Calcific tendinitis of the rotator cuff (RCCT) is frequently diagnosed in patients with shoulder pain, but there is no consensus on its treatment. To compare 2 regularly applied RCCT treatments: ultrasound (US)–guided needling and lavage (barbotage) combined with a US-guided corticosteroid injection in the subacromial bursa (subacromial bursa injection [SAI]) (group 1) versus an isolated SAI (group 2). Randomized controlled trial; Level of evidence, 1. Patients were randomly assigned to the 2 groups. Shoulder function was assessed before treatment and at regular follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant shoulder score (CS, primary outcome), the Western Ontario Rotator Cuff Index (WORC), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Additionally, calcification location, size, and Gärtner classification were assessed on radiographs. Results were analyzed using the t test, linear regression, and a mixed model for repeated measures. This study included 48 patients (25 female, 52.1%; mean age, 52.0 ± 7.3 years; 23 patients in group 1) with a mean baseline CS of 68.7 ± 11.9. No patients were lost to follow-up. Four patients in group 1 and 11 in group 2 (P = .06) had an additional barbotage procedure or surgery during the follow-up period because of persisting symptoms and no resorption. At 1-year follow-up, the mean CS in group 1 was 86.0 (95% CI, 80.3-91.6) versus 73.9 (95% CI, 67.7-80.1) in group 2 (P = .005). The mean calcification size decreased by 11.6 ± 6.4 mm in group 1 and 5.1 ± 5.7 mm in group 2 (P = .001). There was total resorption in 13 patients in group 1 and 6 patients in group 2 (P = .07). With regression analyses, correcting for baseline CS and Gärtner type, the mean treatment effect was 20.5 points (P = .05) in favor of barbotage. Follow-up scores were significantly influenced by baseline scores. Results for the DASH and WORC were similar. On average, there was improvement at 1-year follow-up in both treatment groups, but clinical and radiographic results were significantly better in the barbotage group.

The Western Ontario Rotator Cuff Index (WORC) is an increasingly applied condition-specific outcome measure for rotator cuff (RC) conditions. However, in most WORC validation studies, only a limited number of psychometric properties are studied in indistinct patient groups. To assess psychometric properties of the WORC according to the Scientific Advisory Committee quality criteria for health questionnaires in 3 patient groups with distinct RC conditions. Cohort study (diagnosis); Level of evidence, 2. The WORC (range, 0-100; 21 items, 5 domains) was administered twice (T1, T2) in 92 patients (35 RC tears, 35 calcific tendinitis, 22 impingement). Additionally, the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH) were recorded. Calcific tendinitis patients were reassessed 6 weeks after treatment with needling and lavage or a subacromial injection with corticosteroids (T3). We assessed floor and ceiling effects, internal consistency, test-retest reliability, precision, construct validity, minimally detectable change, and responsiveness in the diagnostic subgroups and the total group. Mean age was 55.0 ± 8.7 years, and 49 of 92 (53%) patients were female. Mean baseline WORC was 46.8 ± 20.4, CS was 63.9 ± 15.4, and DASH was 40.9 ± 18.6. Significant differences were found for the CS and DASH between RC tear patients (severe symptoms) and the other patients, but not for the WORC. There were no floor and ceiling effects. Internal consistency was high: the Cronbach alpha coefficient was .95. The intraclass correlation coefficient of .89 and standard error of measurement of 6.9 indicated high reproducibility. Pearson correlations of the WORC with the CS and DASH were .56 and –.65, respectively (both P < .001). At T3, total WORC improved significantly (mean change, 18.8; 95% confidence interval, 11.3-26.2). Correlations of the WORC change scores with CS and DASH changes were .61 and –.84, respectively (both P < .001). Effect size was 0.96, with a standardized response mean of 0.91, indicating good responsiveness. Applied to a variety of RC patients, the WORC had high internal consistency, moderate to good construct validity, high test-retest reliability, and good responsiveness. These findings support the use of the WORC as a condition-specific self-reported outcome measure in RC patients, but its validity in patients with severe symptoms needs further investigation.

