Article

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults

September 2014
International Journal of Rheumatic Diseases 17(8)

DOI:10.1111/1756-185X.12476

Authors:

Tiffany K Gill

The University of Adelaide

Ernst Michael Shanahan

Flinders Medical Centre

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AimThe aim of this study was to determine the prevalence of structural shoulder pathology using magnetic resonance imaging (MRI) in three groups of older people: those with current shoulder pain, those with a previous history of shoulder pain and those with no history of shoulder pain, within a community-based sample.Methods Thirty subjects (10 within each of the three groups) participated in the study. Subjects were recruited by telephone and underwent a clinical examination of shoulder and neck range of movement (to ensure pain was not referred from the neck). Subjects completed the Shoulder Pain and Disability Index (SPADI) and underwent MRI and X-ray of the relevant shoulder. The X-rays and MRI were read independently by two experienced musculoskeletal radiologists blinded to each participant's symptoms. The MRIs were read using a structured reporting system.ResultsThe mean range of shoulder movement on both the right and left sides was lower for the current pain group compared to both the no and previous pain groups. On X-ray, there was no significant difference between groups in terms of glenohumeral and/or acromioclavicular degenerative changes. Tendinosis and tears of the rotator cuff were present in the majority of participants in each group. Labral abnormalities were rare among all groups.Conclusion Shoulder pathology is apparent in both symptomatic and asymptomatic shoulders and clinical symptoms may not match radiological findings. The cost burden of ordering MRI scans is significant and the relevance of the findings are questionable when investigating shoulder pain.

Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders: a systematic review

Article

Full-text available

Jan 2025
J Orthop Surg Res

Objectives To determine the prevalence of acromioclavicular (AC) joint and subacromial space imaging abnormalities in asymptomatic adults, with a secondary objective of comparing findings between asymptomatic and symptomatic shoulders within the same study populations. Methods We conducted a systematic review of studies examining shoulder imaging abnormalities detected by X-ray, ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in asymptomatic adults (PROSPERO registration CRD42018090041). This report focuses on AC joint and subacromial space abnormalities. Databases searched included Ovid MEDLINE, Embase, CINAHL and Web of Science from inception to June 2023. Our primary analysis used data from population-based studies, and risk of bias and certainty of evidence were evaluated with tools for prognostic studies. Results Thirty-one studies (4 X-ray, 11 US, 15 MRI, 1 both X-ray and MRI) provided useable prevalence data. One study was population-based (20 shoulders), 16 included miscellaneous study populations (2436 shoulders) and 14 focused on athletes (708 shoulders). The certainty of evidence was very low mainly due to high risk of bias, imprecision, and indirectness across studies. Clinical diversity precluded pooling. Population-based prevalence of acromioclavicular osteoarthritis (AC OA) ranged from 85% on MRI to 95% on X-ray. In other study populations, AC OA prevalence in asymptomatic shoulders varied from 6 to 47% on X-ray, 1 to 65% on US, and 0 to 82% on MRI. Among eight studies that included both asymptomatic and symptomatic shoulders, AC OA prevalence ranged from 13 to 95% in asymptomatic shoulders and from 20 to 100% in symptomatic shoulders. Conclusion The prevalence of AC joint and subacromial space abnormalities in asymptomatic shoulders is highly variable, and often comparable to that in symptomatic shoulders. Due to the low certainty of evidence and significant variation among study populations, further research is needed to clarify these prevalence estimates and to guide evidence-based management of shoulder abnormalities.

Systematic Review of Shoulder Imaging Abnormalities in Asymptomatic Adult Shoulders (SCRUTINY): Abnormalities of the Glenohumeral Joint

Article

Full-text available

Jun 2024
OSTEOARTHR CARTILAGE

Objective The primary objective was to determine the population prevalence of glenohumeral joint imaging abnormalities in asymptomatic adults. Method We systematically reviewed studies reporting prevalence of X-ray, ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) abnormalities in adults without shoulder symptoms (PROSPERO registration number CRD42018090041). This report presents the glenohumeral joint imaging findings. We searched Ovid MEDLINE, Embase, CINAHL and Web of Science from inception to June 2023 and assessed risk of bias using a tool designed for prevalence studies. The primary analysis was planned for the general population. The certainty of evidence was assessed using a modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) for prognostic studies. Results Thirty-five studies (4 X-ray, 10 US, 20 MRI, 1 X-ray and MRI) reported useable prevalence data. Two studies were population-based (846 shoulders), 15 studies included miscellaneous study populations (1715 shoulders) and 18 included athletes (727 shoulders). All were judged to be at high risk of bias. Clinical diversity precluded pooling. Population prevalence of glenohumeral osteoarthritis ranged from 15% to 75% (2 studies, 846 shoulders, 1 X-ray, 1 X-ray and MRI; low certainty evidence). Prevalence of labral abnormalities, humeral head cysts and long head of biceps tendon abnormalities were 20%, 5%, 30% respectively (1 study, 20 shoulders, X-ray and MRI; very low certainty evidence). Conclusion The population-based prevalence of glenohumeral joint imaging abnormalities in asymptomatic individuals remains uncertain, but may range between 30 and 75%. Better estimates are needed to inform best evidence-based management of people with shoulder pain.

Diagnostic Dilemma: Which Clinical Tests Are Most Accurate for Diagnosing Supraspinatus Muscle Tears and Tendinosis When Compared to Magnetic Resonance Imaging?

