Thermography of frozen shoulder and rotator cuff tendinitis

Summary The role of thermography in the diagnosis of soft tissue lesions of the shoulder was evaluated by screening 28 patients with unilateral frozen shoulder and 86 patients with unilateral rotator cuff lesions. Index shoulders were then compared with the normal side. Differences in skin temperature distribution were found in 82% of subjects with frozen shoulder, nearly three-quarters of whom had reduced skin temperature. There was no consistent pattern of shoulder skin temperature found in rotator cuff tendinitis patients (49% normal, 28% reduced, 23% increased). Thermography can be helpful in the diagnosis of frozen shoulder but further studies are required to determine whether it is useful in other soft tissue shoulder lesions.     

Shoulder disorders in the elderly (a hospital study).

One hundred acute geriatric inpatients were assessed to investigate the prevalence of shoulder disorders; 21 had symptoms due to shoulder disease. Conditions included supraspinatus tendinitis (five), chronic rotator cuff rupture (seven), frozen shoulder (two), glenohumeral osteoarthritis (two), apatite related shoulder arthritis (one), stroke related shoulder disease (six). (Some patients had more than one shoulder condition.) The last group included painful stiff shoulders (three), glenohumeral subluxation (two), and acute shoulder-hand syndrome (one). Patients with rotator cuff rupture had bilateral disease. Only three patients had sought medical attention for their symptoms. The common occurrence of these conditions has possible implications for rehabilitation, and medical awareness is required as few may volunteer symptoms. A community based study is needed to assess the prevalence in the elderly population.     

MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica

Abstract

Objectives. The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR).

Methods. MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed.

Results. The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05).

Conclusions. Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.     

Clinical implications of rotator cuff degeneration in the rheumatic shoulder

OBJECTIVE: In rheumatoid arthritis (RA) of the shoulder, loss of cartilage and soft tissue degeneration coexists with pain and reduced range of motion. We evaluated the presence of bony and rotator cuff degeneration in RA of the shoulder joint and assessed their relationship with pain and loss of functioning. We hypothesized that rotator cuff degeneration plays an important role in the presence of pain and loss of functioning of the rheumatic shoulder. METHODS: We used a cross-sectional study to assess both bony and rotator cuff involvement using plain anteroposterior radiographs, ultrasound, and computed tomography images. Additionally, we used an electromagnetic tracking device and a force transducer to evaluate range of motion and maximum force of the shoulder muscles. Between January 2003 and July 2004 we included 26 consecutive patients (51 shoulders). Twenty-one shoulders showed no or slight joint destruction, 15 showed intermediate destruction, and 15 showed severe destruction. RESULTS: Only 19 shoulders showed an intact rotator cuff. Proximal migration of the humeral head and fatty degeneration of the infraspinatus muscle especially showed a significantly strong correlation with increased pain and function loss (R2 = 0.36, P < 0.001). In a multivariate regression analysis, proximal migration and fatty degeneration of the infraspinatus muscle were related most significantly with pain and reduced functioning in the shoulder joint. CONCLUSION: Rotator cuff degeneration plays an important role in the daily functioning of the rheumatic shoulder. Prevention of rotator cuff degeneration may therefore play an important part in the treatment of the rheumatic shoulder.     

The efficacy of conservative treatment in patients with full-thickness rotator cuff tears

Rotator cuff tears are a common cause of shoulder pain and disability. Although many studies have reported about the surgical results of full-thickness tears of the rotator cuff, there are few studies about the efficacy of conservative treatment. The aim of this study was to investigate the efficacy of conservative treatment in patients with full-thickness rotator cuff tears by using objective and subjective measurements. Twenty patients with full-thickness rotator cuff tears were included in the study. Outcome measures were range of motion, pain and function according to the shoulder index of the American Shoulder and Elbow Surgeons (ASES), Constant score, Short-Form 36 Health Survey (SF-36), isokinetic shoulder strength, and patient response. Patients were assessed at baseline and after 6 months. In addition, patients were contacted by telephone at 1 year and at 3 years for functional assessment according to ASES, and patient response. The treatment protocol included activity modification, oral nonsteroidal antiinflammatory medications, physical modalities, and a specific exercise program. Statistically significant improvements were obtained in range of motion, pain and function scores according to ASES, Constant score, SF-36 scores, and isokinetic strength (P < 0.05). At the 6-month evaluation, 11 patients (55%) reported that they were "much better", and 9 patients (45%) "better". Conservative treatment of full-thickness rotator cuff tears yields satisfactory results both subjectively and objectively.     