Barbotage (needling and lavage) is often applied in the treatment of calcific tendinitis of the rotator cuff (RCCT). In a previously published randomized controlled trial, we reported superior clinical and radiological 1-year outcomes for barbotage combined with a corticosteroid injection in the subacromial bursa (SAIC) compared with an isolated SAIC. There are no trials with a midterm or long-term follow-up of barbotage available. To compare the 5-year results of 2 regularly applied treatments of RCCT: ultrasound (US)–guided barbotage combined with a SAIC (group 1) versus an isolated US-guided SAIC (group 2). Randomized controlled trial; Level of evidence, 1. Patients were randomly assigned to group 1 or 2 and evaluated before and after treatment at regular time points until 12 months and also at 5 years using the Constant score (CS), the Western Ontario Rotator Cuff Index (WORC), and the Disabilities of the Arm, Shoulder and Hand (DASH). The calcification location and size and Gärtner classification were assessed on radiographs. The rotator cuff condition was evaluated with US. Results were analyzed using t tests, linear regression, and a mixed model for repeated measures. Forty-eight patients were included (mean age, 52.0 ± 7.3 years; 25 [52%] female) with a mean baseline CS of 68.7 ± 11.9. After a mean follow-up of 5.1 ± 0.5 years, the mean CS was 90 (95% CI, 83.0-95.9) in group 1 versus 87 (95% CI, 80.5-93.5) in group 2 (P = .58). The mean improvement in the CS in group 1 was 18 (95% CI, 12.3-23.0) versus 21 (95% CI, 16.2-26.2) in group 2 (P = .32). There was total resorption in 62% of group 1 and 73% of group 2 (P = .45). The US evaluation of the rotator cuff condition showed no significant differences between the groups. With the mixed model for repeated measures, taking into account the baseline CS and Gärtner classification, the mean treatment effect for barbotage was 6 (95% CI, –8.9 to 21.5), but without statistical significance. Follow-up scores were significantly associated with baseline scores and the duration of follow-up. Results for the DASH and WORC were similar. There were no significant complications, but 4 patients in group 1 and 16 in group 2 underwent additional treatment during the follow-up period (P < .001). No more significant differences were found in the clinical and radiological outcomes between barbotage combined with a SAIC versus an isolated SAIC after 5 years of follow-up. NTR2282 (Dutch Trial Registry).

Objectives Knowledge on the epidemiology and long-term course of rotator cuff calcific tendinitis (RCCT) is scarce. We assessed demographics, radiological characteristics, and their association with long-term outcomes in a large patient group. Methods Baseline demographics, radiological characteristics and treatment were recorded in 342 patients. Interobserver agreement of radiological measures was analyzed. Long-term outcome was evaluated with questionnaires (WORC, DASH). The association of baseline characteristics with outcome was assessed. Results Mean age was 49.0 (SD = 10.0), and 59.5 % were female. The dominant arm was affected in 66.0 %, and 21.3 % had bilateral disease. Calcifications were on average 18.7 mm (SD = 10.1, ICC = 0.84 (p < 0.001)) and located 10.1 mm (SD = 11.8) medially to the acromion (ICC = 0.77 (p < 0.001)). Gärtner type I calcifications were found in 32.1 % (Kappa = 0.47 (p < 0.001)). After 14 years (SD = 7.1) of follow-up, median WORC was 72.5 (range, 3.0-100.0; WORC < 60 in 42 %) and median DASH 17.0 (range, 0.0-82.0). Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior WORC. DASH results were similar. Conclusions Many subjects have persisting shoulder complaints years after diagnosis, regardless of treatment. Female gender, dominant arm involvement, bilateral disease, longer duration of symptoms, and multiple calcifications were associated with inferior outcome. Radiological measures had moderate-to-good reliability and no prognostic value. Key Points • Most RCCT studies report on short-term outcome and/or small patients groups. • In this large, long-term observational study, RCCT appeared to not be self-limiting in many subjects. • Negative prognostic factors included female gender, more calcifications, dominant arm affected, and longer duration of symptoms. • Interobserver agreement of general radiological RCCT measures is moderate to good. • More rigorous diagnostics and treatment might be needed in specific RCCT cases.

The Subacromial Impingement Syndrome (SIS) is the most common diagnosed disorder of the shoulder in primary health care, but its aetiology is unclear. Conservative treatment regimes focus at reduction of subacromial inflammatory reactions or pathologic scapulohumeral motion patterns (intrinsic aetiology). Long-lasting symptoms are often treated with surgery, which is focused at enlarging the subacromial space by resection of the anterior part of the acromion (based on extrinsic aetiology). Despite that acromionplasty is in the top-10 of orthopaedic surgical procedures, there is no consensus on its indications and reported results are variable (successful in 48-90%). We hypothesize that the aetiology of SIS, i.e. an increase in subacromial pressure or decrease of subacromial space, is multi-factorial. SIS can be the consequence of pathologic scapulohumeral motion patterns leading to humerus cranialisation, anatomical variations of the scapula and the humerus (e.g. hooked acromion), a subacromial inflammatory reaction (e.g. due to overuse or micro-trauma), or adjoining pathology (e.g. osteoarthritis in the acromion-clavicular-joint with subacromial osteophytes).