Article

Full-text available

Jun 2022

Background: The study aims to investigate the diagnostic accuracy of five clinical shoulder tests in the diagnosis of supraspinatus tears and tendinosis when compared to magnetic resonance imaging (MRI). Methods: A total of 116 shoulders of 106 consecutive patients who experienced shoulder pain were assessed for this cross-sectional diagnostic accuracy study. Patients were assessed with the most commonly used clinical shoulder tests, including the Jobe test (empty can), Neer test, drop arm test, Hawkins test, and full can test to identify supraspinatus tears and tendinosis. MRI examinations were performed on a 1.5 Tesla MRI system, and images were assessed by a blinded radiologist. The primary outcomes were to determine the sensitivity, specificity, and accuracy of the five clinical tests and to establish their correlation with MRI for supraspinatus tears and tendinosis. Results: The Hawkins test had a higher sensitivity and accuracy when diagnosing tears (sensitivity 89.66% [95% CI, 78.83-96.11] and accuracy 56.03% [95% CI, 46.51-65.23], respectively) and higher sensitivity in tendinosis (79.07% [95% CI, 63.96-89.96]). The drop arm test had a lower sensitivity but higher specificity in both tendinosis and tears (sensitivity 0% [95% CI, 0-8.22] and 12.07% [95% CI, 4.99-23.29], respectively, and specificity 87.67% [95% CI, 77.88-94.21] and 96.5% [95% CI, 88.09-99.58], respectively). The Neer test had a higher positive predictive value (PPV) of 37.21% in diagnosing tendinosis. When compared to the Hawkins test, the combination of the clinical tests had no statistically significant contribution to sensitivity and diagnostic accuracy. Conclusion: The Hawkins test had higher accuracy in diagnosing tears and was the most sensitive in diagnosing supraspinatus tendinosis and tears when compared to the MRI findings. The Neer test may also be another reliable tool for the diagnosis of tendinosis due to its higher PPV.

The burden of words in shoulder pain: A case report of a water polo player

Article

Nov 2021

Background and purpose: Shoulder pain is one of the most common musculoskeletal problems of the world's population. In particular, in water polo athletes, the frequency of injuries or pain to this joint is very high. The incidence of psychosocial factors in musculoskeletal pain is well recognized, even if they seem to be more present in chronic pain, rather than in acute pain. Case description The patient was a semi-professional water polo player with acute shoulder pain which occurred during a game. At first, the pain was very mild, but it progressively got worse after the visit to the casualty department where, even in the absence of any confirmed structural lesions, the patient is ordered to refrain from any active movements. The patient became worried, so his anxiety levels increased which worsened his symptoms. The physiotherapist opted for a “hands-off/hands-on approach”. Outcomes Significative improvements were observed in all the considered outcome measures the patient obtained complete recovery in a very short period of time and then he was able to return to his sport. Discussions Psychosocial factors such as anxiety, fear and catastrophizing can modulate pain responses in a subject without structural problems. Thus, counseling and education in pain science can be an effective therapeutic method, especially with conditions of acute, as well as chronic, pain. Level of evidence 4.

Value of Shoulder MRI in Cancer Patients Presenting with Shoulder Related Symptoms

Article

Full-text available

Oct 2019

Nonspecific shoulder pain is common presentation among elderly patients and patients with a history of cancer. The major concern of shoulder pain in cancer patients is the development of metastases. MRI of the shoulder is the most commonly used imaging modality for assessment of suspected soft tissue pathologies associated with the shoulder pain. In this study, we try to examine the role of shoulder MRI in elderly patients with a history of cancer presenting with nonspecific shoulder complaints for assessment of metastases.

Shoulder Pathology on Magnetic Resonance Imaging in Asymptomatic Elite-Level Rock Climbers

Article

Full-text available

Feb 2022

Background The prevalence of findings on shoulder magnetic resonance imaging (MRI) is high in asymptomatic athletes of overhead sports. Purpose/Hypothesis The purpose of this study was to determine the prevalence of atypical findings on MRI in shoulders of asymptomatic, elite-level climbers and to evaluate the association of these findings with clinical examination results. It was hypothesized that glenoid labrum, long head of the biceps tendon, and articular cartilage pathology would be present in >50% of asymptomatic athletes. Study Design Cross-sectional study; Level of evidence, 3. Methods A total of 50 elite climbers (age range, 20-60 years) without any symptoms of shoulder pain underwent bilateral shoulder examinations in addition to dedicated bilateral shoulder 3-T † MRI. Physical examinations were performed by orthopaedic sports medicine surgeons, while MRI scans were interpreted by 2 blinded board-certified radiologists to determine the prevalence of abnormalities of the articular cartilage, glenoid labrum, biceps tendon, rotator cuff, and acromioclavicular joint. Results MRI evidence of tendinosis of the rotator cuff, subacromial bursitis, and long head of the biceps tendonitis was exceptionally common, at 80%, 79%, and 73%, respectively. Labral pathology was present in 69% of shoulders, with discrete labral tears identified in 56%. Articular cartilage changes were also common, with humeral pathology present in 57% of shoulders and glenoid pathology in 19% of shoulders. Climbers with labral tears identified in this study had significantly increased forward elevation compared with those without labral tears in both active ( P = .026) and passive ( P = .022) motion. Conclusion The overall prevalence of intra-articular shoulder pathology detected by MRI in asymptomatic climbers was 80%, with 57% demonstrating varying degrees of glenohumeral articular cartilage damage. This high rate of arthritis differs significantly from prior published reports of other overhead sports athletes.

