1995, The British Journal of Radiology, 68, 716-719
Ultrasound guided aspiration of symptomatic
supraspinatus calcific deposits
1M BRADLEY, MB, ChB, FRCR, 2M S BHAMRA, ChM, FRCS and 2M J ROBSON, FRCS
Departments of 1Medical Imaging and 2Orthopaedics, Rotherham General Hospital NHS Trust, Moorgate Road,
RotherhamS60 2UD, UK
11 consecutive patients with shoulder pain were referred from the shoulder clinic for plain radiography.
Supraspinatus calcific deposits were suspected after other causes of shoulder pain had been eliminated by
clinical examination and local anaesthetic tests. Radiographs confirmed calcific deposits in all 11 shoulders
and all deposits were shown by ultrasound to be lying in the supraspinatus tendon. Using a free-hand
ultrasound guidance technique, a 19 G needle was passed percutaneously into all 11 shoulders in an attempt
to aspirate the deposit. Six patients experienced immediate pain relief or relief on the same day, whilst four
others were pain free at the 2 weeks follow-up clinic. One patient who was thought to have a co-existing
supraspinatus tear diagnosed by the scan was symptomatically unchanged.
Calcium hydroxyapatite deposits are laid down in
many tendons and peri-articular sites, but there is dis-
agreement as to terminology regarding such deposition,
i.e. whether it is "tendonosis" or "tendonitis". The supra-
spinatus tendon is probably the most commonly affected
[1, 2] and, whilst this may be an asymptomatic con-
dition, it is a recognized cause of severe shoulder pain
which can last many weeks, months or even years.
The standard therapeutic approach is usually local
anaesthetic (lignocaine) or steroid injection into the sub-
acromial space, or attempted injection into the tendon.
Needling of the deposits by hand and without radiologi-
cal guidance has been advocated  but this has not
been successful in our experience. Barbotage, needling of
deposits under fiuoroscopic guidance, has the disadvan-
tage of exposing the patient to considerable radiation
dosages . Persistent pain and debility may eventually
require an open or arthroscopic decompression  of
the tendon and the subacromial space.
This study demonstrates our preliminary experience
of ultrasound guided aspiration of these deposits
(Figure 1) which obviates the need for fiuoroscopic con-
trol and has proven effective in relieving symptoms.
Patients and methods
11 consecutive patients were referred from the
shoulder clinic to the Medical Imaging Department. The
mean age of the patients was 63 years (range 54-82
years). The time for presentation was between 3 months
and 3 years from onset of symptoms. All patients had
limitation of movements particularly on 30°-40° of
In all 11 cases, radiographs confirmed the presence
Received 21 September 1994 and in final form 6 February
1995, accepted 23 February 1995.
of calcific deposits and showed no other abnormality
(Figure 2). Ultrasound examinations were then per-
formed using a linear 7.5 MHz probe, with or without
a stand-off medium to obtain the best images.
Longitudinal and transverse scans were" obtained
through the rotator cuff in order to locate accurately the
deposits and to exclude any other coincident pathology.
After identification of deposits, a simple attempt to
Figure 1. Ultrasound in a normal left shoulder demonstrates
the normal supraspinatus tendon in the longitudinal plane
(d, deltoid; h, humeral head; a, acromium; s, supraspinatus;
b, sub-deltoid bursa).
The British Journal of Radiology, July 1995
US guided aspiration of symptomatic supraspinatus calcific deposits
Figure 2. (a) AP radiograph showing a large calcific deposit in
the region of the supraspinatus tendon, (b) The longitudinal
scan confirms the deposit (arrows) within the tendon. This large
deposit is demonstrating "acoustic shadowing", (c) Radiograph
2 weeks post-aspiration confirms full resolution of the deposit,
(s, supraspinatus; h, humeral head; a, acromium).
aspirate the deposits was made; each case utilizing a free-
hand ultrasound guided technique in the longitudinal
plane of the supraspinatus tendon. Aspiration was per-
formed via a 20 ml syringe with a 19 G needle. The tip
of the needle was guided into the centre of the deposit
and suction applied (Figure 3). Local anaesthesia was
Figure 3. Longitudinal scan through the supraspinatus tendon
shows the needle tip in a calcific deposit (arrows) during the
freehand aspiration technique (a, acromium; h, humeral head;
s, supraspinatus; n, needle).
not used routinely but only according to patient
A positive result was achieved when a small quantity
of milky fluid (< 1 ml) was aspirated or when solid gritty
material was seen in the syringe. If neither of these fea-
tures were noted, the needle was then passed repetitively
into the deposit to cause its maximum disruption. All
aspirated material was sent for analysis.
