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The outcome of ultrasound-guided needle decompression
and steroid injection in calcific tendinitis
Jae Chul Yoo, MD
a
, Kyoung Hwan Koh, MD
a,
*, Won Hah Park, MD
a
, Jae Chul Park, MD
a
,
Sang Min Kim, MD
a
, Young Cheol Yoon, MD
b
a
Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
b
Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Hypothesis: Needle lavage is frequently performed before consideration of surgical removal in shoulders
with calcific tendinitis because this may avoid surgery. However, its role in nonoperative treatment has not
been fully investigated in terms of clinical and radiographic response. We hypothesized that needle decom-
pression and subacromial steroid injection would show good clinical results in chronic calcific tendinitis
patients.
Materials and methods: Thirty-five shoulders in 30 consecutive patients with painful calcific tendinitis
were treated by ultrasound-guided needle decompression and subacromial corticosteroid injection. Patients
were prospectively evaluated using American Shoulder and Elbow Surgeons (ASES) and Constant scores
at 1, 3, and 6 months after the intervention. Size and morphology of the calcific deposits were compared
with those in baseline radiographs at each visit.
Results: At 6 months after the index procedure, 25 shoulders (71.4%) showed ASES and Constant score
improvements from 48.0 and 53.7 to 84.6 and 87.9, respectively (P<.01). Ten shoulders (28.6%) showed
no symptom relief at the last follow-up. In shoulders with pain improvement, the mean size of calcific
deposits reduced from 13.6 to 5.6 mm (P<.01), and in shoulders with no pain improvement or that under-
went operation, mean size was 13.1 mm at initial visits and 12.7 mm at final visits (P¼.75).
Discussion: Shoulders showing little evidence of deposit size reduction at 6 months after needle decom-
pression are less likely to achieve symptomatic improvement and may be considered as candidates for
surgical removal.
Conclusion: Needle decompression with subacromial steroid injection is effective in 71.4% of calcific
tendinitis within 6 months. The size of calcific deposits in patients that achieved symptom relief was
reduced.
Level of evidence: Level IV, Case Series, Treatment Study.
Ó2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Calcific tendinitis; shoulder; conservative treatment; needle decompression; subacromial
steroid injection
Calcific tendinitis of the shoulder is a common disease
that accounts for 7% of shoulder pain
19
and is usually well
controlled by oral pain medications, such as nonsteroidal
anti-inflammatory drugs (NSAIDs). However, patients who
do not respond to conservative treatment may be candidates
*Reprint requests: Kyoung Hwan Koh, MD, Department of Orthopaedic
Surgery, Samsung Medical Center, Sungkyunkwan University School of
Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea.
E-mail addresses: helpless@naver.com,shoulderyoo@gmail.com,
coolshoulder@ymail.com (K.H. Koh).
J Shoulder Elbow Surg (2010) 19, 596-600
www.elsevier.com/locate/ymse
1058-2746/2010/$36.00 - see front matter Ó2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2009.09.002
for needle lavage, extracorporeal shock wave therapy
(ESWT), or surgical excision.
1,5,10-14,17,18
In particular,
needle lavage or ESWT is frequently performed before
surgical removal because both have been reported to be
efficient nonoperative treatment modalities and may even
eliminate the need for surgery.
However, some patients who do not respond to needle
lavage or ESWT are considered for surgical removal, and
the effectiveness of needle decompression and steroid
injection before surgery has not been clearly investigated in
terms of clinical response and calcium deposit changes.
Furthermore, recent advances in arthroscopic surgery have
tended to popularize the arthroscopic removal of calcific
deposits owing to its reduced invasiveness.
11,14,18
This study was undertaken to document preliminarily
clinical and radiographic results of ultrasound (US)-guided
fine needle decompression and subacromial steroid injec-
tion in patients with calcific tendinitis of the shoulder.
Emphasis was placed on the natural disease course,
including time to achieve a pain-free state or to decide on
surgical removal after the procedure.
Materials and methods
This study was approved by the Institutional Review Board (IRB)
of Samsung Medical Center (IRB Study No. 2009-06-039).
Patient selection
From October 2007 to August 2008, patients with painful calcific
tendinitis that had been treated by US-guided needle decompres-
sion and subacromial steroid injection were prospectively evalu-
ated. Inclusion criteria were calcific deposits located in the
supraspinatus or infraspinatus that were type A (sharply delin-
eated, dense, and homogenous in appearance) or type B (sharply
delineated, dense, multiple fragments) according to the classifi-
cation of the French Arthroscopic Society, as described previ-
ously,
18
and a deposit size of more than 5 mm in any radiographic
view. All the patients had symptom duration of more than
6 months.