Glenohumeral Osteoarthritis: An Overview of Etiology and Diagnostics

Article

Full-text available

Jul 2020

Background and Aims Osteoarthritis (OA) is the world’s most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5% -17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors. Materials and Methods Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as “glenohumeral,” “osteoarthritis,” “epidemiology,” “etiology,” “imaging,” and “pathophysiology.” Only articles published in English, German, and Finnish between 1957 and 2017 were included. Results The prevalence of radiological shoulder OA has been estimated to be as high as 16% -20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual. Conclusion Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

The Use of Magnetic Resonance Imaging in Patients With Shoulder Pain at King Abdulaziz University Hospital

Article

Full-text available

Jan 2025

Objective: Our study aims to assess the clinical effectiveness of using MRI in diagnosing various shoulder pain-related conditions among patients at King Abdulaziz University Hospital. Methods: 383 patients who were admitted to King Abdulaziz University Hospital and had shoulder magnetic resonance imaging between January 2020 and July 2024 were studied retrospectively. The dataset was subjected to a thorough statistical analysis using descriptive and inferential approaches. The participants' demographic details, such as age, gender, and other attributes, were first compiled by a descriptive analysis, and then, a summary of the study population was given. Results: 383 patients were enrolled in our study for MRI evaluation. Of them, 160 (41.8%) were men and 223 (58.2%) were women. The age ranged from 7 to 91 years, and the mean age was 48.4 years. While 120 (31.3%) individuals reported other problems such as motion limitation, trauma, edema, shoulder instability, or other clinical issues, 262 participants (68.4%) indicated shoulder pain as their primary complaint. 174 participants (45.4%) had their left shoulder MRI, and 209 participants (54.6%) had their right shoulder MRI. In contrast to normal MRI findings (n=24, 6.3%). Abnormal findings were more common (n=358, 93.5%). Conclusion: Our research further supports the importance of MRI in diagnosing shoulder discomfort and associated disorders. The high frequency of anomalies found by MRI highlights its usefulness as a diagnostic technique. By comparing our results with previous research, we emphasize how crucial it is to combine MRI results with clinical evaluation to inform efficient treatment plans for patients with shoulder disorders. Future studies should focus on resolving existing issues and investigating how sophisticated imaging methods might improve diagnostic precision.

Using a Hypotheticodeductive Reasoning Approach to Identify Coronary Artery Stenosis and Myocardial Ischemia in a Patient With Upper Arm, Scapular, and Wrist Pain

Article

Jan 2025

Joey Bikkers

BACKGROUND: A 58-year-old male with left upper extremity pain presented for second opinion via video teleconferencing secondary to his physician’s recommendation for potential rotator cuff surgery. CASE PRESENTATION: He reported subacute variable left upper extremity pain. He denied questioning targeting the cardiopulmonary symptoms but also denied movement-based aggravating factors of the cervical spine and shoulder. OUTCOME: A movement-based exam targeting potential cervical and shoulder differential diagnoses failed to elicit symptoms. The physical therapist advocated for referral by the primary care provider to a cardiologist to rule out an underlying cardiac etiology. Per-recommendation stress EKG testing reproduced his symptoms and caused abnormal EKG behavior, leading to angiography and stenting. FOLLOW-UP: At follow-up forty-eight hours, one week, and four weeks after stent placement, the patient reported complete resolution of symptoms. DISCUSSION: This case underscores the importance of ruling out competing differential diagnoses, the role the physical therapist can have in entry-point care, and the value that telehealth-based services can have in patient triage.

Diagnostic Value of Superb Microvascular Imaging of the Rotator Cuff Interval for the Early Diagnosis of Frozen Shoulder

Article

Full-text available

Jul 2024

Purpose To explore the early diagnostic value of superb microvascular imaging (SMI) features within the rotator cuff gap for frozen shoulder. Patients and Methods This prospective study enrolled patients with acute early-stage frozen shoulder seeking treatment at Zhabei Central Hospital in Jing’an District, Shanghai, between July 2021 and December 2022 were enrolled in this study. Healthy controls were collected in a 1:1 ratio from the same hospital’s physical examination center. All participants underwent SMI and power Doppler ultrasound (PDUS) of the rotator cuff gap. Results The study included 79 patients with frozen shoulder and 77 healthy controls. Compared with the healthy control group, the patient group had a higher proportion of hypoechoic rotator cuff gap (81.0% vs 48.1%, P<0.001), a thicker coracohumeral ligament (2.60±1.01 vs 2.03±0.97, P<0.001), a thicker glenohumeral joint capsule (3.10±0.99 vs 2.46±1.17, P<0.001), and elevated blood grading using SMI (P<0.001) and PDUS (P=0.014). The highest area under the curve (AUC) was observed for SMI blood flow grading (AUC=0.824, 95% CI: 0.755–0.880, P<0.001), resulting in 82% sensitivity and 77% specificity when using a cutoff of 1. SMI blood flow grading was associated with external rotation <30° (P=0.007) and abduction <30° (P=0.013) but not with internal rotation <30° (P=0.630) or flexion <30° (P=0.562). Conclusion The grading of SMI blood flow may emerge as a valuable predictive indicator for the early stages of frozen shoulder. This simple ultrasound technique holds the potential to enhance the diagnostic process, enabling early initiation of treatment and potentially improving patient outcomes.

