Calcific Tendinosis Aspiration & Lavage

Shoulder
Equipment & Medications

Equipment

9–14 MHz Linear Probe 18g or 20g 3.5″ Needle 25g 1.5″ Needle 2 × 10 cc Syringe (lidocaine) 2 × 10 cc Syringe (normal saline) 5 cc Syringe Procedure Tray

Medications

Lidocaine 1% — 2 × 10 cc Normal Saline — 2 × 10 cc Kenalog 40 mg/cc — 2 cc Ropivacaine 0.5% — 3 cc
Procedure Steps
1

Standard pre-procedure workup: consent, indications, contraindications, allergies. Warn patient that pain may temporarily increase after the procedure due to release of hydroxyapatite crystals.

2

Position patient supine.

3

Scan for calcific tendinosis deposits, typically in the supraspinatus tendon. Measure the size of the largest deposit(s).

Long axis supraspinatus with calcific deposit
Click for annotated view
Short axis supraspinatus with calcific deposit
Click for annotated view
4

Mark probe location and probable needle entry site.

5

Prep patient with betadine or chlorhexidine × 3.

6

Place sterile drape and sterile probe cover.

7

Under ultrasound guidance, inject 1% lidocaine superficially using the 25g 1.5″ needle.

8

Exchange 25g needle for the 18g 3.5″ needle.

9

Advance needle under ultrasound guidance to the level of the calcium deposit.

Needle advancing to calcific deposit
Click for annotated view
10

Attach the 10 cc lidocaine syringe. Administer a few cc's of lidocaine into the surrounding tissue to anesthetize the deposit area.

11

Advance needle into the calcium deposit. The pseudocapsule will expand. Intermittently inject small amounts of lidocaine, watching the deposit expand, then aspirate and watch the pseudocapsule collapse. The aspirate will often be milky white. Do not rupture the pseudocapsule.

12

Exchange the lidocaine syringe for a 10 cc normal saline syringe. Repeat the intermittent inject-and-aspirate technique, continuing to look for milky aspirate.

13

Repeat once more with a second 10 cc normal saline syringe.

Post-procedure scan
Click for annotated view

Post-procedure scan demonstrates decreased size and decreased central echogenicity of the deposit with surrounding injectate.

14

While keeping the 18g needle in place, redirect it to the subacromial/subdeltoid bursa. These patients frequently have associated subacromial bursitis.

15

Test-inject with 1% lidocaine. If there is no resistance and you see bursal distention, exchange for the 5 cc syringe with steroid/ropivacaine mixture and inject.

16

Remove needle and place bandage on skin.

References

  1. de Witte PB, Selten JW, Navas A, et al. Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids. Am J Sports Med. 2013;41(7):1665–1673.
  2. de Witte PB, Kolk A, Overes F, et al. Rotator cuff calcific tendinitis: ultrasound-guided needling and lavage versus subacromial corticosteroids: five-year outcomes of a randomized controlled trial. Am J Sports Med. 2017;45(14):3305–3314.
  3. Forogh B, Karami A, Bagherzadeh Cham M. Effect of extracorporeal shock wave therapy and ultrasound-guided percutaneous lavage in reducing the pain of rotator cuff calcific tendinopathy: an updated systematic review and meta-analysis. J Orthop. 2024;56:151–160.
  4. Arirachakaran A, Boonard M, Yamaphai S, et al. Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs. Eur J Orthop Surg Traumatol. 2017;27(3):381–390.