肩关节常见病变：MRI诊断

肩关节常见病变主要为肩袖相关病变和肩关节不稳定。对于肩袖相关病变,肩关节MRI常规扫描可作为首选;对于肩关节不稳定和盂唇病变,则一般首选肩关节MRI造影进行评价。本文系统介绍肩峰下撞击综合征、肩袖变性、肩袖撕裂、肩关节前方不稳、上方盂唇前后向撕裂、肱二头肌长头腱相关病变、钙化性肌腱炎和滑囊炎、肩周炎的MRI表现。     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

The painful shoulder: when to inject and when to refer

Physicians can usually diagnose the cause of shoulder pain by performing a focused history and physical examination and ordering anteroposterior and lateral radiographs. Treatment depends on the cause and can include physical therapy, injections of corticosteroids into the joint space or bursa, and surgery. This paper reviews the diagnosis and treatment of impingement syndrome, adhesive capsulitis, rotator cuff tears, and arthritis of the glenohumeral joint and acromioclavicular (AC) joint.     

肩胛动力障碍及康复治疗的进展

目的 了解肩胛动力障碍的病因、临床评估和分型,以及肩胛动力障碍康复方法。方法 调查近10年国内外相关文献,总结相关内容。结果和结论 总结了肩胛动力障碍的临床评估和分型。肩胛动力障碍可继发于肩袖损伤、肩峰下撞击综合征、盂肱关节不稳、肩锁关节损伤、投掷肩、冻结肩等,肩胛运动训练可进一步改善康复效果。     

Arthrographic and clinical findings in patients with hemiplegic shoulder pain

OBJECTIVES: To identify the etiology of hemiplegic shoulder pain by arthrographic and clinical examinations and to determine the correlation between arthrographic measurements and clinical findings in patients with hemiplegic shoulder pain. DESIGN: Case series. SETTING: Medical center of a 1582-bed teaching institution in Taiwan. PARTICIPANTS: Thirty-two consecutive patients with hemiplegic shoulder pain within a 1-year period after first stroke were recruited. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical examinations included Brunnstrom stage, muscle spasticity distribution, presence or absence of subluxation and shoulder-hand syndrome, and passive range of motion (PROM) of the shoulder joint. Arthrographic measurements included shoulder joint volume and capsular morphology. RESULTS: Most patients had onset of hemiplegic shoulder pain less than 2 months after stroke. Adhesive capsulitis was the main cause of shoulder pain, with 50% of patients having adhesive capsulitis, 44% having shoulder subluxation, 22% having rotator cuff tears, and 16% having shoulder-hand syndrome. Patients with adhesive capsulitis showed significant restriction of passive shoulder external rotation and abduction and a higher incidence of shoulder-hand syndrome (P=.017). Those with irregular capsular margins had significantly longer shoulder pain duration and more restricted passive shoulder flexion (P=.017) and abduction (P=.020). Patients with shoulder subluxation had significantly larger PROM (flexion, P=.007; external rotation, P<.001; abduction, P=.001; internal rotation, P=.027), lower muscle tone (P=.001), and lower Brunnstrom stages of the proximal upper extremity (P=.025) and of the distal upper extremity (P=.001). Muscle spasticity of the upper extremity was slightly negatively correlated with shoulder PROM. Shoulder joint volume was moderately positively correlated with shoulder PROM. CONCLUSIONS: After investigating the hemiplegic shoulder joint through clinical and arthrographic examinations, we found that the causes of hemiplegic shoulder pain are complicated. Adhesive capsulitis was the leading cause of shoulder pain, followed by shoulder subluxation. Greater PROM of the shoulder joint, associated with larger joint volume, decreased the occurrence of adhesive capsulitis. Proper physical therapy and cautious handling of stroke patients to preserve shoulder mobility and function during early rehabilitation are important for a good outcome.     

Diagnostic and therapeutic injection of the shoulder region

The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection. Joint injection should be considered after other therapeutic interventions such as nonsteroidal anti-inflammatory drugs, physical therapy, and activity-modification have been tried. Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis. For the acromioclavicular joint, injection may be used for diagnosis and treatment of osteoarthritis and distal clavicular osteolysis. Subacromial injections are useful for a range of conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa. Persistent pain related to inflammatory conditions of the long head of the biceps responds well to injection in the region. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes.     