The study excluded patients found to have a rotator cuff tear by
diagnostic US imaging and those with a history of needle lavage
or ESWT, surgery, infection, fracture, inflammatory arthropathy of
the affected shoulder, or arthritic change of the glenohumeral
joint.
Radiographic and clinical assessment
Radiographic and clinical evaluations were performed before US-
guided needle decompression and subacromial steroid injection
and at 1, 3, and 6 months after the procedure. If surgical removal
was decided, evaluations were performed before the operation.
Routine radiographic evaluations were performed with
a shoulder anteroposterior (AP) view in neutral rotation, a true AP
view in neutral rotation, an axillary lateral view, and an arch view.
Calcific deposit morphology was classified according to the
French Arthroscopic Society classification,
18
and maximal deposit
sizes (longest length in any dimension) were measured and
recorded before the index procedure and at each outpatient visit.
Demographic information was collected and American
Shoulder and Elbow Surgeons (ASES) scores,
15
and Constant
scores
4
were evaluated before index procedures and at 1, 3, and 6
months after the intervention. Time from symptom onset and
aggravation, defined as when the patient felt subjectively that
previous symptoms were aggravated and thus was prompted to
seek medical assistance, were investigated. At each clinical visit,
all patients were asked subjectively about the duration from index
procedure to the time when all activities of daily living were
possible with nearly no pain. Patients who did not have pain relief
at 6 months after the procedure and those that proceeded to
surgical removal were considered treatment failures. We
compared the clinical scores and maximum sizes of calcific
deposits of those that achieved symptom relief and those consid-
ered failures at 1 and 6 months after the index procedure or the
day before the operation for those who underwent surgical
removal.
US-guided fine needle decompression and
subacromial corticosteroid injection
One musculoskeletal radiologist with more than 10 years experi-
ence performed all procedures under US guidance. Initially,
a diagnostic US examination was performed with the patient
sitting to assess other pathologic lesions, such as, rotator cuff
tears, and determine the locations, sizes, and numbers of calcific
deposits. This was followed by US-guided fine needle decom-
pression with the patient supine.
Briefly, a marker pen was used to depict the calcific deposit
location and size on the skin, and the skin was then cleaned and
draped. After 1% lidocaine local anesthesia, the calcific material
was punctured with an 18-gauge needle under constant monitoring
with a sterilized US transducer. When it was confirmed that the
needle tip was located in a calcific deposit, aspiration of the
calcific material with a 10-mL syringe was attempted. If no
calcific material was aspirated after 2 or 3 additional attempts, the
deposit was punctured multiple times to achieve decompression.
When several calcific deposits were present, aspiration was
attempted for each US targetable deposit.
The final stage of the procedure involved withdrawing the
needle to the subacromial space and injecting a mixture of 1 mLof
1% lidocaine and 1 mL (40 mg) of Depo-Medrol (Pharmacia &
Upjohn, Kalamazoo, MI; 40 mg/mL methylprednisolone acetate).
Oral NSAIDs were prescribed routinely to control pain exacer-
bations for 24 hours after the procedure. No immobilization was
applied, and patients were allowed to use their shoulders without
restriction.
Statistics
The Wilcoxon 2-sample ttest or the Mann-Whitney test with
Bonferroni correction
16
were used to compare ASES and Constant
scores and the size of calcific deposits between the treatment
success and failure groups. The paired ttest was used to test the
improvement of clinical scores and deposit size changes. Statis-
tical analyses were performed with SAS 9.13 software (SAS
Institute Inc, Cary, NC), and a confidence interval of 95% was
used.
Needle decompression in calcific tendinitis 597
Results
Thirty-five consecutive shoulders in 30 patients (10 men,
20 women) underwent US-guided needle decompression
with a subacromial steroid injection. The mean patient age
was 51.3 years (range, 34-77 years), and there were 25 right
and 10 left shoulders. The dominant hand was right in 27
(90%) and left in 3 (10%). The calcific tendinitis involved
the dominant side in 23 (65.7%) and the nondominant side
in 12 (34.3%). Mean time from symptom onset to the
procedure was 44.8 months (range, 6-240 months) and to
aggravation was 11.5 months (range, 1-72 months).
There were 26 type A and 9 type B calcific deposits.
Average deposit size was 13.4 5.0 mm. Aspiration was
successful in only 6 shoulders, and minimal calcific debris
was extracted from 10 shoulders. Calcific material was not
aspirated in 19 shoulders, and only decompression by
multiple puncturing was performed. No immediate or
delayed procedural complications were encountered.