THE LONG-TERM OUTCOME OF ROTATOR CUFF TENDINITIS -- A REVIEW STUDY

Rotator cuff tendinitis is believed to resolve in the majoritybut the long-term outcome has not been well documented. Thisreview of 137 patients treated conservatively found active tendinitisin 35 individuals at a mean of 19 months after presentation.In addition, 40 patients had residual pain and eight developedpain due to another cause. Early presentation and a historyof overuse unrelated to occupation distinguished the 54 whohad resolved from those with active tendinitis (p < 0.01).Dominant arm involvement was associated with a poorer prognosis(p < 0.05) Functional Impairment occurred in 29 patients,two having lost employment. The sizeable proportion of patientswith chronic tendinitis resistant to conservative treatmentsuggests that rotator cuff tendinitis is not an early self-limitingcondition and improvement in management is required. KEY WORDS: Shoulder, Soft tissue rheumatism, Tendon, Prognosis, Management     

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.     

Ultrasonographic findings in hemiplegic shoulders of stroke patients

Shoulder problems are frequently noted in hemiplegic shoulders and compromise rehabilitation. Many tools were used to evaluate the etiology of shoulder problems but most of them are either nonspecific to the evaluation of soft tissue or not convenient. In order to evaluate soft tissue and joint change in hemiplegic shoulders, 82 patients with hemiplegic shoulders caused by cerebral vascular accident (CVA) were collected and evaluated by ultrasonography with 5-12 MHz high-resolution electronic linear scanner (ATL ultrasound HDI 1500, USA). The non-hemiplegic shoulders were also studied as control group. The results showed that ultrasonographic changes were noted in 51 (62.2%) hemiplegic shoulders while changes only occurred in 17 (20.7%) non-hemiplegic shoulders. Effusion and tendinitis were the major changes showing statistical difference compared with non-hemiplegic shoulders, but there was no significant difference in the incidence of supraspinatus tendon tear between hemiplegic and non-hemiplegic shoulders. Further, the interval from the onset of CVA was not significantly correlated with the presence of positive ultrasonographic findings in hemiplegic shoulders. The results demonstrated that ultrasonography is a potential method in the evaluation of hemiplegic shoulder.     

Magnetic resonance imaging of the shoulder in patients with rheumatoid arthritis.

To evaluate the ability of magnetic resonance imaging (MRI) to detect shoulder abnormalities 18 patients (36 shoulders) with rheumatoid arthritis (RA) and shoulder complaints were studied. Osseous abnormalities of the glenoid and humeral head were readily detected with MRI. The imaging planes used were not suitable for the evaluation of acromioclavicular joint involvement. Magnetic resonance imaging depicted soft tissue abnormalities that were not clearly visualised by plain film radiography, such as involvement of rotator cuff tendons and subacromial bursae, joint effusion, and muscular atrophy. Magnetic resonance imaging appears to be a sensitive method for evaluation of glenohumeral joint changes in patients with RA.     

Hand dominance in upper extremity musculoskeletal disorders

OBJECTIVE: To investigate the role of hand dominance in common upper extremity musculoskeletal disorders (UEMSD) in a population study. METHODS: The target population consisted of a representative sample of people aged 30 years or older residing in Finland during 2000-2001. Of the 7977 eligible subjects, 6254 (78.4%) were included in the study. RESULTS: The prevalence of UEMSD was as follows: rotator cuff tendinitis 3.8%, bicipital tendinitis 0.5%, lateral epicondylitis 1.1%, medial epicondylitis 0.3%, carpal tunnel syndrome (CTS) 3.8%, and surgery due to CTS 1.3%. CTS was 2.5 times as prevalent in women as men, whereas the other UEMSD were as common in both sexes. Rotator cuff and bicipital tendinitis and medial epicondylitis were more prevalent in the dominant arm only in women, whereas lateral epicondylitis was more prevalent in the dominant elbow in both sexes. The higher prevalence of rotator cuff and bicipital tendinitis in the dominant side persisted beyond working age. The prevalence of CTS did not differ by hand dominance. Dominant hand had been operated more frequently for CTS in women. CONCLUSION: Our findings show that UEMSD are more prevalent in the dominant than nondominant arm mainly in women. For shoulder tendinitis, the difference persists throughout adult age. Physical load factors may have long-lasting effects on the shoulder and they may play a greater role in women than men.     