Rotator cuff pathology and subacromial impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.     

Self-care for patients with frozen shoulder

"Frozen shoulder" syndrome (adhesive capsulitis or pericapsulitis) refers to any kind of shoulder pain or to limited active or passive glenohumeral joint motions. Treatment options include both Chinese and western medical therapies. However, the key to recovery lies in self-care. This article addresses both Chinese and western treatments for frozen shoulder and suggests optimal treatments and self-care approaches for this debilitating condition. Health professionals can help patients ease their pain and increase joint activity in order to prevent frozen shoulder from turning into chronic adhesive capsulitis.     

Shoulder pain in hemiplegia

Shoulder pain is a common complication in poststroke hemiplegia that reduces functional recovery. Many types of shoulder pathology have been suggested as causes of shoulder pain in hemiplegia,including shoulder subluxation, capsulitis, tendinitis, rotator cuff injury, bursitis, impingement syndrome, spasticity, complex regional pain syndrome, brachial plexus injury, and proximal mononeuropathies. More than one type of pathology may exist in a given patient. Shoulder pain improves in many cases with prompt diagnosis and appropriate management. Although the relationship between subluxation and pain is controversial, upper limb support to reduce subluxation is the standard of care and may prevent the development of pain and secondary complications. Further work is needed to elucidate the natural history of shoulder pain in hemiplegia, including the identification of physiologic common denominators that can lead to improved strategies to treat and prevent shoulder pain.     

The Aetiology of Subacromial Impingement Syndrome

Subacromial impingement syndrome is one of the most common causes of shoulder pathology (Jobe and Jobe, 1983; Kessel and Watson, 1977) with reference to the condition appearing in the literature approximately 150 years ago (Adams, 1852). The pain and dysfunction associated with SIS are generally considered to occur when the shoulder is placed in positions of elevation, an activity commonplace during many sporting and vocational pursuits, as well as during the activities involved in daily living.Although it has been popular to assign blame for this condition on the acromion, considerable evidence suggests that SIS is of multifactorial aetiology. Other factors include rotator cuff over-use and degen-eration, glenohumeral hypermobility and instability, restrictive processes of the shoulder, functional scapular instability as well as poor posture. Many of these models of impingement still remain hypothetical and require confirmation.Further, many other structures may refer symptoms to the shoulder and may mimic the symptoms of SIS. Each category of subacromial impingement may require its own specific treatment and rehabilitation programme. At present there is not enough evidence in the literature to determine the most appropriate assessment methods or treatment strategies for each category of impingement. Key Messages

▪ Subacromial impingement syndrome has been described as the most common form of shoulder pathology.

▪ The pain of subacromial impingement is generally experienced around the anterolateral aspect of the shoulder during activities involving shoulder elevation.

▪ The aetiology of subacromial impingement syndrome is multifactorial. Each potential cause may act independently or in combination with one another.

Biomechanical properties of the glenohumeral joint capsule in hemiplegic shoulder pain

Background

Although many hemiplegic shoulder patients have been suffering from limited range of motion, it is not fully established whether the pathologic biomechanics are same in hemiplegic shoulder pain and adhesive capsulitis. Therefore we aimed to investigate biomechanical properties of glenohumeral joint capsules of hemiplegic shoulder pain with limited range of motions.

Methods

Participants were 14 patients with hemiplegic shoulder pain, 10 controls, and 42 adhesive capsulitis patients matched with the hemiplegic shoulder pain group for sex, age, and range of motion. Demographic data, clinical variables, and sonographic findings were comparable between hemiplegic shoulder pain and adhesive capsulitis groups. We compared capsular capacity, maximal pressure, and capsular stiffness of glenohumeral joint capsule among the 3 groups.

Findings

Hemiplegic shoulder pain and adhesive capsulitis groups had smaller capsular capacity and higher maximal pressure than controls. The capsular stiffness of hemiplegic shoulder pain group was higher than that of controls (P = 0.001) but lower than that of adhesive capsulitis group (P < 0.001).