Percutaneous bone marrow concentrate and platelet products versus exercise therapy for the treatment of rotator cuff tears: a randomized controlled, crossover trial with 2-year follow-up

Article

Full-text available

May 2024
BMC MUSCULOSKEL DIS

Background Surgical repair is recommended for the treatment of high-grade partial and full thickness rotator cuff tears, although evidence shows surgery is not necessarily superior to non-surgical therapy. The purpose of this study was to compare percutaneous orthobiologic treatment to a home exercise therapy program for supraspinatus tears. Methods In this randomized-controlled, crossover design, participants with a torn supraspinatus tendon received either ‘BMC treatment’, consisting of a combination of autologous bone marrow concentrate (BMC) and platelet products, or underwent a home exercise therapy program. After three months, patients randomized to exercise therapy could crossover to receive BMC treatment if not satisfied with shoulder progression. Patient-reported outcomes of Numeric Pain Scale (NPS), Disabilities of the Arm, Shoulder, and Hand, (DASH), and a modified Single Assessment Numeric Evaluation (SANE) were collected at 1, 3, 6, 12, and 24 months. Pre- and post-treatment MRI were assessed using the Snyder Classification system. Results Fifty-one patients were enrolled and randomized to the BMC treatment group (n = 34) or the exercise therapy group (n = 17). Significantly greater improvement in median ΔDASH, ΔNPS, and SANE scores were reported by the BMC treatment group compared to the exercise therapy group (-11.7 vs -3.8, P = 0.01; -2.0 vs 0.5, P = 0.004; and 50.0 vs 0.0, P < 0.001; respectively) after three months. Patient-reported outcomes continued to progress through the study’s two-year follow-up period without a serious adverse event. Of patients with both pre- and post-treatment MRIs, a majority (73%) showed evidence of healing post-BMC treatment. Conclusions Patients reported significantly greater changes in function, pain, and overall improvement following BMC treatment compared to exercise therapy for high grade partial and full thickness supraspinatus tears. Trial registration This protocol was registered with www.clinicaltrials.gov (NCT01788683; 11/02/2013).

Acromioclavicular joint dislocation and concomitant labral lesions: a systematic review

Article

Full-text available

Jan 2024

Acromioclavicular (AC) joint dislocations frequently co-occur with intra-articular glenohumeral pathologies. Few comprehensive studies have focused on labral tears specifically associated with AC joint trauma. This systematic review will address this gap. A comprehensive electronic search was conducted across PubMed, Cochrane Library, and Google Scholar (pages 1–20) spanning from 1976 to May 19, 2023. Seven studies met the inclusion criteria for this systematic review, consisting of three retrospective studies and four case series. These studies collectively involved 1,044 patients, of whom 282 had concomitant labral lesions. The pooled prevalence of intra-articular labral injuries associated with acute AC joint dislocation was 27%. The prevalence of these labral lesions varied significantly between studies, ranging from 13.9% to 84.0% of patients, depending on the study and the grade of AC joint dislocation. Various types of labral tears were reported, with superior labrum anterior to posterior (SLAP) lesions being the most common. The prevalence of SLAP lesions ranged from 7.2% to 77.4%, with higher grades of AC joint dislocations often associated with a higher prevalence of SLAP tears. Moreover, grade V dislocations exhibited a complete correlation with SLAP tears. The studies yielded contradictory findings regarding older age and higher grades of AC joint dislocation as risk factors for concurrent labral lesions. This review underscores the frequent association between labral lesions and AC joint dislocations, particularly in cases of lower-grade injuries. Notably, SLAP lesions emerged as the predominant type of labral tear.

อาการปวดและความผิดปกติของข้อไหล่ที่พบบ่อยในเวชศาสตร์ฟื้นฟ

Article

Mar 2017

ณัฏฐิยา ตันติศิริวัฒน

“I wanted to know what was hurting so much”: a qualitative study exploring patients’ expectations and experiences with primary care management

Article

Full-text available

Sep 2023
BMC MUSCULOSKEL DIS

Background The management of shoulder pain is challenging for primary care clinicians considering that 40% of affected individuals remain symptomatic one year after initial consultation. Developing tailored knowledge mobilization interventions founded on evidence-based recommendations while also considering patients’ expectations could improve primary care for shoulder pain. The aim of this qualitative study is to explore patients’ expectations and experiences of their primary care consultation for shoulder pain. Methods In this qualitative study, participants with shoulder pain and having consulted a primary care clinician in the past year were interviewed. All the semi-structured interviews were transcribed verbatim, and inductive thematic analysis was performed to identify themes related to the participants’ expectations and experiences of primary care consultations for shoulder pain. Results Thirteen participants with shoulder pain were interviewed (8 women, 5 men; mean age 50 ± 12 years). Eleven of them initially consulted a family physician or an emergency physician, and two participants initially consulted a physiotherapist. Four overarching themes related to patients’ expectations and experiences were identified from our thematic analysis: 1) I can’t sleep because of my shoulder; 2) I need to know what is happening with my shoulder; 3) But… we need to really see what is going on to help me!; and 4) Please take some time with me so I can understand what to do!. Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listen to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician. Conclusions Implementing evidence-based recommendations while considering patients’ expectations is important as it may improve patients’ satisfaction with healthcare. Several participants reported that their expectations were not met, especially when it came to the explanations provided. One unexpected finding that emerged from this study was the waiting period between the onset of shoulder pain and when patients decided to consult their primary care clinician.

