.005). The size and tendon injury (9). Simultaneously, the shock
of lesion at T1 was associated with the size at T0 on waves determine a trophic and reparative effect
the same axis (on longitudinal axis: coef. = 0.9; 95% on the tendon tissue, improving the differentiation
CI=0.6 - 1.3; t=5.9; p=0.000) (on axis transverse: of precursor cells towards tenoblast-like cells,
coef.=0.2; 95% CI=0.1-0.3; t=4.8; p=0.000) (on modulating cell morphology and increasing collagen
antero-posterior axis: coef.=0.7; 95% CI=0.3 - 1.0; synthesis of type I (10).
t=3.7; p=0.001) (Fig. 1). The weak points of this study are the short
There were no further associations between the follow-up period, the absence of MRI monitoring,
outcomes and the remaining determinants in analysis the absence of a placebo or untreated control group.
(p>0.05). From the multivariate linear analysis we The strength is verification of the effect of shock
observed an association at the limits of the statistical waves in a new clinical picture, such as tendon tear.
significance between the MMT value at T1 and the It might be interesting to check whether shockwave
MMT value at T0 (coef. = 0.4, t = 2.0, p=0.055). therapy can also be effective for a preventive
Multivariate linear analysis showed an association action in different clinical conditions in which co-
at the limits of statistical significance between ASES morbidities (for example of a metabolic type, such
value at T1 and ASES value at T0 (coef. = 0.7; t = 3.3; as thyroid pathologies) (11) or drug administration
p = 0.003) and group (coefficient = 19.2; t = 3.5; p = (e.g. corticosteroids) (12) are responsible for
0.002). ischemic suffering and degenerative overload of
musculoskeletal tissues.
DISCUSSION In conclusion, ESWT could be indicated for the
treatment of cuff tendon injury. We have excluded
Our data show that in the treatment of RCT, that the mechanical stimulation of the shock waves
shockwave therapy allowed to obtain both speeds up the opening of the tendon lesion, and we
improvement and reduction in the size of the tendon found a stabilization with size reduction on one of the
lesion (on the antero-posterior axis). Our results axes. Further studies will allow to verify the effects
support the interest of comparing the effects of on longer times and in association with exercise.
shock waves with surgery, using either mini-open
or arthroscopic methods, which are increasingly ACKNOWLEDGEMENTS
popular for the management of tendon lesions (2).
Until now, shockwave treatment for rotator cuff The authors thank Maria Assunta Pinto B.A. for
tendinopathy has been reserved almost exclusively language revision.
for cases of calcific tendinosis, in the presence
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