Do you have calcific tendinitis in the shoulder due to calcium deposits build up within the tendons of the rotator cuff.
Has your doctor recommended a barbotage procedure as part of your treatment? Are you wondering if this procedure is effective and how it’s done?
In this article, I share my insights and experiences on this topic as a diagnostic radiographer, drawing upon clinical study results involving individuals who have undergone a barbotage procedure.
At the end of the article, you will find all the sources I rely on, as well as a comment section where you can share your thoughts or ask questions!
Happy reading!😀 and feel free to ask questions in the comments or share your own experience.🙏
Last updated: January, 2026. Written by Juliet Semakula, a diagnostic radiographer.
| Summary: Calcific rotator cuff (RC) tendinopathy is a common cause of shoulder pain with a reported incidence of 2.7% to 22% (Berrigan,2022). An Ultrasound-guided barbotage is one of the minimally invasive percutaneous procedures used to treat it. |
▶️What is a barbotage procedure of the shoulder?
Barbotage, also known as ultrasound-guided lavage, is a minimal procedure primarily used to treat calcific tendinitis, most commonly in the shoulder.
The goal of a barbotage procedure is to:
⚫Help relieve chronic pain.
⚫Restore mobility.
⚫Reduce inflammation.
⚫Avoid surgery.
The aim is to physically break down and remove calcium deposits that have formed within a shoulder tendon.
There are variations in technique and additives for barbotage procedure primarily used for calcific tendinitis.
1️⃣Using ultrasound-guided needle insertion to break up calcium.
2️⃣ Aspirating the debris.
Key variations include the amount of fluid, adding PRP (Platelet-Rich Plasma), or combining it with other therapies like physiotherapy, with the main goal always being to remove painful calcium deposits from tendons in the shoulder.
▶️What do calcium deposits look like on a shoulder?
Calcific tendonitis of the shoulder involves calcium deposits forming in the rotator cuff tendons, most often the supraspinatus.
Image showing cortical erosion and calcium deposition on a shoulder.
Calcific tendinitis in a 40-year-old female shoulder, x-ray demonstrating marrow oedema signal in the humeral head at the greater tuberosity at teres minor tendon footprint and cortical erosion and calcium deposition in rotator cuff tendons (image Lim 2021)
▶️ When is a barbotage shoulder treatment proposed?
As an interventional radiographer, we often encounter individuals to whom doctors recommend ultrasound barbotage procedure primarily in the following situations:
♦️Patients suffering from calcific tendonitis.
♦️Inflammation of the shoulder
♦️Severe or chronic pain (especially at night or with movement).
♦️Stiffness in the shoulder.
♦️️ Reduced motion is often self- limiting.
♦️Or failure of Conservative Treatment
Note! not all patients with these symptoms do have a barbotage procedure: sometimes the symptoms may resolve as deposits dissolve over time and you may require other treatments such as:
♦️Pain relief medication.
♦️Applying cold and heat therapy.
♦️Rest.
♦️Physiotherapy (pendulum, assisted movements).
♦️Steroid injections.
♦️Shockwave therapy.
♦️Or surgery for stubborn cases.
Though the cause is typically unknown but linked to wear-and-tear and middle age.
However, if you have the following symptoms, you will not be eligible for a barbotage treatment.
♦️A full-thickness tendon tear in the same area.
♦️ Had surgery in the same region within the last six months.
♦️A known allergy to local anaesthetics.
♦️ An active infection or cellulitis at the injection site.
▶️Barbotage procedure performed under ultrasound guidance
This approach offers a non-surgical alternative to patients and has a high success rate in alleviating the pain. Many patients report significant pain relief with this procedure (Tafti,2023)
▶️How is a barbotage procedure done?
Before beginning the procedure, a radiologist will have a thorough discussion with you regarding the following:
🔵The steps involved in the procedure, including the use of a needle to break up the crystalline deposits
🔵The potential for pain or significant discomfort during the procedure
🔵 Prior medical conditions or surgeries that could affect the procedure
🔵The possible complications of the procedure such as skin or joint infection, steroid flare (usually within the first 24 hours), and tendon rupture.
▶️Preparation and procedure steps:
✴️You will be lying supine or alternatively if you are unable to lie flat you will sit in a partially reclined chair.