‘More harm than good’ – A qualitative study exploring the attitudes and beliefs of a group of Italian osteopaths about spinal imaging in the management of patients with chronic low back pain

Article

Jun 2023
INT J OSTEOPATH MED

Objectives: Chronic low back pain (CLBP) is one of the leading causes of disability worldwide and its related healthcare costs are constantly increasing. Imaging studies have limited clinical utility in managing this condition and their overuse can lead to negative effects on patients. Clinicians' and patients' misconceptions seem to be one of the main drivers of such unnecessary use. However, there is a lack of research investigating osteopaths' views on imaging. This study explored Italian osteopaths’ attitudes and beliefs towards imaging and its utilisation in the clinical evaluation and management of CLBP patients. Methods: A qualitative study, using elements of constructivist grounded theory, was conducted by means of semi-structured interviews. A purposive sampling approach was used to recruit 14 osteopaths practising in Italy with clinical and educational experiences. Data were collected until real saturation, transcribed verbatim and coded by using qualitative thematic analysis identifying categories, concepts and themes. Results: Two main themes were identified with seven subcategories. The overarching themes were 1) Clinical relevance and utility; 2) Interacting with the patient through a biopsychosocial perspective. Conclusion: The findings highlight that imaging plays a marginal role in the interviewed osteopaths' clinical practice, except for ruling out red flags or contraindications for treatment. Participants have shown awareness about the potential negative effects of imaging in CLBP patients. They underlined the need to reassure and educate patients to minimise the psycho-behavioural impact of diagnostic investigations on patients’ condition and also to provide a clinical value of their use, especially in relation to the complex and multidimensional nature of CLBP.

Fracturas de Hueso Piramidal: Revisión Bibliográfica a Propósito de Cuatro Casos Clínicos

Article

Full-text available

Jun 2023

Resumen Las fracturas del hueso piramidal, o triquetral, son las segundas fracturas más frecuentes de carpo después de las fracturas de escafoides. Normalmente, se producen por impactación ósea tras traumatismos en extensión y desviación cubital de la muñeca. Estas fracturas se clasifican en tres grupos: corticales dorsales, fracturas del cuerpo del piramidal y corticales volares. No es infrecuente que estas lesiones se diagnostiquen de forma tardía, ya que en muchas ocasiones pueden pasar desapercibidas en la atención en los Servicios de Urgencias. Esto se puede evitar mediante la realización de pruebas adicionales radiológicas como la tomografía computarizada (TC) de inicio. Clásicamente, se ha considerado que estas fracturas tienen buen pronóstico y se tratan mediante inmovilización. Sin embargo, la resonancia magnética (RNM) puede ser útil para el diagnóstico de lesiones asociadas en los casos de mala evolución. Recientemente, se ha discutido en la bibliografía los distintos tipos de gestos quirúrgicos a realizar según encontremos una inestabilidad carpiana, pseudoartrosis fibrosa, lesiones de complejo de fibrocartílago triangular, artrosis piso-piramidal, etc. Los objetivos de esta revisión son comparar casos clínicos en dos perfiles diferentes de pacientes que tienen evolución distinta de la misma entidad patológica, así como el de realizar una revisión completa sobre el tema aportando información adicional sobre algunas complicaciones de este tipo de fracturas.

Cardiovascular Disease Risk Factors Predict the Development and Numbers of Common Musculoskeletal Disorders in a Prospective Cohort

Article

Full-text available

Jun 2023
J OCCUP ENVIRON MED

Objective: Assess risk of common musculoskeletal disorders (MSDs) based on cardiovascular disease (CVD) risk scores. Methods: Data from a nine-year prospective cohort of 1,224 workers in 3 states were analyzed. Baseline data included questionnaires, structured interviews, physical examinations, anthropometric measurements, nerve conduction studies, and individualized measurement of job physical factors. Monthly follow-ups were conducted. Framingham risk scores were calculated. A priori case definitions were constructed for carpal tunnel syndrome, lateral epicondylopathy, medial epicondylopathy, and rotator cuff tendinopathy. Results: Adjusted RRs for one or more MSDs increased to 3.90 (95% CI, 2.20, 6.90) among those with 10-year CVD risk scores above 15% and 17.4 (95% CI 3.85, 78.62) among those with 4+ disorders. Conclusions: CVD factors are strongly associated with the subsequent development of common MSDs. Risks among those with multiple MSDs are considerably stronger.

“Please listen to me, I want to know what is wrong with my shoulder”: A qualitative study exploring patients’ expectations and experiences with primary care management.

Preprint

Full-text available

Feb 2023

Background: The management of shoulder pain is challenging for primary care clinicians considering that 40% of affected individuals remain symptomatic one year after initial consultation. Developing tailored knowledge translation interventions founded on evidence-based recommendations while also considering patients’ expectations could improve primary care for shoulder pain. The aim of this qualitative study is to explore patients’ expectations and experiences of their primary care consultation for shoulder pain. Methods: In this qualitative study, participants with shoulder pain and having consulted a primary care physician in the past year were interviewed. All the semi-structured interviews were transcribed into verbatims, and inductive thematic analysis was performed to identify themes related to the participants’ expectations and experiences of primary care consultations for shoulder pain. Results: Thirteen participants with shoulder pain were interviewed (8 women, 5 men; mean age 50 ± 12 years). Eleven of them initially consulted a family or an emergency physician, and two participants initially consulted a physiotherapist. Four overarching themes related to patients’ expectations and experiences were identified from our thematic analysis: 1) I can’t sleep because of my shoulder; 2) I need to know what is happening with my shoulder; 3) But… we need to really see what is going on to help me!; and 4) Please take some time with me so I can understand what to do!. Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listened to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician. Conclusions: Implementing evidence-based recommendations while also considering patients’ expectations is important as it may improve care delivery and patients’ satisfaction with care. Several participants reported that their expectations were not met, especially when it came to the explanations provided. One unexpected finding that emerged from this study was the delay between the onset of shoulder pain and when patients decided to consult their primary care clinician.

