Working Diagnosis:
Gluteus maximus calcific tendinosis and partial tear

Treatment:
Given the patient’s 5-year history of refractory symptoms and our past success with percutaneous treatment of gluteus medius/minimus calcific tendinosis, we opted for an US-guided lavage and aspiration (ie, barbotage) of the gluteus maximus intratendinous calcification, followed by injection with 1 mL of 40 mg/mL methylprednisolone acetate and 2 mL of 0.2% ropivacaine. Case Photo #3
A large amount of white, chalk-like material, consistent with calcium hydroxyapatite was aspirated.

Photo 3- Transverse US image of the sonographically guided left GM calcific tendinosis barbotage using in-plane, posteromedial to anterolateral approach.  Top = superficial, Bottom = deep, Left = anterolateral, Right = posteromedial, Arrows= Femur

Outcome:
The patient tolerated the procedure without complication and reported 80-90% pain improvement at one week follow-up.
The pain briefly returned at 2 months, but at 5 month follow-up the patient reported 95% pain relief.
The patient was able to return to aggressive, long-distance road and mountain biking with “absolutely no pain.”

Author's Comments:
Prior studies have shown US-guided barbotage for rotator cuff calcific tendinopathy is safe and highly effective [3].
There has been only one prior case report of US-guided barbotage for gluteus maximus calcific tendinopathy. Others have reported fluoroscopic and CT guided barbotage [2, 4].
Similar to the clinical course of this case, a previous randomized controlled trial of rotator cuff barbotage with corticosteroid injection described clinical improvement at 6 weeks, followed by symptom recurrence at 3 months, and subsequent resolution [1].
Future studies are needed to determine the safety and efficacy of US-guided barbotage in non-rotator cuff tendons such as gluteus maximus.

Editor's Comments:
Chronic tendinopathies often plague athletes for several years without successful treatment. This case highlights the use of barbotage, one modality that can successfully treat chronic tendinopathy. Because of the multiple modalities used to treat tendinopathy, future studies are needed to evaluate not only the effectiveness of each treatment but also the comparison of each treatment modality with each other.

References:
1. de Witte PB, et al. Calcific tendinitis of the rotator cuff: randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids. Am J Sports Med. 2013;41:1665
2. Choudur HN, et al. Image-guided corticosteroid injection of calcific tendonitis of gluteus maximus. J Clin Rheumatol. 2006 Aug;12(4):176-8.
3. Lanza E, et al. Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy: what is the evidence? A systematic review with proposals for future reporting. Eur Radiol. 2015 Jan 13.
4.Thomason HC 3rd, et al. Calcifying tendinitis of the gluteus maximus. Am J Orthop (Belle Mead NJ). 2001 Oct;30(10):757-8

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