✴️Arm in full extension, either rotated internally or externally (depending on the location of the calcific tendinitis
✴️ The skin entry site should then be cleaned, and a sterile drape should be put in place.
Two-step skin cleaning procedure (coloured/uncoloured antiseptics). The peripheral brownish ring (arrowhead) allows for clear visibility of the cleaned area (Image source: Sconfienza 2013):
✴️ The ultrasound probe is covered with a sterile sleeve.
✴️The skin is sterilized with a solution such as chlorhexidine.
✴️An ultrasound machine with a high-frequency transducer (5 to 12 MHz) is used.
✴️The skin is anesthetized with1% lidocaine (typically 10 to 20 mL)
✴️Saline syringes (typically 2 to 3 saline flushes can be used)
✴️An 18-gauge needle (provider preference) is used Under ultrasound guidance to advance to the location of the coarse calcifications seen on ultrasound.
✴️Aspiration of the crystals should be attempted first without lavage.
✴️After attempts at aspiration, sterile saline should be pulsed through the needle, and then aspiration should be attempted through the same needle (lavage).
✴️The saline injection helps in the aspiration of calcium deposits. Care is necessary to confirm the visualization of multiple aspirate samples of calcifications.
(a) The syringe is connected to one needle. Then, saline solution is injected and flows out through the other needle, thus obtaining a continuous inflow and outflow. (b) A home-made close circuit can be also set up. Arrows indicate water flow direction (image source Sconfienza,2013)
✴️Lavage can be continued (with multiple needles) until a significant amount of calcium is felt to have been fragmented and aspirated.
✴️Upon completing the barbotage and lavage, a small volume of lidocaine can be injected into the residual calcium crystal deposits. However, the steroid should not be injected into the tendon as it can weaken the tendon and lead to rupture.
✴️A mixture of 1 mL of betamethasone 6 mg/mL and 2 mL of bupivacaine 0.5% should then be injected into the subacromial/subdeltoid bursa. This helps with pain relief in the event that calcium crystals are released into the bursa.
✴️Hemostasias should be achieved, and the placement of a sterile dressing is the final step.
X-ray imaging showing pre and post changes of the calcium deposit. A Pre-procedure left shoulder. B, post-procedure left shoulder with decrease in the density of the calcification immediately after the procedure. (image source Berrigan,2022)
▶️Is barbotage painful
Barbotage is generally well-tolerated and the pain is bearable.
The patients I see in interventional normally experience temporary discomfort both during and after the procedure.
This is caused by the fact that a needle is used to physically break up and aspirate calcium deposits.
So, you may experience mild pain, and the area will feel sore or bruised for 2 to 14 days after the numbing medication wears off.
Normally doctors recommend paracetamol and ice packs to manage pain and soreness.
Caution! Most experts advise avoiding NSAIDs (like ibuprofen) immediately following the procedure, as they may interfere with the body’s natural process of reabsorbing the broken-down calcium
▶️What are the risks of barbotage?
A few patients we see in interventional normally have these complications though very rare.
❌Bruising.
❌Hematoma formation
❌Infections.
❌Acute exacerbation of pain.
❌Patients are always advised not to drive after the procedure.
❌Bursitis that develops post-procedure.
❌In rare cases, tendon rupture.
Tafti,2023
▶️What are the benefits and success rates of barbotage?
To answer the question regarding the benefits of barbotage, I prefer to rely primarily on data from clinical studies rather than my own experience.
To do this, I have searched for all studies on the subject published in the medical research database PubMed/Medline.
There are several dozen studies that aim to examine pain outcomes of patients following barbotage of calcific tendinitis
▶️Most people who have had a barbotage procedure normally claim:
♦️Targeted Pain Relief:
♦️ Restored Mobility:
♦️ High Success Rate:
Clinical studies indicate that 80–90% of patients experience significant improvement and are able to return to normal activities within a few weeks. Gatt,2014
However,observed reductions in pain, disability, and calcification size and improvement in degree of movement found in the studies reviewed could not be conclusively attributed to ultrasound-guide needle lavage alone.
A retrospective chart review of 179 ultrasound-guided barbotage interventions for calcific tendinitis of the rotator at a New England urban medical centre.