Suprascapular nerve block for the treatment of adhesive capsulitis: a randomised double-blind placebo-controlled trial

Article

Full-text available

Nov 2022

Objective Adhesive capsulitis is a common painful shoulder condition. Treatment for the condition remains unsatisfactory. Suprascapular nerve block (SSNB) shows promise as a treatment option for adhesive capsulitis but there are no randomised controlled trials that examine its effect on pain or duration of the condition. The objective of this study was to examine the efficacy of SSNB for the management of adhesive capsulitis. Methods A randomised double-blind placebo-controlled trial of SSNB and standard therapy versus placebo and standard therapy was performed. In total, 54 patients were enrolled in the study. 27 patients received a glenohumeral joint (GHJ) injection and physiotherapy plus a 3-month SSNB, and 27 patients received a GHJ injection and physiotherapy plus a 3-month placebo injection. Patients were followed to resolution of their symptoms as measured by a combination of range of movement, pain scores, Shoulder Pain and Disability Index (SPADI) scores and perceived recovery scores. The primary outcome measure was time to resolution of symptoms. Results Participants who received the SSNB reduced the duration of their symptoms of adhesive capsulitis by an average of 6 months (mean time to resolution 5.4 (95% CI 4.4 to 6.3) months vs 11.2 (95% CI 9.3 to 13) months) in the placebo group. They also had reduced pain scores, improved range of movement and lower SPADI scores compared with the placebo group across all time points. Conclusion SSNB reduced the duration of adhesive capsulitis and resulted in improved pain and disability experience for patients. Trial registration number Australian New Zealand Clinical Trials Registry (ANCTRN 12615001378516).

Is routine magnetic resonance imaging necessary in patients with clinically diagnosed frozen shoulder? Utility of magnetic resonance imaging in frozen shoulder

Article

Full-text available

Jun 2022

Background Shoulder magnetic resonance imaging (MRI) is commonly performed in patients with frozen shoulder (FS). However, the necessity of MRI and its diagnostic value is questionable. Therefore, the purpose of the present study was to clarify whether routine MRI could identify additional shoulder pathologies not previously suspected in the clinical examination and if any change in the treatment plan based on these additional MRI findings in FS patients was observed. Materials and methods The medical records of all patients who presented in our outpatient clinic with a diagnosis of FS from January 2017 to December 2018 were retrospectively reviewed. Patient demographics, the number of patients who received a shoulder MRI, changes in the diagnosis or identification of structural shoulder pathologies following MRI examination (if performed), as well as any alternation in the initially suggested treatment plan were recorded. Results A total of 609 patients (male: 241, female: 368) diagnosed with an FS and an average age of 52 ± 10 (range: 18 to 81) years were identified. In 403 of the 609 patients (66%), a shoulder MRI was performed. An additional structural shoulder pathology was identified in 89 of 403 (22%) patients following the shoulder MRI, mostly rotator cuff tears (partial: 46/403 [11.4%], full-thickness: 30/403 [7.4%], rerupture following reconstruction: 10/403 [2.5%]) and labrum tears (3/403 [0.7%]). At minimum 2-year follow-up, 11 of 403 (2.7%) patients were treated surgically for the additional pathology identified on the MRI scan consisting of an arthroscopic rotator cuff reconstruction in 10 patients and a labrum refixation in one patient. Five of the 609 (0.8%) patients were treated for refractory FS by arthroscopic capsulotomy. Conclusions Although additional pathologies were identified in 22% of the patients, a change in treatment plan due to the MRI findings was only observed in 2.7% (37 MRIs needed to identify 1 patient with FS requiring surgery for the additional MRI findings). Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated.

In vivo evaluation of rotator cuff internal impingement during scapular plane abduction in asymptomatic individuals

Article

Jul 2022

Internal impingement – or entrapment of the undersurface of the rotator cuff tendon against the glenoid during overhead activities – is believed to contribute to articular‐sided tears. However, little is known about internal impingement outside athletic populations. Therefore, the objectives of this study were to: 1) describe glenoid‐to‐footprint distances and proximity centers during dynamic, in vivo motion in asymptomatic individuals, and 2) determine the extent to which these measures differed between individuals with and without a rotator cuff tear. Shoulder kinematics were assessed in 37 asymptomatic individuals during scapular plane abduction using a high‐speed biplane radiographic system. Glenoid‐to‐footprint distances and proximity center locations were calculated by combining the kinematics and CT‐derived bone models. Glenoid‐to‐footprint contact was presumed to occur when the minimum distance was less than the estimated labral thickness. The condition of the supraspinatus tendon (intact, torn) was assessed using ultrasound. Minimum distances and proximity centers were compared over humerothoracic elevation angles (90°, 110°, 130°, 150°) and between supraspinatus pathology groups using two‐factor mixed model ANOVAs. The minimum distance decreased consistently across elevation angles (p<0.01) without a significant difference between groups. Contact was estimated to occur in all participants. The proximity center was generally located on the anterior half of the rotator cuff footprint and the posterosuperior glenoid. Clinical Significance: Internal impingement during overhead motions may be a prevalent mechanism of rotator cuff pathology as contact appears to be common and involves the region of the rotator cuff footprint where degenerative rotator cuff tears are thought to originate. This article is protected by copyright. All rights reserved.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