Interpretation

The stiffness of glenohumeral joint capsules in hemiplegic shoulder pain and adhesive capsulitis patients was substantially higher than that in controls, suggesting that hemiplegic shoulder pain patients had stiffer capsules as adhesive capsulitis patients did although the severities were different. This finding implicates that hemiplegic shoulder pain may share common pathologic properties of tighter capsules with adhesive capsulitis. However, there may be additional mechanisms contributing to range of motion limitation in hemiplegic shoulder pain because capsular stiffness in those patients was not as severe as that in adhesive capsulitis patients with similar range of motion limitation.     

肩袖损伤合并肩峰下撞击综合征的MRI表现

目的探讨肩袖损伤合并肩峰下撞击综合征的MRI影像表现。材料与方法对33例X线片无骨折但临床怀疑肩袖损伤或肩峰下撞击综合征的患者,用1.5 T MRI机检查,观察肩袖损伤及肩峰下撞击综合征在MR上的影像特征,分析两者的相关性,并与手术结果对比,计算准确率。结果 33例中肩袖损伤20例(合并肩峰下撞击综合征10例),肩峰下撞击综合征15例(合并肩袖损伤10例)。肩袖损伤和肩峰下撞击综合征术前MR诊断准确率分别约为95.0%、71.3%。结论肩关节MRI扫描对肩袖损伤及肩峰下撞击综合征的诊断有较高的临床应用价值,肩袖损伤者中至少半数合并肩峰下撞击综合征,临床和影像应予重视。     

肩部撞击综合征的发生机制和影像学表现

肩部撞击综合征是临床上常见的引起肩关节疼痛和活动障碍的一组疾病,以肩袖、肱二头肌肌腱等结构的炎症及损伤为主要病理改变.广义的肩部撞击综合征包括肩峰下撞击、喙突下撞击和内撞击三型,对其发生机制尚存在争议,本文就肩部撞击的发生机制和影像学表现进行综述.     

Rotator cuff tendonitis in lymphedema: a retrospective case series

OBJECTIVES: To report rotator cuff tendonitis as a complication of lymphedema and to discuss the possible etiology and treatment options. DESIGN: Retrospective review of 8 cases. SETTING: University hospital outpatient clinic. PARTICIPANTS: A total of 8 breast cancer patients with a history of lymphedema and ipsilateral shoulder pain. INTERVENTION: Patients with lymphedema and ipsilateral shoulder pain were diagnosed with rotator cuff tendonitis if all of the following 3 tests were positive: supraspinatus test, Neers impingement test, and Hawkins impingement test. Patients diagnosed with rotator cuff tendonitis were prescribed a nonsteroidal anti-inflammatory drug (NSAID) and physical therapy (PT). MAIN OUTCOME MEASURES: Improvement in symptoms of shoulder pain at a 4- to 6-week follow-up, as measured by visual analog scale (VAS). RESULTS: Seven of 8 patients reported a subjective decrease in their symptoms of shoulder pain at a 4- to 6-week follow-up. The average improvement in shoulder pain as measured by VAS was a 4.5-point decrease from the original pain score given. One of 8 patients had a full-thickness supraspinatus tendon tear and required additional decongestive therapy and PT to obtain relief of symptoms. CONCLUSIONS: Rotator cuff tendonitis is a complication of lymphedema caused by internal derangement of tendon fibers, which may be subject to impingement, functional overload, and intrinsic tendinopathy. Conservative treatment with NSAIDs and PT is a safe and effective treatment.     

