Shoulder ultrasonography in the diagnosis of polymyalgia rheumatica: a case-control study

OBJECTIVE: Magnetic resonance imaging (MRI) showed that subacromial/subdeltoid bursitis is the most frequent shoulder lesion in polymyalgia rheumatica (PMR). We evaluated whether shoulder ultrasonography (US) was as effective as MRI in the detection of this lesion and assessed the sensitivity and specificity of bilateral subacromial/subdeltoid bursitis in the diagnosis of PMR. METHODS: A case-control study of 57 consecutive case patients with untreated PMR and 114 controls seen over a 6 month period in 3 secondary referral rheumatology centers. Control patients consisted of the next 2 consecutive patients with bilateral shoulder aching and stiffness observed after the case patient. In all case and control patients the glenohumeral joint space, bursae, and long head biceps tendon were assessed by bilateral shoulder US. The first 24 case patients were also examined by bilateral shoulder MRI. RESULTS: US showed subacromial/subdeltoid bursitis in 55/57 (96%) patients with PMR and in 25/114 (22%) controls (p < 0.001). The lesion was bilateral in 53/55 (96%) case patients and in 1/25 (4%) controls (p < 0.001). The frequency of glenohumeral joint synovitis and biceps tenosynovitis did not differ significantly between case patients and controls. In 100% of case patients MRI showed subacromial/subdeltoid bursitis confirming US findings. The sonographic evidence of bilateral bursitis had a sensitivity of 92.9%, specificity of 99. 1%, and positive predictive value of 98. 1% for the diagnosis of PMR. CONCLUSION: US and MRI were equally effective in confirming bilateral subacromial and subdeltoid bursitis in PMR. This finding, in view of its high sensitivity and specificity, could be used as a new diagnostic criterion for PMR.     

Fat suppression magnetic resonance imaging in shoulders of patients with polymyalgia rheumatica

OBJECTIVE: To evaluate the sites of inflammatory process in the shoulders of patients with polymyalgia rheumatica (PMR) using fat suppressed magnetic resonance imaging (MRI). METHODS: Six consecutive, untreated new patients with PMR were investigated. Five patients with early rheumatoid arthritis (RA) and 4 patients with early psoriatic arthritis (PsA) with bilateral shoulder symptoms served as a control group. Bilateral shoulder fat-suppressed MRI sequences were performed in all patients and controls. We evaluated the presence of joint synovitis, bursitis, tenosynovitis, and bone and soft tissue edema. RESULTS: Bilateral subacromial/subdeltoid bursitis was found in all patients with PMR, in 1/5 (20%) patients with RA (p < 0.05), and in none with PsA (p < 0.02). Glenohumeral synovitis was present in all case and controls. Biceps tenosynovitis was observed in 4/6 (67%) patients with PMR, in 4/5 (80%) with RA (not significant, NS), and in all 4 patients with PsA (NS). No evidence of bone edema adjacent to the joint capsule and entheseal insertions or in the soft tissues was present in either cases or controls. CONCLUSION: The absence of extracapsular abnormalities in the early shoulder disease of PMR does not confirm the hypothesis of a capsular-based disorder.     

Ultrasound assessment of new onset bilateral painful shoulder in patients with polymyalgia rheumatica and rheumatoid arthritis

The aim of our study was to investigate by ultrasound (US) the anatomical structures affected during a new episode of bilateral painful shoulder in patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA) and to compare the findings between these two conditions. PMR and RA patients complaining of new onset bilateral painful shoulder were included. Subjects without any known rheumatic condition with a new onset unilateral painful shoulder were assessed as a control group. US evaluation includes the depiction subacromial–subdeltoid (SAD) bursitis, long head biceps (LHB) tenosynovitis and/or gleno-humeral (GH) synovitis. Thirty patients with PMR, 30 with RA, and 60 controls were included for a total of 60 shoulders per group. Unilateral SAD bursitis and LHB tenosynovitis were significantly more frequent in patients with PMR when compared to those with RA (p?<?0.0001 and p?<?0.01, respectively) and controls (p?<?0.001 and p?<?0.01, respectively). Unilateral GH synovitis was more common in RA than in PMR and controls (p?<?0.05 and p?<?0.01, respectively). Bilateral SAD bursitis was significantly more frequent in patients with PMR than in those with RA (p?<?0.01) as was bilateral LHB tenosynovitis (p?<?0.01). No significant differences were found in bilateral GH synovitis. US-detected periarticular inflammatory involvement more frequently in PMR both unilaterally and bilaterally and intra-articular inflammatory involvement was commonly in RA but only unilaterally.     