The natural history of the frozen shoulder syndrome.

A prospective study has been made of 49 patients with the frozen shoulder syndrome (as distinct from tendinitis, calcific deposits and frozen shoulders occurring after coronary infarction or with pulmonary tuberculosis) of whom forty-one have been followed up for 5-10 years, always to their greatest recovery. There were three consecutive stages: pain, stiffness, and recovery. The stiffness stage was usually related to the duration of the recovery stage. The total duration was longer than is generally supposed (an average total of 30.1 months in contrast to about 18 months as often postulated). Generally speaking, the longer the stiffness stage is, the longer is the recovery stage. In 4 patients the second shoulder became similarly affected, 6 months to 7 years after the first, and followed a similar chronological sequence to the first. After greatest recovery, slight restriction of movement was found in more than half the cases, but in only 3, all of long duration, was the restriction a handicap. Arthrography, carried out on both shoulders in all patients during the recovery stage, showed in the affected shoulder fewer rotator cuff defects than expected at this age and fewer (four) than in the contralateral one (twenty-three); seemingly, the condition leads to the obliteration of some defects.     

Inter and intraobserver variability in DePalma's classification of shoulder calcific tendinitis

OBJECTIVE: To determine the intraobserver reproducibility and interobserver reliability of DePalma and Kruper's classification of calcific tendinitis of the rotator cuff. The result of this classification influences the choice of therapeutic procedures in patients with symptomatic calcific tendinitis. METHODS: Plain anteroposterior radiographs of shoulders from 100 patients with symptomatic calcified deposits of the rotator cuff were classified according to the criteria of DePalma and Kruper by 6 independent observers at 2 different time points within 4 months. The kappa values of intraobserver reproducibility and interobserver reliability were calculated. RESULTS: Kappa values of intraobserver reproducibility had a mean of 0.487 (SD 0.094); kappa values of interobserver reliability were 0.234 for the first test and 0.273 for the second test. CONCLUSION: Determination of intraobserver reproducibility gave satisfactory to sufficient results and interobserver reliability was satisfactory for both tests indicating that studies based on the classification of DePalma and Kruper should be interpreted cautiously.     

Treatment for frozen shoulder combined with calcific tendinitis of the supraspinatus

Calcific tendinitis of the shoulder is a process that involves calcium deposition in the rotator cuff tendons. It is usually a self-limiting process and is often chronic in nature. However, it can lead to acute pain resulting in frozen shoulder syndrome. We report 32 cases in which frozen shoulder was associated with calcific tendinitis of the supraspinatus. The aim of this study was to use arthroscopic brisement of the glenohumeral joint and make multiple punctures in the calcific spot to treat the frozen shoulder associated with calcific tendinitis of the supraspinatus. In our study, 30 patients had satisfactory results after a 2-year follow-up. Five patients experienced some postoperative calcium shadows, but there was also greater improvement in the range of motion and pain relief in this study compared with other reports in the literature of frozen shoulder cases.     

Comparison of clinical and patient-based measures to assess medium-term outcomes following shoulder surgery for disorders of the rotator cuff

OBJECTIVE: To compare different assessments following shoulder surgery for impingement syndrome with or without rotator cuff tear or repair. METHODS: A prospective study of 93 patients was conducted. Standard assessments were performed before, at 6 months, and at 4 years following shoulder surgery using the patient-based Oxford Shoulder Score (OSS), the Medical Outcomes Study Short Form-36 (SF-36) questionnaire, and a surgeon-assessed Constant Shoulder Score. Patients were categorized according to the surgery received in relation to the presence of cuff tears: full repair, partial repair, cuff tear/no repair, no tear/no repair. RESULTS: Most patients (57%) received subacromial decompression for impingement with no cuff tear. This group had the fewest pre- and postoperative symptoms. The category of patients who received only partial repair of a cuff tear had worse scores on all outcome assessments compared with other groups. Patient-based measures were more stable over time than the Constant. CONCLUSION: The shoulder-specific measures had greater sensitivity than the SF-36 in registering significant differences in outcomes between comparison groups at 6 months and 4 years.     