Post-procedure scans and radiographs were performed
and a further radiograph was obtained at the 2 week
Ultrasound guided aspiration was the initial thera-
peutic procedure in eight patients, while in the other
three patients hydrocortisone injection into the sub-
acromial space had been performed. These latter three
patients had not responded to the injections after 6 weeks
and were therefore referred for ultrasound guided aspir-
ation. 10 of the patients had no other identifiable pathol-
ogy on ultrasound examination, while one patient was
seen to have a tear of the supraspinatus tendon in
addition to the calcific deposit.
Vol.68, No. 811
M Bradley, M S Bhamra and M J Robson
Six patients experienced immediate pain relief at the
end of the ultrasound aspiration with complete reso-
lution of all shoulder symptoms at 1 week. Four other
patients had complete pain resolution when reviewed in
the shoulder clinic at 2 weeks. The remaining patient
had limited pain relief, and was the patient who had a
rotator cuff tear demonstrated on ultrasound.
In five shoulders there was residual calcification on
the post-aspiration radiograph (Figure 4) but the follow-
up films performed at 2 weeks confirmed complete reso-
lution of the calcific deposit in all 11 cases (Figure 2c).
The post-procedure ultrasound scans were difficult to
interpret due to artefacts in the area of interest, presum-
ably due to local bleeding.
At aspiration only four of the 11 patients' deposits
were fluid in nature—less than 1 ml of milky fluid being
obtained in each case. In the remaining seven shoulders,
the aspirated material was solid and gritty. Birefringent
crystals were confirmed on microscopy, and staining with
Alizarin Red S suggested the presence of hydroxyapatite
crystals in all the fluid and solid specimens.
Patients were followed up for 6 months post-procedure
with only one patient with persistent symptoms being
treated for 14 months. Patients were asked to contact
the shoulder clinic if there was any recurrence of pain.
There were no further communications up to 14 months
"Calcific tendonitis" is characterized by deposition of
calcium phosphate crystals, predominantly hydroxyapa-
tite, in tendons. The most frequent site is around the
shoulder in the supraspinatus and long head of biceps
brachii tendons , although any of the rotator cuff
tendons can be involved. This may be either a primary
or idiopathic condition or a secondary phenomenon
associated with other disease processes which include
end stage renal disease, collagen vascular disease,
Vitamin D intoxification and tumoral calcinosis .
There have been many theories of the pathogenesis of
peri-articular calcium deposits and the debate remains
open. Consequently, terms such as "tendonosis" and
"tendonitis" are used interchangeably by authors.
In the supraspinatus tendon there is a relatively hypo-
vascular section approximately 1 cm from its insertion.
Hypoxia in this "critical area" may lead to fibrocartilag-
enous metaplasia and this has a propensity to calcify
Figure 4. (a) AP radiograph immediately
revealing a small remaining fragment of the calcific deposit,
(b) The scan confirmed this deposit in the supraspinatus tendon
post-procedure (arrow), (c) The 2 week follow-up AP radiograph
shows full resolution of the calcific deposit (a, acromium;
s, supraspinatus; h, humeral head).
The British Journal of Radiology, July 1995
US guided aspiration of symptomatic supraspinatus calcific deposits Download full-text
Calcific tendonitis affects middle-aged women slightly
more commonly than men. The condition may present
with chronic or recurrent pain and disability, or as an
acute severe shoulder pain with tenderness. Bosworth
 found it to be an asymptomatic condition in one-
third of cases.
Moseley  described the natural history of this
condition in three phases. During the "silent phase", the
calcium deposit is contained within the tendon and
appears radiographically as a sharply defined circum-
scribed deposit. When removed, this appears as a cheesy
material. These patients have minimal symptoms.