Inflammatory changes of hip synovial structures in polymyalgia rheumatica

OBJECTIVE: To investigate the hip inflammatory lesions and to evaluate the accuracy of clinical examination compared to magnetic resonance imaging (MRI) in patients with polymyalgia rheumatica (PMR) with pelvic girdle symptoms. Secondary end-point was to evaluate the sensitivity and specificity of ultrasonography (US) compared to MRI in the assessment of hip lesions. METHODS: Case-control study of 20 consecutive PMR patients and 40 controls with different rheumatic conditions. Both groups were clinically assessed for the presence of hip synovitis, trochanteric, iliopsoas and ischiogluteal bursitis. Hip MRI was performed in all case-patients and in 10 controls. Both groups were examined by US. An additional group of 10 healthy controls was examined by hip US. RESULTS: Both MRI and US detected trochanteric bursitis in 100% of PMR patients, bilateral in 18/20 (90%), and in 12/40 (30%) controls (p < 0.001). Hip synovitis was detected in 17/20 (85%) by MRI and in 9/20 (45%) by US (p < 0.02) in case-patients and in 18/40 (45%) controls. In PMR, MRI and US showed iliopsoas bursitis in 10/20 (50%) and 6/20 (30%) and ischiogluteal bursitis in 5/20 (25%) and 4/20 (20%) with no differences compared to controls. Clinical examination showed a good accuracy for hip synovitis, trochanteric and ischiogluteal bursitis, while it overestimated the presence of iliopsoas bursitis. US was less sensitive than MRI for the detection of hip synovitis and iliopsoas bursitis (53% and 60%). CONCLUSION: Trochanteric bursitis represents the most frequent hip lesion in PMR. A careful physical examination allows to detect all inflammatory lesions excluding iliopsoas bursitis. US is less sensitive than MRI in the assessment of hip synovitis and iliopsoas bursitis.     

Clinical characteristics of polymyalgia rheumatica in Japanese patients: evidence of synovitis and extracapsular inflammatory changes by fat suppression magnetic resonance imaging

Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology characterized by diffuse pain and morning stiffness involving neck, shoulder, and pelvic girdles. To facilitate an understanding of PMR and its proper diagnosis, we evaluated clinical symptoms, laboratory data, and radiographic findings of 32 Japanese patients with it. Distal musculoskeletal manifestations were more frequently observed than had been thought before (81% of the patients), and peripheral arthritis was most common (75%). The joints most often affected were knees and wrists, and most episodes were presented as bilateral oligo- or polyarthritis. A swelling of hands was observed in 34% of the patients. Using contrast-enhanced fat suppression magnetic resonance imaging (MRI) of the shoulder, we found the evidence of subacromial and subdeltoid bursitis (100%), glenohumeral joint synovitis (93%), and biceps tenosynovitis (57%) in the PMR patients examined. Inflammatory changes in soft tissues around the joint capsule were prominent. By knee MRI, suprapatellar bursitis and joint synovitis were visualized in all cases examined, and extracapsular abnormalities were also prominent in 90% of the patients. Serum matrix metalloproteinase-3, a parameter of synovial inflammation, was significantly increased in PMR patients. Anticyclic citrullinated peptide antibody was useful for differential diagnosis between PMR and elderly onset rheumatoid arthritis. In conclusion, joint and periarticular synovitis seems to be commonly and primarily responsible for the proximal and distal musculoskeletal symptoms of PMR. The presence of the extracapsular change, probably a nonspecific extension of synovitis, can explain the severe discomfort that radiates toward the periphery. To avoid making a wrong diagnosis, we should be aware that peripheral synovitis is one of the hallmarks of PMR.     

