Shoulder Tendinitis Responds to Lavage and Needle Aspiration

BILBAO, Spain, Sept. 27 -- For calcific tendinitis of the shoulder, ultrasound-guided percutaneous needle aspiration and lavage can improve range of motion and provide both short- and long-term relief of pain, reported investigators here.

One year after ultrasound-guided needle aspiration and lavage, 91% of treated shoulders had substantial improvement or complete resolution of calcific tendinitis, 64% had full range of motion, and 89% had radiographic evidence of complete or near-complete resolution of calcifications, reported Jose Luis del Cura, M.D., of the Hospital de Basurto here, and colleagues.

However, nearly half of the shoulders that experienced improvement after the procedure had a transitory recurrence of pain at about 15 weeks, the investigators reported in the September issue of the American Journal of Roentgenology.

"When the recurrence did occur, the symptoms were different; milder and predominately at night, lasted several weeks and finally disappeared, usually without sequels," Dr. del Cura said. "We hypothesized that this may have been the result of reparative changes inside the tendon."

Although needle lavage and aspiration is far from a new technique, the results that Dr. del Cura and colleagues achieved were better than those currently obtainable with more recent technologies, such as low-frequency sonography, commented Joseph Iannotti, M.D., Ph.D., chairman of orthopedic surgery at the Cleveland Clinic, who was asked about the study.

"For a level three study -- a retrospective, non-controlled study -- they show pretty good results," Dr. Iannotti said.

"An 89% radiographic improvement or almost complete resolution, 91% clinical, is pretty darn good, especially in a patient population that by and large had already had some non-surgical treatment that failed," he added.

The key to their success, the Spanish investigators said, is the use of ultrasound guidance to place the needle near but not in areas of calcification to prevent blockage of the needle, the use of a single, large-bore (20-gauge) needle for both lavage and aspiration, and restricting the aspiration to one per area of calcification, to avoid further damage to the tendon.

To evaluate the short-term and long-term efficacy and safety of percutaneous needle aspiration, the investigators enrolled 70 consecutive patients who presented to their center's emergency department with acute shoulder pain. Two of the patients had bilateral treatment, for a total of 72 shoulders.

The patients subjectively rated their pain and disability on the Shoulder Pain and Disability Index questionnaire, and the investigators measured their baseline range of motion. Patients also underwent radiography and sonography for evaluation of calcifications.

The patients then underwent lavage and aspiration with a 20-gague percutaneous needle introduced under ultrasound guidance, with the patients under conscious sedation.

The patients were given a prescription for an NSAID in case of post-procedure pain, and were asked to return for radiography and sonography at five and 10 weeks and one year after the procedure. Patients who had bilateral problems could have the second shoulder treated after the one-year visit.

Five patients were lost to follow-up at one year, leaving 65 patients with 67 treated shoulders available for analysis. The patients, 25 men and 40 women, ranged in age from 31 to 72 (mean 47).

In 57 shoulders the supraspinatus tendon was involved, the infraspinatus was involved in 12, and three had involvement of the subscapularis. Five patients had calcifications in two tendons.

The time from the onset of symptoms to treatment ranged from one to 168 months (mean 30 months). All shoulders had been previously treated with either NSAIDs, local steroid injections, or rehabilitation.

In all, 83.6% of the shoulders had radiographically evident dense, homogeneous, and well-defined calcifications. All calcifications were clearly visible on sonography.

Three patients reported feeling faint and lost consciousness during the procedure, and two of these patients suffered seizures, prompting the investigators to add 0.25 mg of alprazolam (Xanax) 30 minutes before the procedure to reduce anxiety, and no further complications occurred. Sixteen shoulder required retreatment.

There were significant improvements in pain scores, which decreased from a mean of 56.5 points at baseline to 32 at week 10 and 17.4 at one year (P<0.001). Shoulder disability scores also decreased, from a mean of 43.9 points at baseline, to 22 at week 10 and 12.1 at one year (P<0.001).

Before treatment, only 1.5% of patients had full range of motion without pain, compared with 28% at 10 weeks, and 69% at one year.

In addition, one year after treatment, 78.1% of shoulders showed no signs of calcifications on radiography, whereas 3.1% showed no changes. There was also sonographic evidence of clearing at successive follow-ups.

"In the survey performed one year after treatment, 34 shoulders (50.7%) were completely free of symptoms, another 27 (40.3%) had experienced a substantial improvement, and three more (4.5%), a moderate improvement. Only three shoulders (4.5%) showed no improvement," the authors wrote.

Among the shoulders that showed improvement at one year, there was a transient recurrence of symptoms beginning at weeks five through 28 (mean 15 weeks), lasting from two to 20 weeks (mean six weeks) in 44.3%.

The temporary flare-up was associated with significantly worse Shoulder Pain and Disability Index scores (P<0.0001) and a lower sum of shoulder range of motion angles (P<0.002) at one year.

In the final survey, however, 24% of these patients said they had no symptoms, and 64% reported notable improvement.

"In our patients, in the long term, calcifications resolved completely or nearly completely in 89%, and a substantial or complete clinical improvement was achieved in 91% of shoulders," the authors wrote. "These results are similar to the best results published for shockwave therapy and are not worse than those for surgery, but percutaneous needle aspiration and lavage is minimally invasive and painful, is widely available, and allows patients return to work quickly."

The authors noted that their study was limited by the lack of a control group and by the difficulty in comparing results with those of other studies because of differences in measures of shoulder pain and disability.