Patient pain scores were analysed using a Friedman’s analysis of variance at a significance level of α = 0.05, and statistical significance between groups was elucidated using nonparametric post-hoc tests of significance between groups (Werry,2024)
🟠Outcome:Pain scores at pre-procedure from 2-month, 6-month and 12-month follow-ups
Yielded significant differences, the table shows patients demographics and results totals
⚪Over 179 procedures were analysed for pain score evaluation.
⚪Of 71 people within a 2-month follow-up.
⚪Of 64 people within a 6-month follow-up
⚪Of 59 people within a 12-month follow-up
Results: pain scores were lost at an increasing amount at each subsequent follow-up time point
⚪At 60.3% patients at a 2-month follow-up had less pain.
⚪At 64.3% at 6 months follow up pain had decreased.
⚪At 67.0% at 12 months follow up pain had disappeared.
Source: Werry,2024
Overall,it appears universal that barbotage provides a degree of symptom relief for calcific tendinitis in most patients
Despite this, there is variability in the degree of success. In a systematic review of barbotage for calcific tendinitis, it was determined that there is insufficient evidence to conclude that ultrasound-guided needle lavage is a superior treatment option to other methods of addressing calcific tendinitis
Over 47.5% of patients who continued to feel pain went on to require a subsequent procedure for the respective shoulder. Such as corticosteroid injection, additional barbotage, or surgery.
Note: Corticosteroid injections are another proven effective treatment option for calcific tendinitis
▶️What Rehabilitation is needed after a barbotage procedure?
After a barbotage procedure, rehabilitation primarily involves a period of:
Initial rest followed by a structured course of physiotherapy to restore the shoulder’s strength, flexibility, and range of motion.
⚪Your physiotherapist will design a personalized exercise plan that typically progresses from gentle passive range of motion exercises
⚪Consistency in following your tailored home exercise program is the most important factor in a successful and timely recovery
⚪You will likely have a follow-up appointment with your clinician or physiotherapist a few weeks after the procedure to monitor progress.
▶️What is the recovery like after barbotage shoulder treatment?
Recovery after barbotage shoulder treatment is generally quick, with most patients experiencing only mild to moderate discomfort for a few days as the body reabsorbs the loosened calcium deposits
⚪Pain and Discomfort: Temporary soreness, pain, or swelling is normal for the first 2-5 days.
⚪Some patients may experience a “steroid flare,” where pain temporarily worsens for 1-3 days.
⚪Initial Restrictions Day 1 to 2, It is advised to rest the shoulder, avoid heavy lifting, and apply ice packs for 10-minute intervals during the first 48-72 hours.
⚪Most patients can resume light activities within a few days and return to full activity within 4-6 weeks, though individual recovery times vary.
Hope I have answered some of your questions, wishing you a quick recovery!🙋
📚Source:
Lim, Wanyin & Barras, Christen & Zadow, Steven. (2021). Radiologic Mimics of Osteomyelitis and Septic Arthritis: A Pictorial Essay. Radiology Research and Practice. 2021. 1-18. 10.1155/2021/9912257.
Tafti D, Byerly DW. Ultrasound-Guided Barbotage. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025
Berrigan W, Olufade O, Negron G, Easley K, Sussman WI. Calcific Tendinopathy of the Shoulder: A Retrospective Comparison of Traditional Barbotage Versus Percutaneous Ultrasonic Barbotage. Clin J Sport Med. 2022 Sep 1;32(5):458-466. doi: 10.1097/JSM.0000000000001039. Epub 2022 Apr 22. PMID: 35533134.
Werry WD, Hedeman M, Sharma A, Garfi J, Elentuck D, Samuelsen B, Kasparyan G, Lemos M. Determining the efficacy of barbotage for pain relief in calcific tendinitis. JSES Int. 2024 Jun 19;8(5):1039-1044. doi: 10.1016/j.jseint.2024.06.005. PMID: 39280166; PMCID: PMC11401591.
Gatt DL, Charalambous CP. Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients. Arthroscopy. 2014 Sep;30(9):1166-72. doi: 10.1016/j.arthro.2014.03.013. Epub 2014 May 10. PMID: 24813322.
Sconfienza LM, Viganò S, Martini C, Aliprandi A, Randelli P, Serafini G, Sardanelli F. Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks. Skeletal Radiol. 2013 Jan;42(1):19-24. doi: 10.1007/s00256-012-1462-x. Epub 2012 Jun 19. PMID: 22710923.