Clinical characteristics of polymyalgia rheumatica in Japanese patients: evidence of synovitis and extracapsular inflammatory changes by fat suppression magnetic resonance imaging

Abstract

Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology characterized by diffuse pain and morning stiffness involving neck, shoulder, and pelvic girdles. To facilitate an understanding of PMR and its proper diagnosis, we evaluated clinical symptoms, laboratory data, and radiographic findings of 32 Japanese patients with it. Distal musculoskeletal manifestations were more frequently observed than had been thought before (81% of the patients), and peripheral arthritis was most common (75%). The joints most often affected were knees and wrists, and most episodes were presented as bilateral oligo- or polyarthritis. A swelling of hands was observed in 34% of the patients. Using contrast-enhanced fat suppression magnetic resonance imaging (MRI) of the shoulder, we found the evidence of subacromial and subdeltoid bursitis (100%), glenohumeral joint synovitis (93%), and biceps tenosynovitis (57%) in the PMR patients examined. Inflammatory changes in soft tissues around the joint capsule were prominent. By knee MRI, suprapatellar bursitis and joint synovitis were visualized in all cases examined, and extracapsular abnormalities were also prominent in 90% of the patients. Serum matrix metalloproteinase-3, a parameter of synovial inflammation, was significantly increased in PMR patients. Anticyclic citrullinated peptide antibody was useful for differential diagnosis between PMR and elderly onset rheumatoid arthritis. In conclusion, joint and periarticular synovitis seems to be commonly and primarily responsible for the proximal and distal musculoskeletal symptoms of PMR. The presence of the extracapsular change, probably a nonspecific extension of synovitis, can explain the severe discomfort that radiates toward the periphery. To avoid making a wrong diagnosis, we should be aware that peripheral synovitis is one of the hallmarks of PMR.     

Myalgien bei Polymyalgia rheumatica, Arteriitis temporalis und anderen Vaskulitiden

Myalgias most commonly occur in polymyalgia rheumatica (PMR). About 45% of patients with giant cell arteritis present with symptoms of PMR. Other vasculitides may also lead to arthralgia and myalgia. While shoulder and pelvic pain is characteristic for PMR pain often also occurs in the back of the neck and in the region of the thoracic spine. In addition, patients often present with malaise, morning stiffness and weight loss. CRP and ESR are elevated. Ultrasound and MRI delineate minor synovitis, tenosynovitis and bursitis in the shoulder. Hip joint synovitis and trochanteric bursitis are also commonly seen. PMR should be distinguished from rheumatoid arthritis. The initial treatment comprises a prednisolone dose of 15-25 mg/day, followed by a weekly decrease of 1-2.5 mg. Once 10 mg/day has been reached the dose should be reduced more slowly.     

Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard

Objective

To assess the intra‐ and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard.

Methods

Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI.

Results

The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant.

Conclusion

Overall agreements between gray‐scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.     

Ultrasonography of the glenohumeral joints – a helpful instrument in differentiation in elderly onset rheumatoid arthritis and polymyalgia rheumatica

In a prospective study, the glenohumeral joints of 51 patients (aged 60 or above) were examined, using ultrasonography. Twenty-two patients were suffering from characteristic polymyalgia rheumatica (PMR) symptoms. In contrast, 29 other patients initially had similar complaints, but were diagnosed as having elderly onset rheumatoid arthritis (EORA, rheumatoid factor negative) upon development of typical symptoms. Ultrasound examination revealed glenohumeral joint inflammation in 40.9% (9/22) of the patients with PMR and 65.5% (19/29) of the patients with EORA. A discrete symmetrical biceps tendon sheath effusion was found in only three patients and unilateral in six patients with PMR. In contrast, 12 patients with EORA presented a massive effusion of the biceps tendon sheath, in some cases combined with a bilateral subdeltoid bursitis, and an intraarticular (i.a.) effusion/synovitis. To summarize our results: an i.a. effusion/synovitis, subdeltoid bursitis and biceps tendon sheath effusion were more frequent in patients with EORA, with a predominate symmetry and signs for massive inflammation. The typical ultrasonographic result in patients with PMR was a unilateral inflammation of the glenohumeral joint with predominate discrete biceps tendon sheath effusion and, in comparison with the EORA group, with signs of a low grade inflammation. We conclude that the results of our prospective study might be helpful in the differentiation of PMR and a rheumatoid factor negative subgroup of EORA at the first time of manifestation where clinical overlaps can be observed. However, ultrasonography of the glenohumeral joints might be a good and helpful instrument of differentiation in both diseases. Received: 29 February 2000 / Accepted: 2 March 2000     

