What is the recommended management of calcific tendinitis of the rotator cuff in a 45‑year‑old woman, including initial conservative therapy and subsequent treatment options?

Management of Calcific Tendinitis of the Rotator Cuff

Begin with conservative therapy including NSAIDs, physical therapy, and activity modification for at least 6 weeks, followed by corticosteroid injections if symptoms persist, reserving ultrasound-guided needling and lavage (barbotage) for patients who fail initial conservative measures. 1, 2, 3

Initial Conservative Management (First-Line)

Start all patients with a trial of conservative therapy, as approximately 90% can be successfully managed non-operatively. 2

• NSAIDs and rest: Use oral anti-inflammatory medications to control pain and reduce inflammation 1, 3, 4
• Physical therapy: Implement range of motion exercises, pendulum exercises, and modalities (heat, cold, diathermy) to prevent loss of joint mobility and control pain 1, 2
• Activity modification: Avoid repetitive overhead activities and movements that exacerbate symptoms 1
• Duration: Continue conservative therapy for at least 6 weeks before escalating treatment 2, 3

Important Caveat

While corticosteroid injections are widely used, their role remains somewhat controversial since the inflammatory component in tendinopathies is unclear, and they may theoretically inhibit healing and reduce tensile strength, though this risk must be balanced against their proven symptomatic benefit. 1

Second-Line Treatment: Corticosteroid Injections

If conservative measures fail after 6 weeks, proceed to subacromial corticosteroid injections. 3, 4

• Inject corticosteroids into the subacromial bursa to provide pain relief 5, 3
• Expect initial symptom improvement, though symptoms may recur around 3 months as the corticosteroid effect wanes 5
• This approach is safe and widely used despite limited high-quality evidence for long-term efficacy 1

Third-Line Treatment: Ultrasound-Guided Needling and Lavage (Barbotage)

For patients with persistent symptoms despite conservative therapy and corticosteroid injections, ultrasound-guided barbotage is the most effective minimally invasive option, particularly for those with larger calcific deposits (≥12-17mm). 5, 6, 4

Optimal Candidates for Barbotage

• Patients with one or more large calcific deposits (12-17mm) show the greatest improvement 5, 6
• Younger adults (30-40 years old) achieve better outcomes than older patients 6
• Soft calcifications on ultrasound respond better than hard, dense deposits 6
• Patients with middle-sized calcifications demonstrate more relevant improvement compared to very small or very large deposits 6

Barbotage Technique

The procedure involves ultrasound-guided puncture of the calcific deposit with an 18G needle, followed by flushing with saline solution and passive aspiration of dissolved calcium, combined with subacromial corticosteroid injection. 5

Expected Outcomes

• Substantial symptom reduction occurs within the first weeks after barbotage 5
• At 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life, with results superior to subacromial injections and ESWT 5
• Clinical success occurs even when calcium cannot be fully aspirated, as the perforation itself stimulates resorption 5, 6
• Success rate of approximately 70% with quick and significant symptom reduction at 1 month 6

Alternative Third-Line Option: Extracorporeal Shock Wave Therapy (ESWT)

ESWT can be considered as an alternative to barbotage, though meta-analyses suggest barbotage produces superior clinical outcomes at 1-2 years. 5, 3, 4

• ESWT uses acoustic shock waves to reduce pain and promote tendon healing 1
• Both barbotage and ESWT result in reduction of calcific deposits and significant pain reduction 5
• ESWT may be less effective for larger deposits, whereas barbotage shows better results with larger calcifications 5

Surgical Management (Last Resort)

Reserve arthroscopic debridement and removal of calcific deposits for severe chronic recalcitrant cases that fail all conservative and minimally invasive treatments. 5, 4

• Arthroscopic procedures remove calcific deposits and may include subacromial decompression 4
• The role of subacromial decompression and repair of rotator cuff defects created during deposit removal remains controversial 4
• Surgery should only be considered after exhausting non-operative options 2, 3

Critical Pitfall to Avoid

At 5 years postoperatively, there are no significant differences in outcomes between barbotage and subacromial injections, suggesting a self-limiting course in the long term—this underscores the importance of attempting conservative measures first. 5