Hello, I'm Rick Lawley. I'm an assistant professor at Loyola University in Chicago. We're going to be discussing an ultrasound consult on a patient who presented with shoulder pain. In the ultrasound case, the patient was noted to have calcification in the anterior shoulder over the lesser tuberosity. The supplementary cases we'll discuss today will visualize calcifications in the rotator cuff tendons. The supraspinatus is one of the most common locations to see calcific tendinopathy. Here we can see the scanning location on the left, as well as a normal appearing supraspinatus tendon on the right. The scanning position is a somewhat sagittal or parasagittal oblique on the anterior aspect of the supraspinatus. I like to find the long head of the biceps tendon in long axis, and then slide laterally to find the anterior most fibers of the supraspinatus, and then continue to scan laterally from there. On the image on the right, there is normal fibrillar echo texture. There are no calcific lesions seen here, nor any evidence of tendinosis or tendinopathy. Here we see two images showing calcific tendinopathy of the supraspinatus tendon. On the left, we see an ultrasound image of the calcific lesion involving the supraspinatus. The calcification is characterized by a hyperechoic rim and a somewhat heterogeneous hypoechoic core. There is posterior acoustic shadowing obscuring the greater tuberosity somewhat. On the right, we can see that corresponding x-ray of the right shoulder with the calcific density and the soft tissues over the greater tuberosity. The transducer location for the image on the left is directly over the calcification as shown by the red rectangle on the right. Use a sine loop of the calcification with the transducer sliding from an anterior to posterior direction. Again, left will be lateral in this case. The calcification is a bit more irregular posteriorly and a bit more rounded anteriorly. Use another sine loop of that same calcification with the transducer turned about 90 degrees, and this will be sliding from a medial to lateral direction with anterior to the left. A common treatment for calcific lesion within the tendon is called a barbitage. This is essentially needling and lavaging. So this can help break up the lesion and potentially help with the resorption of the lesion as well. Here, we can see a 25-gauge needle just on the periphery of the lesion to help with the local anesthesia. This image shows the 18-gauge needle just about to penetrate into the calcific lesion. And finally, this image shows the needle tip within the calcification. The tip is a little bit obscured because of the overlying calcification. Here we can see a sine loop of the barbitage with pulsation of the saline lavage. A mature calcification may be difficult to lavage, so it may just need to be needled. This lesion was not fully mature, but it was relatively difficult to puncture the cortex with the 18-gauge needle. We were able to wash out quite a bit of the calcification with pulses of sterile saline as seen here. If you only have one entry point, pushing the saline in will wash out the calcification and that will get pushed back into the syringe. Here we can see the calcium buildup that we were able to collect from the barbitage. The calcium has collected at the bottom of the syringes and is resting on the plunger. Here are two images to compare before and after the procedure. The image on the left is before. The image on the right is after. While not all the calcification was obtained, this was after about 30 to 40 minutes of lavage and needling, you can see an improvement in the posterior acoustic shadowing on the image on the right. Depending on the patient's symptoms, this procedure can be repeated later on as needed. The remainder of the calcification may be resorbed as well. Here's another case of calcific tendinopathy affecting the supraspinatus tendon. This has a nearly anechoic central clearing and the calcification is essentially forming a shell around the central clearing. Here's a sine loop with the transducer sliding in the posterior to anterior direction. You can see the biceps tendon appear at the end of the loop. Left side of the image is lateral. Here's another sine loop with the transducer sliding in a lateral to medial direction. Left side is anterior. You can see the long head of the biceps tendon on the left side towards the end of the loop. This calcification did have some hyperemia near the rim as well. With puncture of the rim, the calcific contents went directly into the syringe without any negative pressure on the plunger. This sine loop demonstrates a saline lobage. You can see some interlesional debris with pulses of the saline. And here is a picture of the calcification obtained from this barbiturate. It is less than the first case, but the syringe on the left has the most calcium. It hasn't quite settled out from the suspension yet.

3rd Edition, CASE 51

3rd Edition

Shoulder

calcific tendinopathy

supraspinatus tendon

ultrasound imaging

barbotage treatment

shoulder calcification