Sites of inflammation in painful rheumatoid shoulder assessed by musculoskeletal ultrasound and power Doppler sonography

Ultrasonography (US) and power Doppler sonography (PDS) was used to investigate causes of new onset of shoulder pain and sites of shoulder inflammation in 157 shoulders of 99 patients with rheumatoid arthritis (RA). US detected effusion and/or synovitis in 92/157 glenohumeral joints, subdeltoid bursitis in 56/157 shoulders and tenosynovitis of biceps tendon in 55/157 shoulders. Bursitis and/or tenosynovitis were accompanied by glenohumeral synovitis in 68/90 shoulders. 68% of serologically active and 12% of serologically inactive patients had glenohumeral synovitis. PDS showed increased microvascular blood flow in 33 of the 44 investigated shoulders. Glenohumeral synovitis was correlated to elevated C-reactive protein levels (p = 0.0001) and microvascular blood flow assessed by PDS (p = 0.02). This study shows that rheumatoid shoulder pain is not caused by glenohumeral synovitis in 32% of patients, despite serologically active RA. US and PDS are mandatory to elucidate the origin of inflammatory and noninflammatory shoulder pain.     

New-onset Polymyalgia Rheumatica Following the Administration of the Pfizer-BioNTech COVID-19 Vaccine

We herein report the case of an 80-year-old Japanese woman who presented to our hospital with bilateral pain in the shoulders and hips lasting for a month since 2 days after the second dose of the BNT162b2 COVID-19 vaccine. Her physical findings, laboratory data, and ultrasonographic findings of bilateral biceps tenosynovitis and lateral subacromial bursitis were consistent with a diagnosis of polymyalgia rheumatica (PMR). She was successfully treated with oral prednisolone 15 mg/day. Although a causal relationship could not be definitively confirmed, PMR should be considered as a differential diagnosis in cases of persistent myalgia after administration of the BNT162b2 vaccine.     

Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in patients with adhesive capsulitis: Glenohumeral versus subacromial approaches

Aim of the work

To evaluate the efficacy of intra-articular steroid injection of the shoulder joint with exercises in the management of patients with adhesive capsulitis and to compare glenohumeral (GH) versus subacromial subdeltoid (SASD) ultrasound-guided approaches.

2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.     

Subacromial bursitis related to HIV infection: case report

ObjectiveDescribe a subacromial bursitis at the right shoulder of a 45-year-old male subject. The patient has been living with HIV/AIDS for 22 years.MethodsThe ultrasonography and the MRI revealed the presence of a pronounced subacromial effusion, with an inflammatory reaction of adjacent tissues. The tumoration was handled firstly with a needle-puncture aspiration, with a thick liquid outflow, followed by an open drainage. Histopathological evaluation showed no evidence of any AIDS defining disease. There was complete remission of the infection after five months thereafter the symptoms had started.ConclusionAfter reviewing the scarce literature in the area, no reports of subacromial bursitis in HIV/AIDS patients were found. The authors point out that, although rare, this disease should be considered as differential diagnosis of shoulder diseases in HIV-infected subjects.     

Accuracy of physical examination in subacromial impingement syndrome

Objective. Shoulder pain is a common complaint, frequently causedby subacromial impingement syndrome (SIS). There are a numberof physical examination (PE) manoeuvres that explore the subacromialspace. MRI provides an accurate anatomic image of the subacromialspace, being the current gold standard in the diagnosis of SIS.The aim of this study is to evaluate the accuracy of the PEin the diagnosis of SIS and/or subacromial–subdeltoidbursitis (SSB) confirmed by MRI. Methods. Consecutive outpatients with an episode of shoulderpain were prospectively included in the study. They were examinedby a rheumatologist and, within 3 days, an MRI was done. Sensitivity,specificity, positive and negative predictive values, and accuracyof PE manoeuvres were calculated using a 2 x 2 table. Results. Fourteen males and 16 females were included. All thetests exhibited acceptable sensitivity. As a result Yocum manoeuvrewas considered the most sensitive and most accurate for SIS.With regard to SSB, the Gerber test was the most sensitive.The majority of the PE manoeuvres showed low specificity. Conclusions. Most PE manoeuvres identify reasonably well subacromialimpingement of the shoulder, although, in general, they havelow specificity. The Yocum test has the best sensitivity andprecision. Our data suggest that imaging techniques should berecommended to better define shoulder lesions. KEY WORDS: Painful shoulder, Subacromial impingement syndrome, Subacromial–subdeltoid bursitis, Clinical evaluation, MRI Submitted 29 October 2007; revised version accepted 8 February 2008.     

