Ultrasound-guided calcific tendonitis lavage
Welcome to our comprehensive resource on Rotator Cuff Calcific Tendinosis, a detailed exploration of a common yet often misunderstood condition affecting the shoulder’s rotator cuff tendons. This page provides an in-depth look into the anatomy, pathology, diagnostic methods, and advanced treatment techniques for this condition, which is characterized by the deposition of calcium hydroxyapatite crystals within the tendons.
Our tables offer a structured overview of the pertinent anatomy, highlighting the involvement of specific tendons in the rotator cuff and the common pathways of the disease. We delve into the advanced imaging findings, particularly focusing on the role of ultrasound in diagnosis and treatment guidance.
The treatment section details the intricacies of ultrasound-guided percutaneous lavage aspiration, a minimally invasive technique that has revolutionized the management of this condition. From the preparation and equipment needed, to the step-by-step procedure and post-treatment care, we provide all the necessary information for both medical professionals and patients seeking a deeper understanding of this treatment.
Shoulder Pain and Disability Index (SPADI)
| Anchors | Questionnaire | Score for each Question |
|---|---|---|
| Pain scale | 1. At its worst? 2. When lying on the involved side? 3. Reaching for something on a high shelf? 4. Touching the back of your neck? 5. Pushing with the involved arm? | ‘No pain at all - 0’ to ‘Worst pain imaginable - 10’. |
| Functional scale | 1. Washing your hair? 2. Washing your back? 3. Putting on an undershirt or jumper? 4. Putting on a shirt that buttons down the front? 5. Putting on your pants? 6. Placing an object on a high shelf? 7. Carrying a heavy object of 10 pounds (4.5 kilograms)? 8. Removing something from your back pocket? | ‘No difficulty - 0’ to ‘So difficult it required help - 10’. |
| Interpretation of Scores | 1. Total pain score: Sum of pain dimension / 50 x 100 = % 2. Total disability score: Sum of functional dimension / 80 x 100 = % 3. Total SPADI score: Sum of both dimensions / 130 x 100 = % | 1. Adjust denominator if questions are unanswered (e.g., 40 for 1 pain question missed). 2. Total score range: 0 (best) to 130 (worst). 3. Minimum Detectable Change (90% confidence) = 13 points. |
Understanding calcific tendonitis lavage
| Category | Subcategory | Details |
|---|---|---|
| Anatomy | Rotator Cuff Composition | 1. Four tendons: Supraspinatus, Infraspinatus, Subscapularis, Teres Minor. 2. Most common involvement: Supraspinatus > Infraspinatus > Subscapularis > Rare in Teres Minor. |
| Clinical Presentation and Epidemiology | Symptoms and Prevalence | 1. Common between ages 40-60, more in women and diabetics. 2. Sudden, severe pain during resorptive phase, often referred to deltoid region. 3. Can mimic adhesive capsulitis or rotator cuff tear. |
| Common Pathology | Calcific Material | 1. Calcium hydroxyapatite deposits. 2. Usually near tendon attachments to greater/lesser tuberosities. 3. May extend to subacromial bursa. 4. Three stages: Precalcific, Calcific (with formative, resting, resorptive phases), Postcalcific. |
| Diagnosis | 1. Clinical presentation: Limited motion, pain with arm elevation, worst at night. 2. Differential diagnosis: Rotator cuff tears, bursitis, joint arthrosis, adhesive capsulitis. 3. Symptoms vary based on stage and location. |
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| Ultrasound Imaging Findings | Visualization and Localization | 1. Radiographically visible in symptomatic cases. 2. Shows hyperechoic focus in tendon with posterior acoustic shadowing. Sonographic appearance varies with disease phase. 3. Used to evaluate adjacent bursa and perform percutaneous treatment. |
| Treatment Options | Conservative Management | 1. First line: NSAIDs, corticosteroid injections, physiotherapy. 2. About 30-50% of patients may have residual symptoms post-conservative therapy. |
| Advanced Interventions | 1. ESWT: Effective but limited by treatment course length, discomfort, and cost. 2. Surgery: Effective but with risks and extended recovery. 3. US-guided barbotage: High success rate, minimal invasiveness. Techniques include single-needle and double-needle (use two 16- gauge needles) approaches. |
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| Indications for Treatment | Lavage and Aspiration | 1. Indicated when clinical presentation aligns with calcific tendinosis and confirmed by ultrasound. 2. Limited value of physical therapy and anti-inflammatory medication for long-term relief. 3. Surgery is a last resort due to its complexity and risks. |
| Equipment and Technique | Equipment Needed | 1. Needles (25-gauge for anesthesia, 16– to 19-gauge for lavage). 2. Injectates (anesthetic, corticosteroid). 3. Lavage syringes (upto 8 - 10 ml syringes per session) with saline-anesthetic mixture (ratio 1.5-2.5:1). 4. High-frequency linear array transducer. |
| Technique | 1. Patient positioning varies based on calcification location. 2. Needle tip is advanced to the centre of the deposition in single pass without interruption of opposite wall. 3. Techniques include single-puncture approach, lavage until calcium removal, fenestration of remaining deposits. 4. Apply alternating pressure and suction using the syringe plunger to initiate a cavity within the calcified area. 5. Observe the movement of hyperechoic substances within the cavity while conducting the lavage. 6. Following the extraction, an injection combining anesthetic and corticosteroid is administered into the nearby subacromial bursa. |
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| Postprocedure Care and Follow-Up | Care Guidelines | 1. Post-treatment, radiographic imaging is conducted to confirm the removal of calcifications. 2. Rest shoulder for 48 hours, avoid heavy lifting for 2 weeks. 3. NSAIDs for pain relief, physiotherapy after 1 week. 4. Follow-up radiographs for decreased calcification. |
| Complications | Potential Risks | 1. Minimal immediate complications. 2. Possible transient worsening of symptoms or rare cases of frozen shoulder, septic bursitis |
- Pagnini F, D’Amuri FV, Bevilacqua A, Sabatino V, Russo U, Zappia M, Natella R, Palumbo P, Pradella S, Miele V, De Filippo M. Ultrasound-guided percutaneous irrigation of calcific tendinopathy: technical developments. Acta Biomed. 2019 Apr 24;90(5-S):95-100. doi: 10.23750/abm.v90i5-S.8333. PMID: 31085978; PMCID: PMC6625565.
- Lafrance S, Doiron-Cadrin P, Saulnier M, Lamontagne M, Bureau NJ, Dyer JO, Roy JS, Desmeules F. Is ultrasound-guided lavage an effective intervention for rotator cuff calcific tendinopathy? A systematic review with a meta-analysis of randomised controlled trials. BMJ Open Sport Exerc Med. 2019 Mar 9;5(1):e000506. doi: 10.1136/bmjsem-2018-000506. PMID: 31191964; PMCID: PMC6539165.
- Zhang, Tao MDa; Duan, Yanji MDc; Chen, Jing MDb; Chen, Xiao MDc,∗. Efficacy of ultrasound-guided percutaneous lavage for rotator cuff calcific tendinopathy: A systematic review and meta-analysis. Medicine 98(21):p e15552, May 2019. | DOI: 10.1097/MD.0000000000015552
- Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991 Dec;4(4):143-9. PMID: 11188601.