 This is one such procedure which will give you immense satisfaction and it will give great amount of relief to the patient and even the surgeon is very happy to refer the patient to you so that you give good immediate relief to the patient because the patients are sometimes are in such pain that it's difficult for them even to immediately take up for a arthroscopic surgery. So typically you have the calcifications in the tendon substance. The softer ones are acutely painful from acute leakage of calcium hydroxyapatite. So typical pain is the patient will suddenly get up one fine day morning with severe pain without any trauma and the pain is because of the stretching of the tendon fibers and some amount of calcium leaking into the bursa. Then there are other ones which are hard which are more chronically painful and basically because of impingement and bursal irritation. So this is how they look like on ultrasound in the rotator cuff. So what you do is see this is the calcification partly into the tendon and partly which is extruded into the bursa. So what you do is you first inject a good amount of local anesthesia maybe around 2-3 ml. The needle comes from here and you inject within the bursa, within the skin and subcutaneous tissue and around the calcifications. So what this does is it gives immediate relief to the patient and then after giving the local anesthesia with a 26 gauge needle then what you do is you put in your main 18 gauge spinal needle into the calcification there that's the 18 gauge spinal needle and then you try to pulse it with lignocaine around 5-6 ml of lignocaine. When you pulse it what happens is you are pulsing into a cavity of calcification. So that whatever you inject that goes into the bursa or that goes into the tendon and immediately comes back into the syringe and what you get back in your syringe is nothing but the powdered calcification. So now you see after doing a pulsing kind of a manure the majority of the calcification has come out into the syringe. Sometimes if it does not come out of the syringe it will go into the bursa and it will get automatically absorbed. So now you can see here majority of the calcification has gone and now whatever is remaining I am just pulsating it with normal saline. So this is how we remove calcification and break it down within the rotator cuff. This were the calcifications which were measured earlier and now you see you hardly see any calcifications. What you see here is just the empty cavity which will heal on its own. These ones are the hard tough ones which are difficult to maneuver. So for them you have to have a lot of patience. What you need to do is first inject a good amount of local around these calcifications. This is the impingement which is happening underneath the acromion. So first you give local your needle reaches up to here. You give local up to here and then with an 18 gauge needle what you try to do is you try to go into that rock hard poke the calcification hard. See you are given local so the patient won't get any pain. So you poke the patient hard so that once you have to basically enter the calcification the outer shell is very hard but inside if you go it's all that fibrous paste kind of gelatin like material. So once you go inside then you start pulsating with local anesthetic first that is 2% lignocaine. When you're pulsating with 2% lignocaine what is happening is the calcification the inner part of the calcification is slowly and slowly breaking down and coming in your syringe. See that it's moving it's breaking down and then you do it with saline. So repeat it alternately with lignocaine and saline and then what happens is something like this. You see it is clear saline that's my needle and when you do it you see I'm pulsating now I've started pulsating after adjusting my needle I'll pulsate it and when I pulsate it you can see this puff of smoke which comes here. See that puff of smoke which is coming there some amount of powder of calcification is basically gravitating at the bottom of my syringe there the near the saline is becoming more turbid now. So this is how when you pulsate the calcification comes into your syringe and then you can push it in a sterile container there and when you aspirate it more because sometimes the needle gets blocked you can see that puff of smoke coming lot of calcium coming. So typically when you use a spinal needle it is always better because you have a steelet which can remove that blockage because sometimes the calcium is so hard it blocks the needle. So this is like the end point majority of the calcium is broken you can see the cavity which is giving that sort of opening closing kind of a picture see earlier it was a hard shell like thing now you have broken the shell your broken majority of the contents you see the end point you see only the cavity there see that. So this is the time when you know that yes I have destroyed more than 70% of the calcification I need to stop now inject one dose of steroid within the subacromial bursa come out and give the post procedure instructions. The most important thing is planning the correct approach before immediately taking the patient on the couch and explaining him properly taking a proper consent and planning the procedure first by seeing the MR report CT reports or whatever the patient has is most important. And finally we need to learn how to follow up with patients after the procedure is over we should not forget the patient maybe you should tell the patient to come after one week two weeks or maybe just put in a message and maybe scan after six weeks how much calcification is remaining and how well the patient is so that's how we develop a good practice in interventions thank you very much.