Comparison of Patients with Different Pathologies in Terms of Shoulder Protraction and Scapular Asymmetry

[Purpose] The aim of this study was to compare cases with different shoulder and cervical pathologies in terms of shoulder protraction and scapular asymmetry. [Methods] A total of 216 patients, aged between 30–70 years, were included, 108 of which were in the patient group (subacromial impingement, rotator cuff problems, adhesive capsulitis, disc herniations) and 108 of which were in the control group. The control group consisted of cases with no prior neck and shoulder problems or pain. Pain was evaluated using the visual analogue scale (VAS); the asymmetry of scapula was evaluated using the Lateral Scapular Slide Test (LSST) with two additional positions; and the protraction of the scapula was evaluated using the shoulder protraction test. [Results] According to the data obtained, the affected side scapular asymmetry and protraction in the patient group were significantly greater than in the control group. When the patient groups were compared in terms of different pathologies, there were no differences between scapular asymmetry and shoulder protraction. [Conclusion] In conclusion, the pathologies of the neck and shoulder were found to cause scapular asymmetry and shoulder protraction. However, patients with different pathologies had similar scapular asymmetry and shoulder protraction.Key words: Scapular asymmetry, Shoulder pathologies, Pain     

Chronic shoulder pain: part II. Treatment

Chronic shoulder pain is a common problem in the primary care physician's office. Effective treatment depends on an accurate diagnosis of the more common etiologies: rotator cuff disorders, adhesive capsulitis, acromioclavicular osteoarthritis, glenohumeral osteoarthritis, and instability. Activity modification and analgesic medications comprise the initial treatment in most cases. If this does not lead to improvement, or if the initial presentation is of sufficient severity, a trial of physical therapy that focuses on the specific diagnosis is indicated. Combined steroid and local anesthetic injections can be used alone or as an adjuvant to the physical therapy. The site of the injection (subacromial, acromioclavicular joint, or intra-articular) depends on the diagnosis. Injections into the glenohumeral joint should be done under fluoroscopic guidance. Symptoms that persist or worsen after six to 12 weeks of directed treatment should be referred to an orthopedic specialist.     

The painful shoulder: Part II. Intrinsic disorders and impingement syndrome

Intrinsic disorders that can cause shoulder pain include arthritis, gout, pseudogout and osteonecrosis. In its mildest form, impingement syndrome may cause only minimal discomfort. At its worst, impingement syndrome may lead to rotator cuff tear. Bicipital tendinitis and rupture of the biceps tendon may also be associated with impingement. Early rehabilitative intervention is important. Physical therapy is directed toward restoring range of motion and muscle strength.     

Adhesive capsulitis: a review

Adhesive capsulitis is a common, yet poorly understood, condition causing pain and loss of range of motion in the shoulder. It can occur in isolation or concomitantly with other shoulder conditions (e.g., rotator cuff tendinopathy, bursitis) or diabetes mellitus. It is often self-limited, but can persist for years and may never fully resolve. The diagnosis is usually clinical, although imaging can help rule out other conditions. The differential diagnosis includes acromioclavicular arthropathy, autoimmune disease (e.g., systemic lupus erythematosus, rheumatoid arthritis), biceps tendinopathy, glenohumeral osteoarthritis, neoplasm, rotator cuff tendinopathy or tear (with or without impingement), and subacromial and subdeltoid bursitis. Several treatment options are commonly used, but few have high-level evidence to support them. Because the condition is often self-limited, observation and reassurance may be considered; however, this may not be acceptable to many patients because of the painful and debilitating nature of the condition. Nonsurgical treatments include analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs), oral prednisone, and intra-articular corticosteroid injections. Home exercise regimens and physical therapy are often prescribed. Surgical treatments include manipulation of the joint under anesthesia and capsular release.     

肩关节镜下肩袖修复术治疗肩袖损伤的临床效果

目的探讨肩关节镜下肩袖修复术治疗肩袖损伤的临床效果。方法将我院2018年2月至2019年2月收治的52例肩袖损伤患者随机分为对照组(26例,开放式肩袖修复术)和观察组(26例,全肩关节镜下肩袖修复术)。比较两组的治疗效果。结果治疗后,两组的肩关节前屈、内旋、外旋活动度及Constant-Muley肩关节评分均增加,数字评估量表(NRS)评分均降低,且观察组显著优于对照组(P<0.05);观察组的治疗优良率显著高于对照组(P<0.05)。结论肩关节镜下肩袖修复术治疗肩袖损伤的临床效果显著,能够有效减轻患者疼痛,加快患者术后肩关节功能的恢复,值得临床推广应用。