Sports Medicine Research: In the Lab & In the Field: What is the Best Treatment Option for Calcific Tendinitis of the Rotator Cuff? (Sports Med Res)
Monday, July 1, 2013

What is the Best Treatment Option for Calcific Tendinitis of the Rotator Cuff?

Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial of Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids.

de Witte PB, Selten JW, Navas A, Nagels J, Visser CP, Nelissen RG, Reijnierse M. Am J Sports Med. 2013 May 21. [Epub ahead of print]

Take Home Message:  Barbotage treatment enhances functional outcome measures and reabsorption of the calcific deposit in patients with rotator cuff calcific tendinitis.

Calcific tendinitis of the rotator cuff typically occurs in patients between 30 to 50 years of age and can cause significant pain.  There are several treatment options involving injections or physical therapy; however, there is no consensus to a preferred treatment; nor have there been any randomized controlled trails to evaluate the current treatments.  One treatment gaining popularity is barbotage, which involves flushing the calcific deposit with saline solution followed by repeatedly perforating the deposit with an 18-gauge needle.  The authors compared ultrasound-guided barbotage and subacromial corticosteroids with just subacromial corticosteroids.  Forty-eight patients with calcific tendinitis were randomized into two groups and blinded to the treatment.  Patients received standard radiographs and completed a Constant shoulder score (CS), the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Western Ontario Rotator Cuff Index (WORC), and a visual analog scale (VAS) for pain prior to treatment.  The authors evaluated calcific deposits on radiographs with the Gartner classification.  Follow-up evaluations were performed at 6 weeks, 3 and 6 months, and 1 year.  In the barbotage group 3 patients required an additional barbotage treatment after 6 months and in the corticosteroid-only group 9 patients required the barbotage after 6 months.  In addition, 1 patient required surgery after 6 months in the barbotage group and 2 patients required surgery after 5 months in the corticosteroid only group.  Therefore, the authors only compared 19 patients in the barbotage group and 14 patients in the corticosteroid-only group.  There were no significant differences between groups at any of the timepoints for the VAS.  At 1-year follow-up, the barbotage group had better self-reported shoulder outcomes (CS and WORC) and better decreases in calcific lesion size than patients that received corticosteroids only.  . 

This is the first randomized controlled trial to examine the effectiveness of two ultrasound-guided injection treatments for calcific tendinitis of the rotator cuff.  The results demonstrated that barbotage combined with corticosteroids provided the best resolution of clinical disability and absorption of the calcific deposit.  Although this treatment demonstrated enhanced results, it is clearly more painful compared to the standard corticosteroid treatment.  Clinicians often use local anesthetics to minimize the pain; however, patients may still be cautious due to the potential pain associated with the treatment.  It seems that the barbotage treatment initiates the resorption of the calcific deposit; however, the mechanism remains unknown.  Due to the combination with a corticosteroid it is unlikely due an inflammatory response.  It would be interesting to examine this treatment without a corticosteroid to see if the effects are further enhanced or reduced. 

Questions for discussion:  What is your experience with this treatment?  Do you think this treatment would be effective for other calcific deposits? 

Written by:  Stephen Thomas
Reviewed by: Jeffrey Driban

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de Witte PB, Selten JW, Navas A, Nagels J, Visser CP, Nelissen RG, & Reijnierse M (2013). Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial of Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids. The American Journal of Sports Medicine PMID: 23696211

8 comments:

Unknown said...

I was unaware that this treatment option was even available. Aside from physical therapy, cortisone injections were the only other non-operative treatment I knew of to help address rotator cuff calcific tendinitis. This is great to have this option available to patients. I would be curious to see if this technique could be used in cases of myositis ossificans.

Anonymous said...

I think it would be interesting to observe the long term effects of repeated barbotage treatments and whether or not they would be more beneficial than corticosteroid injections in the long run. Also, I think more research should be done to determine the amount of time between treatments to have the best possible outcome. Although this provides patients with another treatment option, I wonder how many of them would choose this procedure over a corticosteroid injection considering the intense amount of pain experienced with barbotage.

Stephen Thomas, PhD, ATC said...

Thanks for the comments. It may be possible to be used for myositis ossificans if more traditional methods (ultrasound) arent effective. Although I am unaware of this technique being used for it.

I agree that some patients may need multiple treatments for complete resorption, however this study only used one treatment and did follow patients over a years time. It is true that many patients won't want to receive this treatment initially due to the associated pain. However, if this condition has been causing them pain for several months or years which isnt uncommon then I think many patients will be inclined to receive barbotage.

Bethany Rohl said...

Prior to this article I was unfamiliar with this treatment technique. It seems like there have been some positive results for absorption. One of the concerns often associated with corticosteroids is the potential of tendon weakening. Would barbotage be a means of injection without the potential of later weakening? I would also be interested to see what the outcomes would be in a group who only received the barbotage. If the barbotage group tended to have better self reported outcomes and a smaller lesion, but their pain was rated similarly. While pain is not the sole goal of this treatment, is it worth it if the procedure itself is initially more painful and then there is not a significant difference between groups on the VAS.

Stephen Thomas, PhD, ATC said...

Bethany thanks for the comment. You are correct about the effects of corticosteroids on tendon strength however just one injection doesn't seem to lead to long term deficits.

I agree it would be a great idea to perform an animal model study to address the question of tendon weakening following this treatment.

Based on these results it seems that the major improvements were in shoulder function. It seems that the pain decreased in both groups. I would think patients would seek out this treatment if their function would improve.

Caitlyn Richbourg said...

Before I came across this article, I had never heard of a barbotage treatment. After reading more about it, I am intrigued by this second non-operative treatment for rotator cuff calcific tendonitis besides a corticosteroid injection.

Further down the road, I would be extremely interested to see the comparison of longer term (> 1 year) effects of the barbotage treatment versus a corticosteroid injection and perceived levels of function. I was very intriguing to read the the barbotage treatment was able to help the body reabsorb more of the calcific growths in a relatively short amount of time, and so far, I think the barbotage is an advantageous treatment and look forward to reading more about it.

Greg said...

Good article. This seems to be a procedure that is quickly gaining traction especially as more practitioners become comfortable with using ultrasound. We use it as first line treatment. Our MSK radiologists perform the procedure, generally under US guidance and the outcomes have been tremendous. They may use another agent along with the injection that helps to break up the deposit but I am uncertain. I think there is some variety in how the procedure is performed which could certainly effect the outcomes.
Interesting long term outcomes in the attached article: http://radiology.rsna.org/content/252/1/157.long

Stephen Thomas, PhD, ATC said...

Greg thanks for the comment. Its great to hear you are using it with great success. Also thank you for the additional reference.

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