Article

Feb 2022
REV BRAS FISIOTER

Background There is a lack of standardized criteria for diagnosing Rotator Cuff Related Shoulder Pain (RCRSP). Objective To identify the most relevant clinical descriptors for diagnosing RCRSP. Methods A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search equation was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. Results Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the “subjective examination” domain, 1 item was included in the “patient-reported outcome measures” domain, 3 items in the “diagnostic examination” domain, 2 items in the “physical examination” domain”, and 2 items in the “functional tests” domain. No items reached consensus within the “special tests” domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. Conclusion In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Herzratenvariabilitätsbasiertes Lifestyle-Coaching bei Patient*innen mit subakromialem Schmerzsyndrom – eine Pilotstudie

Article

Dec 2021

Matthias Kalmring

Zusammenfassung Hintergrund Mehrere Studien konnten einen Einfluss von psychologischem Stress auf Schmerzmodulation und Wundheilung aufzeigen. Die Erweiterung der physiotherapeutischen Behandlung um die psychosoziale Ebene des biopsychosozialen Modells stellt komplexe Anforderungen an die behandelnden Physioherapeut*innen. Ziel Untersucht wurde der Einfluss von auf Herzratenvariabilität (HRV) basierendem Lifestyle-Coaching auf die Entwicklung der funktionellen Einschränkungen und das Schmerzempfinden bei Patient*innen mit subakromialem Schmerzsyndrom (SAPS). Es erfolgte zudem eine Analyse der Machbarkeit für Folgestudien. Methode 15 Proband*innen mit SAPS wurden randomisiert in 2 Gruppen eingeteilt. Die Interventionsgruppe erhielt zusätzlich zu der in beiden Gruppen durchgeführten übungstherapeutischen Intervention ein Lifestyle-Coaching. Als Kontrollparameter wurden der SPADI-Score (SPADI), das maximale Schmerzempfinden (NRSmax) und anhand der Kurzzeit-HRV-Messung die High Frequency (HF), Low Frequency (LF), LF/HF-Ratio, Root Mean Square of Successive Difference (Rmssd) sowie die Standard Deviation NN (SdNN) erhoben. Bezüglich der Machbarkeit wurden mögliche Störfaktoren, Optimierungsmöglichkeiten und eine adäquate Stichprobengröße eruiert. Ergebnisse Einen signifikanten Unterschied zeigten die Variablen des SPADI-Scores, SPADI (95 % CI –59,3 bis –4,6; p = 0,026; d = –1,5), NRSmax (95 % CI –5,5 bis –0,1; p = 0,042; d = –1,35) und der HRV-Messwert HF (95 % CI 505,3–1753,3; p = 0,002; d = 2,23) im Vergleich zur Kontrollgruppe. Schlussfolgerung Das Design dieser Studie ist machbar und für Folgestudien mit größeren Stichproben geeignet. Anpassungen bei der Randomisierung sowie den verwendeten Assessments sollten dabei vorgenommen werden. Für eine gültige Aussagekraft der Ergebnisse wurde die dafür nötige Stichprobengröße mit n = 66 ermittelt. Die Auswertung der klinischen Parameter weisen auf eine Steigerung der parasympathischen Aktivität (HF) sowie einer Reduktion von SPADI und NRSmax hin. Letztere können hierbei als potentiell positive Wirkung auf die Funktion und Schmerzreduktion in der Interventionsgruppe eingeschätzt werden.

Shoulder pain prevalence by age and within occupational groups: a systematic review

Article

Full-text available

Dec 2021

Background Shoulder pain was previously shown to diminish in older populations and it was suggested that this could be explained by reduced usage with age. Our objectives were to investigate if estimates of shoulder pain continue to increase after the age of 50 in working populations and to compare these estimates in physically demanding occupations with sedentary occupations. Methods A systematic review of retrospective, cross-sectional, prospective, or longitudinal. studies reporting prevalence or incidence of non-specific shoulder pain in occupational groups stratified by age. Searches were conducted in PubMed, Scopus, and CINAHL from inception until January 2020. Study characteristics and prevalence estimates stratified by age were extracted. Two reviewers independently performed a critical analysis of the included studies to determine their validity and risk of bias. Results Twenty studies with a total of 40,487 participants and one study of a clinical data base were included and assigned a direction of the estimates for shoulder pain as either ‘increasing’, ‘remaining stable’ or ‘decreasing’ past the age of 50. Shoulder pain generally increased past 50, with 16 of the 21 included studies reporting higher estimates/odds ratios in older participants. In the more physically active occupations over 50, the estimates increased in 14 of the 18 samples compared to only two of the four involving sedentary occupations. Conclusions Shoulder pain prevalence remains common in workers beyond the age of 50. Prevalence continues to increase in physically demanding occupations. Clinicians should consider factors of occupation when managing shoulder pain. Trial registration PROSPERO (CRD42019137831).

