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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