Rotator cuff calcific tendinitis barbotage

Last revised by Andrew Murphy on 23 Mar 2023

Rotator cuff calcific tendonitis can be treated with various techniques including ultrasound-guided barbotage, which is also known as ultrasound-guided needling and lavage. It is often performed in conjunction with a subacromial bursal injection. Alternative treatments include extracorporeal shock wave therapy (ECSW) or shoulder arthroscopy. 

  • active skin infection
  • coagulopathies and anticoagulation medication (relative)
  • review contraindications
  • review previous images and localize calcific deposits
  • informed consent
  • sterile dressing pack, probe cover, ultrasound gel
  • sterile gloves 
  • skin disinfectant
  • 16 to 22 G long needles (user preference)
  • syringes (volume depending on technique)
  • normal saline
  • local anesthetic e.g. 1% lidocaine, 0.5% bupivacaine
  • corticosteroids: e.g. methylprednisolone
  • sterile technique
  • sonographic visualization of the calcific deposit (typically on a lateral transverse view)
  • infiltration of local anesthetic (e.g. 10 mL 1% lidocaine) using a 25 G needle along the expected needle track and into the subacromial bursa +/- adjacent to or within the calcific deposit 1-4
  • insertion of an 18 G needle attached to a 5 mL syringe containing 4 mL normal saline into the center of the calcific deposit, ensuring a horizontal lie, and the calcification is flushed
  • if calcific material flows back into the syringe, lavage the calcific deposit with calcific debris layering dependently in the syringe to avoid re-injection
  • exchange syringes when the saline has become cloudy and continue lavage until backflow is clear 1-3
  • 2 x 16 G needles are inserted into the calcific deposit as parallel as possible to the ultrasound transducer so that both can be seen simultaneously
    • the deeper needle should be inserted first with the bevel rotated upwards
    • the superficial needle should have its bevel rotated downwards
    • needle tip distance should be very close (2-3 mm)
  • normal saline is injected using a 20 mL syringe into one needle with free drainage of saline and calcium from the other needle 4

N.B. Corticosteroid (e.g. 40 mg methylprednisolone) is usually injected into the subacromial subdeltoid bursa after lavage as the patient can experience a chemical bursitis from leak of calcification into the bursa3.  A new or different needle from the 'barbotage' needle, should be used to inject the bursa with corticosteroid.

N.B. Warmed saline may facilitate removal of calcification over room temperature saline 4

Post-procedural complicates are rare 4 but could potentially include infection.  There is an associated risk of tendon rupture, which should be included in the pre-procedure consent.  

Barbotage has been shown to be an effective short-to-medium term treatment for rotator cuff calcific tendonitis and is superior to subacromial bursal injection alone 1,3. An average pain improvement with barbotage of 55% has been reported 1. Lessened improvement in pain scores post-procedure are associated with 3:

  • multiple procedures
  • poor initial response
  • longer onset of symptoms
  • smaller calcific deposit size

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