Corticosteroid injections in polymyalgia rheumatica: a double-blind, prospective, randomized, placebo controlled study

OBJECTIVE: To determine the efficacy and safety of shoulder corticosteroid injections in polymyalgia rheumatica (PMR). METHODS: Twenty consecutive patients with active PMR were randomized into a 7 month, double blind, placebo controlled study. Patients received either bilateral shoulder injections of 40 mg of 6-methylprednisolone acetate or placebo (1 ml saline solution). Responders were treated weekly with the same regimen for a total of 4 bilateral injections and then followed for 6 months. Response was defined as a 70% reduction in visual analog scale (VAS) score for pain and for patient and physician global assessment, and duration of morning stiffness. Bilateral shoulder magnetic resonance imaging (MRI) was performed at different times to evaluate the response of lesions to therapy. RESULTS: All 10 corticosteroid treated patients responded to the first injection with a significant reduction in duration of morning stiffness, VAS pain scale, patient and physician global assessment, erythrocyte sedimentation rate, and C-reactive protein. Interleukin 6 serum levels were significantly reduced after the 2nd injection. In 5 patients, the response persisted throughout the followup period. The other 5 withdrew within 4 weeks after the 4th injection due to recurrence of symptoms. None of the 10 patients of the placebo group responded to the first injection. The difference between the 2 groups was significant (p = 0.03). No side effects were recorded. MRI showed marked improvement of shoulder lesions one week after first injection and an almost complete resolution one week after last injection in the responders. CONCLUSION: Shoulder corticosteroid injections seem to be an effective and safe therapy for PMR.     

Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a common chronic inflammatory rheumatic disease with unknown aetiology, affecting predominately people of middle age and older. Besides clinical symptoms and diagnostics, imaging techniques including sonography and magnetic resonance imaging may provide evidence of typical inflammatory lesions with bilateral bursitis subdeltoidea or subacromialis, tenosynovitis of the biceps tendon sheath and/or synovitis of the shoulder joints and thus may support the diagnosis of this disease in difficult cases. Corticosteroids are the cornerstone of treatment of PMR, but adverse events because of chronic corticosteroid use are observed in more than 50% of treated patients. Whether immunosuppressants, such as methotrexate and tumour necrosis factor-α inhibitors are effective in the therapy of PMR has still not yet been clarified.     

Pes anserinus tendino-bursitis: what are we talking about?

We studied the ultrasonographic (US) features of the pes anserinus insersion (PA) and subcutaneous medial knee fat in patients clinically diagnosed of pes anserinus tendino-bursitis (PATB) syndrome. Thirty seven consecutive patients with suspected PATB were clinically evaluated and their knees examined using a 7.5 MHz linear probe. In twenty-three patients with unilateral clinical PATB (group A) the painful knee was compared with their painless opposite knee. Six patients with bilateral clinical PATB (group B) were compared with 6 healthy controls (group C). All patients were women with radiographic knee osteoarthritis in 93% and body mass index > 27 in 75%. US pes anserinus tendinitis was found in one symptomatic knee and pes anserinus bursitis in two symptomatic knees and in one asymptomatic knee. No US signs of panniculitis were found in patients and controls. In conclusion, patients diagnosed of PATB syndrome in rheumatology rarely have US tendinitis or bursitis of the PA.     

Staphylococcal infection of the subacromial/subdeltoid bursa

A patient with a Staphylococcus aureus infection of the subacromial/subdeltoid bursa is described. Instillation of radiocontrast dye into the purulent cavity provided evidence that the infection was localized to the subacromial/subdeltoid bursa. The use of bursography/arthrography to define the site and extent of shoulder infections may help to determine the optimal duration of antibiotic therapy and the prognosis for cartilage and/or bone destruction.