Painful shoulder syndromes

Painful shoulder conditions are common primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with marked pain, weakness, and reduced mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI will usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects of peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.     

A DOUBLE-BLIND TRIAL COMPARING SUBACROMIAL METHYLPREDNISOLONE AND LIGNOCALNE IN ACUTE ROTATOR CUFF TENDINITIS

Fifty-five patients with shoulder pain due to rotator cuff tendinitisof less than 12 weeks' duration were randomized to receive either40 mg methylprednisolone and lignocaine or lignocaine alone.No statistically significant difference could be discerned betweenthe two groups during 12 weeks of follow-up. KEY WORDS: Rotator cuff tendinitis, Treatment, Steroid, Local anaesthetic     

Sonography and MRI in the evaluation of painful arthritic shoulder

We evaluated 31 painful shoulders of 30 patients with chronic arthritis by ultrasonography (US) and compared the results with those of magnetic resonance imaging (MRI). Both US and MRI revealed effusion in the subacromial-subdeltoid (SA-SD) bursa, biceps tendon sheath (BTS) and glenohumeral (GH) joint, but MRI was more accurate in depicting joint inflammation because of its ability to visualize synovial hypertrophy. US visualized biceps tendon ruptures equally well as MRI. MRI was better able to reveal full-thickness tear of the supraspinatus tendon, whereas US showed better other changes of the supraspinatus tendon (degeneration or partial-thickness tear). Both of the imaging methods were able to depict erosions of the humeral head, but the locations occasionally differed. Inexpensive and easily available US can be recommended as the first imaging method for the detection of soft- tissue changes in the arthritic shoulder, but in rotator cuff problems both methods may be needed.      

Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial

Objective

To explore the effectiveness of naturopathic care (NC) on rotator cuff tendinitis using a prospective randomized clinical trial design.

Methods

Canadian postal workers with rotator cuff tendinitis for a duration of >6 weeks were randomized to receive NC (n = 43) or standardized physical exercises (PEs; n = 42) over 12 weeks. Participants in the NC group received dietary counseling, acupuncture, and Phlogenzym (2 tablets 3 times/day). The PE intervention group received passive, active‐assisted, and active range of motion exercises and matched placebo. The primary outcome measure was the Shoulder Pain and Disability Index (SPADI), and secondary outcomes were the pain visual analog scale (VAS), Short Form 36 (SF‐36), Measure Yourself Medical Outcomes Profile (MYMOP), and shoulder maximal range of motion. Participants and assessors were blinded to group and placebo allocation.

Results

Seventy‐seven participants (87%) completed ≥8 weeks of the trial. Final total SPADI scores decreased by 54.5% (P < 0.0001) in the NC group and by 18% (P = 0.0241) in the PE group. Between‐group differences in changes to SPADI scores showed statistically significant decreases in shoulder pain and disability in the NC group compared with the PE group (P < 0.0001). Significant differences between groups were also observed in the pain VAS, MYMOP, SF‐36, and shoulder extension, flexion, and abduction, with the NC group showing superiority in each outcome. No serious adverse reactions were observed.

Conclusion

NC and PE provided significant improvements, with greater improvement in shoulder function in the NC group compared with the PE group. Statistically significant improvements in quality of life measures were observed in the NC group as compared with the PE group.     

Effect of extracorporeal shock wave therapy for rotator cuff tendonitis: A protocol for systematic review and meta-analysis

Background:Rotator cuff tendinitis is a highly prevalent cause of shoulder pain and leads to decreased patient quality of life. Extracorporeal shock wave therapy (ESWT) and ultrasound-guided needling are considered beneficial for rotator cuff tendinitis. A systematic review and meta-analysis comparing ESWT with sham-ESWT or ultrasound-guided needling in the management of pain and calcification is lacking.Methods:We will search the following up database from its inception to August 2020 without language restriction: PubMed, Cochrane Library, Web of Science, EMBASE, China National Knowledge Infrastructure, China Biomedical Literature Database, Chinese Science Journal Database, and WangFang database. All randomized controlled trials compared the effect of ESWT and sham-ESWT or ultrasound-guided needling of rotator cuff tendinitis will be included in pain and calcification. Two researchers will operate literature retrieval, screening, information extraction, quality assessment, and data analysis independently. The analysis will be conducted using Review Manager 5.3 Software.Results:The findings will be submitted to a peer-reviewed publication.Conclusion:This systematic review and meta-analysis will provide high-quality evidence for the treatment of patients with rotator cuff tendinitis.INPLASY registration number:INPLASY202080028     

Glycosaminoglycans of human rotator cuff tendons: changes with age and in chronic rotator cuff tendinitis.

