What are the best treatments for calcific tendinitis of the rotator cuff?

Treatment of Calcific Tendinitis of the Rotator Cuff

For calcific tendinitis of the rotator cuff, begin with NSAIDs and exercise therapy as first-line treatment, and if symptoms persist after 6-12 months, proceed to ultrasound-guided percutaneous needling and lavage (barbotage) with corticosteroid injection, which provides superior outcomes compared to other minimally invasive options. 1, 2

First-Line Conservative Management

• Start with NSAIDs combined with exercise programs as the initial approach for symptomatic calcific tendinitis, based on moderate-grade evidence from the American Academy of Orthopaedic Surgeons 3, 1

• Paracetamol can be used concurrently with NSAIDs or COX-2 inhibitors for more effective pain control 1

• Home exercise programs have demonstrated significant improvements in pain at rest, nighttime pain, and functional scores after 3 months of treatment 1

• Reserve opioids strictly for rescue analgesia when other methods fail, not as first-line treatment 1

Second-Line Interventional Treatment

Ultrasound-Guided Barbotage (Preferred Minimally Invasive Option)

When conservative treatment fails after 6-12 months, ultrasound-guided percutaneous needling and lavage is the most effective treatment option, showing superior clinical outcomes at 1-2 years compared to extracorporeal shockwave therapy and corticosteroid injections alone 2, 4

Technical Approach:

• Perform the procedure with the patient supine under ultrasound guidance 2
• Inject the subacromial bursa with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) using a 21G needle 2
• Puncture the calcific deposit with an 18G needle and flush repeatedly with 0.9% saline solution until no more calcium enters the syringe 2
• For solid deposits that cannot be aspirated, fragment the deposits through repeated perforations to promote resorption 2

Patient Selection for Barbotage:

• Best candidates are patients aged 30-40 years with middle-sized calcifications (12-17 mm) that appear soft on ultrasound 5
• Larger deposits (≥1 large calcific deposit) show greater improvement following barbotage compared to smaller deposits 2
• Success rates reach 70% with quick and significant symptom reduction at 1 month 5

Expected Outcomes:

• Substantial symptom reduction occurs within the first weeks after barbotage 2
• Symptoms may recur around 3 months as corticosteroid effects wane, but patients show substantial improvement in pain, function, and quality of life at 6 months and 1 year 2
• Clinical outcomes are not dependent on successful aspiration of calcium—the perforation itself stimulates resorption 2

Alternative Corticosteroid Injection

• A single subacromial corticosteroid injection with local anesthetic provides short-term improvement in pain and function, supported by moderate evidence 1

• Avoid multiple repeated corticosteroid injections—limit to single injections for short-term relief 1

• For severe pain requiring additional intervention, interscalene brachial plexus blockade is the first-choice regional analgesic technique 1

Third-Line Surgical Management

• Arthroscopic debridement and removal should be reserved as a last resort for severe chronic recalcitrant cases that fail all conservative and minimally invasive treatments after at least 6-12 months 2, 4

• Arthroscopy is specifically indicated in patients with chronic persistent calcific tendinitis who did not benefit from previous non-surgical treatments 4

Modalities with Insufficient Evidence

The American Academy of Orthopaedic Surgeons cannot recommend for or against ice, heat, iontophoresis, massage, TENS, or PEMF due to lack of sufficient evidence 3, 1

Common Pitfalls to Avoid

• Do not use opioids as first-line treatment—they should only be used for rescue analgesia 1

• Avoid overusing corticosteroid injections—multiple injections are not supported by evidence and should be limited 1

• Do not assume barbotage failure if calcium cannot be aspirated—the perforation itself promotes resorption and provides clinical benefit 2

• Recognize that calcific tendinitis is generally self-limiting, with no significant differences between barbotage and subacromial injections at 5 years, though barbotage provides faster relief 2