Mean ASES and Constant scores of the 35 shoulders at
initial visits were 48.2 and 54.2, respectively. At 6 months
after the procedure, 34 shoulders were available for eval-
uation, and 1 patient was interviewed by telephone. Of
these, 25 shoulders (71.4%) were almost pain free, and 22
showed symptom relief within 3 months (mean 2.7 months
for 25 shoulders). Mean ASES and Constant scores of 25
shoulders that were almost pain free at 6 months improved
from 48.0 and 53.7 to 84.6 and 87.9, respectively (P<.01).
In 6 shoulders (17.1%), arthroscopic removal was
decided due to unresolved or aggravated pain at a mean of
4.7 months. The 6 patients who had an operation had
a relatively serious rotator cuff defect after removal of the
calcific deposit: 5 underwent repair using suture anchors,
and 1 had a side-to-side repair after de
´bridement of path-
ologic tissue. Two patients who had impingement possibly
caused by an osteophyte, hook type acromion, or fraying of
the coracoacromial ligament as a result of diagnostic
arthroscopy, underwent acromioplasty. Four other shoul-
ders (11.4%) showed no symptom relief at 6 months after
the index procedure, but the patients refused an operation at
final follow-up.
Among the 6 patients who had arthroscopic removal of the
calcific deposits, 4 showed symptom relief and the mean
ASES score was 94, Constant score was 92, and pain visual
analog scale(PVAS) was 1.6 at 1 year after surgery. Two
patients showed improvement but are in the phase of recovery
from surgery, with a mean follow-up of 4.7 months.
Comparison between treatment successes and
failures
Ages, symptom durations, calcific deposit sizes, ASES
scores, and Constant scores at initial visits were similar in
these 2 groups. In the treatment success group, mean deposit
size reduced from 13.6 5.0 mm at initial visits to 5.6 6.5
mm at 6 months after the index procedures (P<.01), and pain
improvement was noted at a mean 2.7 months after the
procedure. In the treatment failure group, mean deposit size
was 13.1 4.8 mm at initial visits and 12.7 7.1 mm at the
last visits (P¼.75). Calcific deposit sizes at the last follow-up
visits were statistically different between the 2 groups (P<
.01); however, there was a statistical difference in the type of
calcific deposit (P¼.04). There were 16 type A and 9 type B
calcific deposits in the treatment success group, and all of
10 shoulders in the treatment failure group were type A.
Both groups showed clinical score improvements at
1 month after the procedure, and no intergroup difference
was evident (P¼.51 for ASES scores, P¼.24 for Constant
scores), but group ASES and Constant scores at last follow-
up were significantly different. Comparisons between the
2 groups are summarized in Table I.
Discussion
Our study showed that 71.4% of shoulders can improve
clinically and radiographically at 6 months after US-guided
needle decompression with subacromial steroid injection
among those who have calcification exceeding 5 mm in size.
Our results also suggest that shoulders showinglittle evidence
of deposit size reduction at 6 months after the procedure are
less likely to achieve symptomatic improvement and may be
considered as candidates for surgical removal.
NSAIDs, needle lavage, and ESWT are the mainstay of
nonoperative treatments of calcific tendonitis, and all
of them are often successful.
10
In addition, subacromial
steroid injections have been used widely in conjunction
with oral pain medication even though they are not the
fundamental treatment in the original disease course and
are considered harmful if administered repeatedly.
10,20
Among them, needle aspiration of calcific deposits is
known to be effective, especially during the resorptive
phase, and reported clinical success rates vary from 67.5%
to 91% in calcific tendinitis.
1,3,5,8,12
Our results, however,
show that in 28.6% of shoulders, a relatively large
proportion, needle lavage failed.
Aina et al
1
reported good results for US-guided needle
decompression with subacromial steroid injection at
53 days after the procedure. In the present study, all but
3 shoulders in the treatment success group reported
symptom relief within 3 months, and deposit sizes were
substantially decreased at 6 months. This finding somewhat
correlates with Aina et al.
1
However, the treatment failure
group showed persistent pain 6 months after the procedure,
and sizes of calcific deposits were almost unchanged, from
a mean 13.1 to 12.7 mm (P¼.75), although the treatment
failure group also achieved some symptom improvements
at 1 month after the procedure. The symptoms recurred
soon and were even aggravated. We presume that brief
symptom relief is mainly due to the temporary effect of
steroid injection, as in the study by Aina et al.
598 J.C. Yoo et al.
Del Cura et al
5
reported 91% substantial or complete
improvement and 89% complete or nearly complete
resorption at 1 year after needle lavage and steroid injec-
tion. Partial removal of deposits is known to enable
decompression of calcium-containing cavities and promote
spontaneous resorption.