The deposit may then enlarge in the "mechanical
phase", which is accompanied by impingement symp-
toms. The deposit liquefies, leading to bursitis, and the
radiograph now shows a less well defined deposit. This
is associated with an acutely painful shoulder. These
"fluid" deposits are particularly amenable to complete
aspiration by our procedure, as seen in four of our
patients. The calcium may disperse at this stage into the
subacromial or subdeltoid bursa. The disappearance of
the deposit does not always correlate with the clinical
course. In the late stages of "adhesive periarthritis", the
patient is greatly debilitated by pain and limited shoulder
movement. The calcium deposits are associated with an
Neer  discusses four types of pain in the aetiology
of calcification. Firstly, pain due to the ability of the
calcium to cause chemical irritation of the tissue.
Secondly, pain due to swelling of the calcium deposit as
a result of a hydrophilic reaction, leading to a semi-
liquid state in the deposit and an unrelenting pain due
to raised pressure. Thirdly, the chemical irritation leads
to bursal thickening, which can result in pain when the
tendons are squeezed against the acromion. Finally, there
may be stiffness of the shoulder due to chronic calcium
Moseley's  final group and Neer's  third and
fourth groups may derive most benefit from a surgical
procedure where the deposit may be removed by curett-
age and any adhesive capsulitis is decompressed .
The large chalk-like deposits are likely to have been
present for a long time prior to the onset of the acute
The results in the small group of patients in this study
suggest that aspiration of these chronic deposits may
lead to adequate relief, even though they may only be
partially aspirated. Presumably the needle must decrease
intratendinous pressure and cause sufficient disruption
and localized bleeding for the remainder of the material
to be absorbed or dispersed into the subacromial space.
Ark et al  also noticed that even though arthroscopy
did not fully aspirate the calcium deposits, significant
pain relief was maintained.
The arthroscopist can accomplish calcium deposit
removal as well as bursectomy, coraco-acromial liga-
ment release and acromial resection. It was shown that
all our successful cases had calcium deposition as the
only cause of their symptoms.
This study relied on clinical examination and ultra-
sound to exclude other pathology to explain shoulder
pain, but other clinicians may have individual prefer-
ences. The plain radiograph was extremely useful in
enhancing diagnostic confidence, as it was felt that the
ultrasound scan alone may underestimate small deposits
or be misinterpreted for other pathology. In the authors'
opinion, the advantage of ultrasound over fluoroscopy
for needle guidance was easier positioning of the needle
in relation to the calcium deposit without the need for
1. PAINTER, C F, Subdeltoid bursitis Boston Med. Surg.
J. 156, 345-349(1907).
2. KESSEL, L and BAYLEY, J I L, Clinical Disorders of the
Shoulder (2nd edn) (Churchill Livingstone, London),
3. NEER, C S II, Shoulder Reconstruction (W B Saunders
Company, Philadelphia, USA), pp. 427-433 (1990).
4. COMFORT, T H and ARAFILES, R P, Barbotage of the
shoulder with image intensified fluoroscopic control of
needle placement for calcific tendonitis, Clin. Orthop., 135,
5. ARK, J W, FLOCK, T J, FLATOW, E L and BIGLIANI,
L U, Arthroscopic treatment of calcific tendonitis of the
shoulder, Arthroscopy, 8, 183-188 (1992).
6. GOLDMAN, A B, Calcific tendonitis of the long head of
biceps brachii distal to the gleno-humeral joint: plain film
radiographic findings, AJR, 153, 1011-1016 (1989).
7. HAYES, C W and CONWAY, W F, Calcium hydroxyapa-
tite deposition disease, Radiographics, 10,1031-1048 (1990).
8. UTHOFF, H, SARKAR, K and MAYNARD, J, Calcifying
tendonitis: a new concept of its pathogenesis, Clin. Orthop.,
9. BOSWORTH, B M, Calcium deposits in the shoulder and
subacromial bursitis: a survey of 122 shoulders, JAMA, 116,
10. MOSELEY, H F, Shoulder Lesions (3rd edn). (Williams and
Wilkins, (Baltimore), pp. 99-118 (1969).
11. LITCHMANN, H M, SILVER, C M, SIMON, D D and
ESHRAGI, A, The surgical management of calcific ten-
donitis of the shoulder, Int. Surg., 50, 475-479 (1968).
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