Calcific tendonitis & Ultrasound-guided barbotage

Ultrasound guided barbotage for calcific tendonitis

What is Calcific tendonitis?

Relevant anatomy

What is Calcific tendonitis?

Calcific tendonitis (calcific tendinopathy) refers to the deposition of calcium material within the rotator cuff tendons. The patients usually do not recall a specific reason for the pain, which can be severe, causing restriction to shoulder movements, and can be mistaken for other conditions like frozen shoulder.

Relevant anatomy

The shoulder is a ball and socket type of joint. The ball is formed by the humeral head (the upper end of the arm bone), and the socket is formed by the glenoid, the part of the shoulder blade that articulates with the humerus. The rotator cuff muscles are located at the front, back and on top of the shoulder blade and consist of 4 muscles (the supraspinatus, infraspinatus, subscapularis and teres minor tendons). Their tendons form a complete cuff of tissue that attach to the humerus (the ball component of the shoulder joint). The rotator cuff muscles and tendons are vital in shoulder movement and stability. They are essential for shoulder rotation and lifting the arm and ensure the ball remains well-centred within the socket throughout the range of movement. The supraspinatus tendon is the one most commonly affected by the disease. Dr Al-Ani has published an article about the various conditions that can affect the rotator cuff tendons.

The rotator cuff tendons run immediately underneath the subacromial bursa, an important anatomical structure. A bursa is a thin fluid-containing sac usually seen adjacent to a bone to provide cushioning effect and protection. We have a few of these within our body (like in the shoulder and hip). Unfortunately, these can get injured or irritated, resulting in bursal inflammation (bursitis). The sub-acromial bursa is the largest in the body, located within the shoulder and runs on top of the rotator cuff tendons. It ensures smooth gliding of the rotator cuff tendons during shoulder movements. Sub-acromial bursitis is inflammation of this bursa and is commonly seen in rotator cuff disease/pain.

How common is shoulder calcific tendonitis?

Calcific tendonitis is reported in about 5% of the population but approx. 20% of the cases can be asymptomatic. Supraspinatus tendon is most commonly involved with calcification (approx. 80% cases). The infraspinatus and subscapularis are less commonly affected (15% and 5%, respectively).

What is the cause of calcific tendonitis?

The exact aetiology of calcific tendinitis has yet to be fully understood. However, some research suggests a transformation of the cells that produce tendon tissue into a different type of cell that produces cartilage. This, in turn, can result in calcium deposition within the tendon. It is more common in diabetic patients and women between 40 and 60. It is also more common in people who use their arms excessively, like manual workers and athletes. Deposition of calcium is also reported following trauma.

What are the symptoms of shoulder calcific tendonitis?

Calcific tendonitis can result in sudden onset, severe pain in the shoulder, especially when the calcium material irritates the subacromial bursa. The pain can refer down the arm and interfere with sleep.

It can also cause severe restriction to movement in all directions and mimic a frozen shoulder.

What other shoulder conditions can mimic calcific tendonitis?

Calcific tendonitis vs frozen shoulder

Calcific tendonitis is more prevalent in younger people between 20 and 40. Frozen shoulder is more common between the age of 40-60 years. Calcific tendonitis pain usually starts suddenly, while frozen shoulder symptoms develop more gradually over a period of time. Also, in a frozen shoulder, the restriction in movement will be a more prominent clinical feature.

Calcific tendonitis vs shoulder subacromial impingement

Shoulder impingement is an umbrella term to describe a few shoulder conditions that result in pain due to pinching of the bursa and the rotator cuff tendons. These include Rotator cuff tendinosis, subacromial bursitis and acromioclavicular joint arthritis. Some may include calcific tendonitis as one of the conditions of subacromial impingement, although the disease process is different.

How to diagnose shoulder calcific tendonitis?

When the condition is suspected clinically, a shoulder ultrasound scan is an excellent modality for the assessment. It can readily visualise and measure the size of the area of calcification within the rotator cuff tendons. MRI is also useful for assessment. Both ultrasound and MRI can assess for any associated inflammation within the tendon and the subacromial bursa. A shoulder X-ray can be performed if there is uncertainty about the diagnosis, as it is excellent in picking up calcification. The benefit of ultrasound is that it can also guide a barbotage-lavage procedure.

What is the treatment for shoulder calcific tendonitis?

Usually, shoulder calcific tendonitis is self-limiting and managed by rest, physiotherapy and anti-inflammatory tablets. However, it may take some time to settle down.

What if conservative management is not working?

If your shoulder pain is not responding to conservative management, ultrasound-guided injection therapy is a well-recognised treatment option. There are two types of injection therapy:

What is Ultrasound-guided sub-acromial bursa steroid injection?

Corticosteroid (cortisone) is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis and tendinosis). In calcific tendonitis, the calcium deposit within the rotator cuff tendon may irritate the bursa resulting in inflammation and pain. There is some evidence that this process (i.e. bursal inflammation and irritation secondary to the calcium) is the main cause of shoulder pain in calcific tendonitis. A cortisone injection will reduce the inflammation in the bursa and allow you to manage the condition, usually by undergoing a physiotherapy program. The most commonly used type of steroid injection for subacromial bursa is methylprednisolone (Depo-medrone). This is a long-acting preparation that takes a few days to start working. Performing these injections under ultrasound guidance is very useful as it allows for direct visualisation of the needle to ensure accurate placement into the bursa at the site of inflammation. Please read our article Ultrasound-guided subacromial bursa steroid injection for more information.

What is shoulder barbotage-lavage for calcific tendonitis?

In this procedure, Aspiration or breaking down of the calcium material is accurately attempted under ultrasound guidance using a special needle. This is combined with a subacromial bursa steroid and local anaesthetic injection. The lavage and breaking down of the calcification will help the body to get rid of the calcium deposit, and the subacromial bursa injection will help settle down the bursal inflammation. Numbing medication (local anaesthetic) injection is usually used before the procedure to numb the skin and the subacromial bursa. To find out more, please see our article ultrasound guided barbotage-lavage.

Will I need more than one injection for my shoulder calcific tendonitis?

Sometimes, there is residual calcification and bursal inflammation after the first procedure. In these cases, the pain might return (but usually not as bad) after a few months. In such cases, we recommend repeating one of the abovementioned procedures to help reduce the inflammation and attempt to aspirate more of the calcium deposit.

Do I need to have ultrasound-guided barbotage-lavage for my shoulder pain?

Not all calcium deposits within the rotator cuff tendons are painful. Some are located deep inside the tendon without causing any symptoms. Therefore, your shoulder pain might be related to another issue, and the calcium deposit was picked up incidentally. Therefore, getting a consultation with a shoulder specialist and having the appropriate scans is essential for the diagnosis.

Is shoulder calcific tendonitis related to diet?

No. There is no evidence of this. However, evidence suggests increased shoulder calcific tendonitis in patients with high body mass index and diabetic people.

What other treatment options are available for shoulder calcific tendonitis?

Shockwave therapy is a treatment option and can help. Surgery is generally the last resort if all the above measures (including 1-2 injections/ barbotage-lavage) do not give good results.