2,3,7,20
The treatment success group
showed significant deposit size reduction at 6 months after
the procedure, but the treatment failure group did not,
which probably supports the existence of a correlation
between symptom severity and deposit size. However, the
aspiration amounts were small even in the treatment
success group, and thus, the decompression of the tendon
(not the aspiration amounts) appears to be important in the
present study.
Up to 71.4% of treatment successes in the present study
might be the result of short follow-up. In longer follow-up,
one might expect more patients with recurrent pain and
symptoms. By the same token, those who were resistant to
needling might have some pain relief even without further
intervention.
Previous studies, however, have reported symptom
duration from 17 to 43.1 months before the procedure,
whereas in the present study, the mean time from symptom
onset to needle lavage was 44.8 months. It is considered
that needle lavage or any other procedure can be surpris-
ingly successful in the resorptive phase. Our patients were
more chronic cases, however, with dense chalky calcifica-
tion that imply that our results truly reflect the success of
the needle lavage.
When we compared the symptom duration between the
treatment success and failure group, it was notable that
the treatment success group had apparently longer
symptom duration (69.7 months) than the treatment
failure group (33.7 months). It might suggest a different
phase of the disease, although the standard deviation was
large, with no statistical difference. Furthermore, the
deposit types were different in both groups (P¼.04): all
of the treatment failures (10 shoulders) had type
A deposits vs 16 type A and 9 type B deposits in the
treatment success group. Although the study population is
small, type A and type B may represent different disease
phases, and accordingly, the treatment and response may
differ respectively. Therefore, it seems that the phase of
disease can be thought to be the single most important
predictive factor.
We investigated whether there was any difference
between treatment success and failure groups in the
involved shoulder, and as pointed out, we also investigated
if there was any difference according to the deposit type.
Although the number was small, there were no statistical
differences in the involved shoulder between the treatment
success and failure groups (P¼.99).
There was a female predominance in this study, as has
been pointed out in prior studies.
1,5,6,9
Among the 30 tar-
geted patients, 20 (66.7%) were women and 10 (33.3%)
were men. When the association of diabetes or thyroid
disease with the calcific tendinitis is considered,
9
there
might be various risk factors, including endocrine or
hormonal problems, and it seems that risk factors need to
be further studied in the future.
The study has several limitations. First, the inclusion of
5 bilateral patients constitutes a study limitation, and
Table I Demography and comparison of clinical and radiologic results between the treatment success and failure group
Variable Success Failure P
(n ¼25) (n ¼10)
Age, mean (range) 51.5 (34-77) 50.7 (41-64) .65
Symptom duration, mean SD, mos 69.7 92.3 33.7 34.4 .19
Involved shoulder
Right, No. 18 7 .99
Left, No. 7 3
FAS type
18
A, No. 16 10 .04
B, No. 0 0 .04
Before needling procedure
ASES score, mean SD 48.0 14.5 48.6 9.4 .99)
Constant score, mean SD 53.7 16.3 55.4 7.4 .99)
Deposit size, mean SD, mm 13.6 5.0 13.1 4.8
1 month after procedure
ASES score, mean SD 71.9 13.3 65.9 17.7 .51)
Constant score, mean SD 74.0 19.9 71.5 10.0 .24)
Last follow-up
ASES score, mean SD 84.6 12.8 47.5 17.5 <.01)
Constant score, mean SD 87.9 8.7 58.8 16.9 <.01)
Deposit size, mean SD, mm 5.6 6.5 12.7 7.1 .02
ASES, American Shoulder and Elbow Surgeons scores; FAS, French Arthroscopic Society; SD, standard deviation.
)
Bonferroni correction.
14
Needle decompression in calcific tendinitis 599
although these were not concurrent, these patients may have
caused bias because symptoms in one shoulder can influence
those in the other. Furthermore, a cohort of 35 shoulders is
probably too small to evaluate the natural treatment course. It
is also true that a follow-up of 6 months may have been
insufficient for evaluation purposes. Actually, 2 patients who
were symptom free at 6 months, without a deposit size
reduction, decided to undergo surgery at 8 months because of
pain aggravation. Another patient without symptom relief at
6 months, and who was classified as a treatment failure at
6 months, changed his mind about surgical removal because
the pain decreased at 10 months.
Conclusion
Ultrasonography-guided needle decompression with
subacromial steroid injection is effective in reducing
symptoms in 71.4% of shoulders with calcific tendinitis
at 6 months after the procedure. Furthermore, patients
who achieved symptom relief showed deposit size
reductions at 6 months after the procedure.
Acknowledgments
The authors thank JoongHyun Ahn and SeonWoo Kim
for the statistical analysis.
Disclaimer
The authors, their immediate families, and any
research foundations with which they are affiliated
have not received any financial payments or other
benefits from any commercial entity related to the
subject of this article.
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