Barbotage for Calcific Tendinitis of the Shoulder

What is calcific tendinitis?

Calcific tendinitis (also called calcific tendinopathy) is a condition in which deposits of calcium build up within a tendon. It most commonly affects the rotator cuff tendons of the shoulder, particularly the supraspinatus tendon. The cause is not fully understood, and it is most common between the ages of 30 and 60.

The deposits can cause:

• Shoulder pain, often worse at night or when lying on the affected side
• Pain when lifting the arm, particularly above shoulder height
• Stiffness or a catching sensation
• Sudden, severe flare-ups of pain, which can occur as the body starts to break down the calcium

In many people the calcium is eventually reabsorbed naturally, but this can take months or years, and symptoms can be very disabling in the meantime.

What is barbotage?

Barbotage (also known as ultrasound-guided lavage or needling) is a minimally invasive procedure to break up and remove calcium deposits from the tendon. Using ultrasound to see the deposit, a fine needle is passed into the calcium and it is repeatedly washed with sterile saline. This breaks up the deposit and allows some of the calcium to be drawn out through the needle. It also stimulates the body to reabsorb what remains.

At the end of the procedure, a steroid and local anaesthetic injection is always given into the space above the tendon (the subacromial bursa). Breaking up the calcium can irritate this space and cause inflammation (bursitis), so the steroid is given to reduce that risk and to ease pain afterwards.

Who is it suitable for?

Barbotage is usually considered when:

• Symptoms have persisted despite rest, painkillers, physiotherapy or a steroid injection
• An ultrasound or X-ray has shown a calcium deposit that is likely to be causing the symptoms
• The deposit is suitable for treatment – this will be assessed on ultrasound

How effective is it?

Most patients experience a meaningful improvement in pain and shoulder function, usually over the weeks following the procedure. In a randomised controlled trial, patients treated with barbotage and a steroid injection improved more over one year than those treated with a steroid injection alone (de Witte et al., American Journal of Sports Medicine, 2013). Some patients need a repeat procedure, and a small number may go on to need surgery.

Before your procedure

Please tell us if you:

• Take blood-thinning medication (for example warfarin, apixaban, rivaroxaban or clopidogrel)
• Have diabetes, as the steroid can raise blood sugar levels for a few days
• Have an allergy to local anaesthetic, steroid, latex or skin preparations
• Have a skin infection on the shoulder or are generally unwell
• Are pregnant or may be pregnant

You can eat and drink normally beforehand. Wear loose clothing that allows easy access to your shoulder.

What happens during the procedure?

The procedure is carried out as an outpatient and usually takes around 20–30 minutes, though you should allow longer for your appointment.

• You will be positioned lying or sitting with your shoulder exposed
• The skin is cleaned and the area is numbed with local anaesthetic
• Using ultrasound guidance, one or two fine needles are placed into the calcium deposit
• The deposit is washed repeatedly with sterile saline to break it up and remove as much calcium as possible
• A steroid and local anaesthetic injection is given into the subacromial bursa
• A small dressing is applied

Will it hurt?

Most people find the procedure very tolerable because of the local anaesthetic. You may feel pressure or a dull ache while the deposit is being treated. Please let us know if you are uncomfortable.

After the procedure

• You can usually go home straight away, but you should not drive yourself home
• Your shoulder may feel numb for a few hours while the local anaesthetic wears off
• It is common to have a flare of pain for 24–72 hours, which can occasionally be marked. Regular simple painkillers and an ice pack (wrapped in a cloth) can help
• Keep the dressing dry for 24 hours
• Use the arm gently for everyday tasks, but avoid heavy lifting and repetitive overhead activity for around 2 weeks
• Begin or continue physiotherapy exercises as advised – these are an important part of recovery

Improvement usually develops gradually over several weeks.

After barbotage, we will refer you to one of our local specialist upper limb (shoulder) surgeons for follow-up care, and send a report to your GP.

Risks and complications

Serious complications are uncommon.
Common: temporary pain flare, bruising, temporary rise in blood sugar if you have diabetes, facial flushing.
Uncommon: incomplete removal of calcium or persisting symptoms, need for a repeat procedure.
Rare: infection, bleeding, skin thinning or colour change at the injection site, tendon injury.

When should I seek medical advice?

Contact us, your GP or NHS 111 urgently if you develop:

• Increasing redness, heat or swelling around the shoulder
• A fever or feel generally unwell
• Severe pain that is getting worse rather than better after the first few days

Alternatives

• Watchful waiting – the calcium often resolves naturally over time
• Painkillers and physiotherapy
• Steroid injection alone – can relieve pain, but does not remove the calcium
• Shockwave therapy (ESWT) – not offered by our service, but we can recommend local physiotherapy practices that provide it
• Keyhole (arthroscopic) surgery to remove the deposit – usually reserved for cases that do not respond to other treatment

Arranging treatment

Barbotage is performed by Dr Andrew Carne, Consultant Musculoskeletal Radiologist.

• If you have been referred by your GP, a surgeon, a sports physician or a physiotherapist, the procedure can usually be booked directly, without a separate consultation first.
• If you are referring yourself, you can book a telephone consultation with a consultant radiologist, who can arrange a shoulder ultrasound scan. If the scan confirms calcific tendinitis that is suitable for treatment, barbotage can usually be performed at the same appointment. Please read this page before your scan, and tell us in advance if you take blood-thinning medication or have diabetes.

To arrange treatment or a consultation, please email info@guildfordradiology.com or telephone 07591 798735.