CT can be helpful in evaluating osseous involvement [52] and is the most accurate modality in evaluating the consistency of the deposit, which may be helpful when planning intervention [53] but is not routinely obtained. FDG-PET/CT Skull Base to Mid-Thigh There is insufficient evidence to support the use of FDG-PET/CT skull base to mid-thigh in the evaluation of chronic shoulder pain when radiographs demonstrate calcific tendinopathy or calcific bursitis. Areas of calcium hydroxyapatite deposition in tendon, bursa, or bone can result in increased FDG uptake, which can potentially be confused with a neoplastic process and result in diagnostic confusion. Image-Guided Anesthetic +/- Corticosteroid Injection Shoulder or Surrounding Structures If calcium hydroxyapatite is seen on radiographs, calcium hydroxyapatite lavage with imaging guidance can be performed both for both therapeutic and diagnostic purposes. US or, less commonly, fluoroscopy can be used for guidance. US-guided calcium lavage has been shown to be a highly effective percutaneous treatment in patients with suspected calcific tendinitis [54-62]. Outcomes are similar whether the procedure is performed with the 1 or 2 needle technique [63]. Injection of corticosteroid into the subacromial subdeltoid bursa as part of the barbotage procedure has been shown to have significant impact on pain and function 3 months after the procedure [64,65]. The degree of calcium removal does not necessarily correlate with pain improvement from the procedure [66]. Lavage may be less effective at providing pain relief for patients with intraosseous migration of calcium hydroxyapatite [67]. Given the high efficacy of calcium hydroxyapatite lavage in the rotator cuff, if patient symptoms do not resolve following calcium hydroxyapatite lavage, then other diagnostic entities for shoulder pain should be considered and further imaging evaluation can be performed subsequently.
Chronic Shoulder Pain PCAs. CT can be helpful in evaluating osseous involvement [52] and is the most accurate modality in evaluating the consistency of the deposit, which may be helpful when planning intervention [53] but is not routinely obtained. FDG-PET/CT Skull Base to Mid-Thigh There is insufficient evidence to support the use of FDG-PET/CT skull base to mid-thigh in the evaluation of chronic shoulder pain when radiographs demonstrate calcific tendinopathy or calcific bursitis. Areas of calcium hydroxyapatite deposition in tendon, bursa, or bone can result in increased FDG uptake, which can potentially be confused with a neoplastic process and result in diagnostic confusion. Image-Guided Anesthetic +/- Corticosteroid Injection Shoulder or Surrounding Structures If calcium hydroxyapatite is seen on radiographs, calcium hydroxyapatite lavage with imaging guidance can be performed both for both therapeutic and diagnostic purposes. US or, less commonly, fluoroscopy can be used for guidance. US-guided calcium lavage has been shown to be a highly effective percutaneous treatment in patients with suspected calcific tendinitis [54-62]. Outcomes are similar whether the procedure is performed with the 1 or 2 needle technique [63]. Injection of corticosteroid into the subacromial subdeltoid bursa as part of the barbotage procedure has been shown to have significant impact on pain and function 3 months after the procedure [64,65]. The degree of calcium removal does not necessarily correlate with pain improvement from the procedure [66]. Lavage may be less effective at providing pain relief for patients with intraosseous migration of calcium hydroxyapatite [67]. Given the high efficacy of calcium hydroxyapatite lavage in the rotator cuff, if patient symptoms do not resolve following calcium hydroxyapatite lavage, then other diagnostic entities for shoulder pain should be considered and further imaging evaluation can be performed subsequently.