Barbotage vs Steroid Injection for Longstanding Calcific Tendonitis
Yes, it is reasonable and evidence-based to trial barbotage rather than steroid injection for calcific tendonitis that has persisted beyond one year, as barbotage demonstrates superior long-term outcomes and directly addresses the underlying pathology by promoting calcium deposit resorption.
Why Barbotage is Preferred in This Clinical Scenario
Superior Efficacy for Chronic Calcific Tendonitis
Barbotage shows superior clinical outcomes at 1-2 years compared to corticosteroid injections alone, making it the most effective minimally invasive treatment option according to multiple meta-analyses 1.
At 6 months post-barbotage, patients demonstrate significant improvement in pain scores (VAS), American Shoulder and Elbow Surgeons scores, and Constant scores, with only 1 in 36 patients requiring surgical intervention 2.
The procedure stimulates the resorption process through perforation of calcium deposits, with clinical success not dependent on complete aspiration of calcium 1.
Limitations of Steroid Injections Alone
Corticosteroid injections provide better acute pain relief than NSAIDs but do not alter long-term outcomes in tendinopathies 3, 4.
Subacromial steroid injections show no significant difference from barbotage at 5-year follow-up, suggesting the self-limiting nature of the condition, but barbotage provides faster and more substantial relief in the critical 6-month to 2-year window 1.
The role of inflammation in tendinopathies remains unclear, which complicates the theoretical basis for corticosteroid use as a standalone treatment 4.
Optimal Treatment Algorithm for Your Patient
Patient Selection Criteria
Ideal candidates have ≥1 large calcific deposit confirmed on ultrasound or radiograph 1.
Symptomatic calcific tendonitis should be confirmed via diagnostic ultrasound and/or physical examination prior to barbotage 1.
Patients with larger deposits show greater improvement following barbotage compared to those with small deposits 1.
The Recommended Procedure
Ultrasound-guided barbotage with concurrent subacromial steroid injection combines the benefits of both interventions 1, 2:
The barbotage component directly addresses the calcium deposits through needle perforation, fragmentation, and lavage with saline 1.
The concurrent subacromial bursa injection (typically 4 mL bupivacaine 5 mg/mL + 1 mL methylprednisolone 40 mg/mL) provides immediate pain relief during the resorption phase 1.
An 18G needle is used for the barbotage after local anesthesia, with repeated flushing until no more calcium enters the syringe 1.
Expected Timeline and Outcomes
Substantial symptom reduction occurs within the first weeks after barbotage 1.
Symptoms may recur around 3 months as the corticosteroid effect wanes, but this is temporary 1.
At 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life superior to subacromial injections alone 1, 2, 5.
Important Clinical Considerations
Technical Nuances
For solid deposits where aspiration is difficult, gentle rotation and repeated puncture promotes disaggregation and fragmentation, which is sufficient for clinical benefit 1.
Ultrasound guidance significantly increases injection accuracy (87% for ultrasound vs. 98% for fluoroscopy) 4.
The procedure should be performed with peritendinous rather than intratendinous injection technique to avoid tendon weakening 4.
Post-Procedure Management
Patients should be instructed to take analgesics and apply ice to the shoulder post-procedure 1.
No significant correlation exists between initial calcific deposit size and clinical outcomes, so even incomplete calcium removal can yield good results 2.
When Barbotage May Not Be Optimal
Patients with very small deposits may be less symptomatic at baseline and therefore less likely to demonstrate dramatic improvement 1.
If conservative treatment (rest, NSAIDs, physiotherapy for 3-6 months) has not been adequately trialed, this should be completed first, though your patient's one-year duration satisfies this requirement 3, 6.
Comparison with Alternative Treatments
Extracorporeal shock wave therapy (ESWT) is another option, but barbotage demonstrates superior outcomes at 1-2 years 1, 7.
ESWT shows worse outcomes with larger deposits, whereas barbotage shows better outcomes with larger deposits 1.
Arthroscopic excision remains reserved for severe chronic recalcitrant cases or those with complications like rotator cuff tears 1, 6.