OBJECTIVES--To analyse the glycosaminoglycans of the adult human rotator cuff tendon matrix, to characterise changes in the glycosaminoglycan composition with age and in chronic rotator cuff tendinitis. METHODS--Rotator cuff (supraspinatus) tendons (n = 84) and common biceps tendons (n = 26) were obtained from cadavers with no history of tendon pathology (age range 11-95 years). Biopsies of rotator cuff tendons (supraspinatus and subscapularis tendons, n = 53) were obtained during open shoulder surgery to repair shoulder lesions (age range 38-80 years). Glycosaminoglycans were extracted by papain digestion and analysed by cellulose acetate electrophoresis, the carbazole assay for uronic acid and the dimethylmethylene blue dye-binding assay for sulphated glycosaminoglycans. Some digests were analysed for keratan sulphate by 5D4 monoclonal antibody ELISA. Soluble proteoglycans were extracted in 4M guanidine hydrochloride and analysed by 4-15% SDS PAGE. RESULTS--The mean (SD) sulphated glycosaminoglycan (GAG) content of the normal cadaver supraspinatus tendon was 12.3 (4.3) micrograms/mg dry weight, between three and ten times greater than in the common biceps tendon [1.2 (0.6) micrograms/mg dry weight]. The major GAG was chondroitin sulphate [6.9 (2.6) micrograms/mg dry weight], with a smaller proportion of dermatan sulphate [2.5 (1.2) micrograms/mg dry weight]. In contrast, the common biceps tendon contained predominantly dermatan sulphate [0.8 (0.2) microgram/mg dry weight] with less chondroitin sulphate [0.2 (0.2) microgram/mg dry weight]. There was no difference in the concentration of hyaluronan in these tendons [9.3 (2.8) micrograms/mg dry weight and 10.8 (4.3) micrograms/mg dry weight respectively] and there was no significant change of hyaluronan with age. Keratan sulphate was a small but significant component of the supraspinatus tendon [0.43 (0.33) microgram/mg dry weight, n = 25], whereas there was little or none in the common biceps tendon [0.04 (0.05) microgram/mg dry weight, n = 8] and there was no significant change across the age range. In the supraspinatus tendon, there was a significant decrease in total glycosaminoglycan, chondroitin sulphate and dermatan sulphate with age (p < 0.001), whether expressed relative to the tendon dry weight or total collagen content, and no change in the relative proportion of the different GAG types. There was, however, a large degree of variation within the samples. Supraspinatus tendons from patients with chronic tendinitis had a significantly increased concentration of hyaluronan [30.4 (10.1) micrograms/mg dry weight, p < 0.001], chondroitin sulphate [8.4 (1.8) micrograms/mg dry weight, p < 0.05] and dermatan sulphate [3.8 (1.1) micrograms/mg dry weight, p < 0.001] compared with normal cadaver supraspinatus tendons, although the keratan sulphate content was not significantly different [0.18 (0.05) microgram/mg dry weight]. CONCLUSIONS--The normal supraspinatus tendon has the proteoglycan/glycosaminoglycan of tendon fibrocartilage, which it is suggested is an adaptation to mechanical forces (tension, compression and shear) which act on the rotator cuff tendons in the shoulder, although other factors such as reduced vascularity, low oxygen tension and the influence of local growth factors may also be important. This functional adaptation may have important consequences for the structural strength of the supraspinatus tendon and to influence the ability of the tendon to repair after injury. The glycosaminoglycan composition of tendon specimens from patients with chronic tendinitis is consistent with acute inflammation and new matrix proteoglycan synthesis, even in relatively old tendon specimens and after at least one injection of corticosteroid.