Phenotyping the shoulder patient based on ultrasound-detected pathologies: a cross-sectional study in general practice

Article

Dec 2020
FAM PRACT

Background Shoulder complaints arise from a single pathology or a combination of different underlying pathologies that are hard to differentiate in general practice. Subgroups of pathologies have been identified on the basis of ultrasound imaging that might affect treatment outcomes. Objective Our aim was to validate the existence of different subgroups of patients with shoulder complaints, based on ultrasound-detected pathology, and compare clinical features among them. Profiling shoulder patients into distinct shoulder pathology phenotypes could help designing tailored treatment trials. Methods This was a cross-sectional study in general practice. Data were extracted from 840 first visit patient records at a single diagnostic centre in the Netherlands. Exclusion criteria were age <18 years and previous shoulder surgery. Latent class analysis was used to uncover cross-combinations of ultrasound detected pathologies, yielding subgroups of shoulder patients. The uncovered subgroups were compared for demographic and clinical characteristics. Results We uncovered four distinct subgroups of patients with shoulder complaints: (i) Frozen shoulder group (11%), (ii) Limited pathology group (44%), (iii) Degenerative pathology group (31%) and (iv) Calcifying tendinopathy group (15%). Group comparisons showed significant differences in demographic and clinical characteristics among subgroups, consistent with the literature. Conclusion In a general practice population, we uncovered four different phenotypes of shoulder patients on the basis of ultrasound detected pathology. These phenotypes can be used designing tailored treatment trials in patients with shoulder complaints.

High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades

Article

Full-text available

Aug 2020

Background Despite the relatively high number of cases of acromioclavicular joint (AC) separation in the athletic population, optimal clinical outcomes are not achieved in every case. Limited data exist regarding the prevalence of intra-articular glenohumeral pathologies (IAPs) associated with acute AC separation of all injury grades. Purpose To determine the prevalence of IAPs associated with AC separation, regardless of severity. Study Design Case series; Level of evidence, 4. Methods A total of 62 patients (mean age, 37.6 years) with acute AC separation were included in this study; 41 were nonoverhead recreational athletes. All patients underwent magnetic resonance arthrography (MRA) to evaluate for IAPs. Arthroscopic data from patients undergoing surgical treatment were correlated with MRA results. Results Patients sustained acute AC separation of Rockwood grade 1 (16.1%), grade 2 (46.8%), grade 3 (25.8%), and grade 4 (11.3%). A concomitant IAP was present in 48 of 62 (77.4%) patients and included superior labral anterior-posterior tears (72.6%), anterior labral tears (24.2%), posterior labral tears (4.8%), supraspinatus tears (3.2%), and inferior glenohumeral ligament ruptures (1.6%). There were 18 (29.0%) patients who had a concomitant pathology in >1 intra-articular structure (combined IAPs). Additionally, 71.8% of patients with grade 1 and 2 AC separation had associated IAPs, and 23.1% had combined IAPs. Furthermore, in patients younger than 40 years, 64.0% of those with grade 1 to 3 AC separation demonstrated associated labral pathologies. There was no difference when comparing age or severity of AC separation and the prevalence of concomitant labral tears ( P = .36 and .22, respectively). Conclusion There was a high prevalence of IAPs among patients undergoing MRA after AC separation. While an IAP has been described in association with high-grade AC separation previously, the high prevalence of IAPs in low-grade separation in our study was unexpected and suggests that a thorough evaluation and clinical follow-up for patients with all grades of AC separation may be beneficial.

Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

Article

Aug 2020

Context There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making. Objective To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology. Data Sources PubMed, MEDLINE, Ovid, and Cochrane Reviews databases. Study Selection Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination. Study Design Systematic review. Level of Evidence Level 2. Data Extraction Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities. Results A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21). Conclusion The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

Treatment of Unresolved Shoulder Pain with Platelet-Rich Plasma Therapy

Article

Full-text available

Feb 2019

Background : Platelet-rich plasma (PRP) is a minimally invasive surgical alternative that uses platelets from a patient’s own blood to heal musculoskeletal conditions. The objective of this study was to report the outcomes of patients with unresolved shoulder pain in response to PRP injections. Methods : 52 patients and 61 shoulders underwent a series of one through seven PRP injections for unresolved shoulder pain. Patients were separated into three groups based on number of PRP treatments received. Group 1 received 1 treatment, Group 2 received 2 treatments and Group 3 received 3 or more treatments. Patients in Group 2 received a series of treatments 20.22 days apart and patients in Group 3 received treatments 20.00 days apart. Outcomes of resting pain, active pain, upper functionality scale and overall improvement percentage were compared to baseline and between groups. Group 1 reported outcomes a mean 4.79 months after treatment, Group 2 reported outcomes a mean 6.97 months after treatment, and Group 3 reported outcomes a mean 7.38 months after treatment. Results : Patients who received one treatment experienced significant improvements in active pain and functionality when compared to baseline and also experienced 38.35% total overall improvement. Patients in Groups 2 and 3 experienced signif- icant improvements in resting pain, active pain, and functionality score in addition to experiencing 48.33% and 55.53% total overall improvement respectively. Conclusions : These results are encouraging and provide evidence that PRP may be an effective treatment modality for un- resolved shoulder pain and warrants further investigation.

Assessment of abduction motion in patients with rotator cuff tears: an analysis based on inertial sensors

Article

Full-text available

Dec 2019
BMC MUSCULOSKEL DIS

Background: Reduced range of motion in the shoulder can be a source of functional limitation. The use of inertial sensors to quantify movement in addition to more common clinical assessments of the shoulder may allow clinicians to understand that they are potentially unnoticed by visual identification. The aim of this study was to generate an explanatory model for shoulder abduction based on data from inertial sensors. Method: A cross-sectional study was carried out to generate an explanatory model of shoulder abduction based on data from inertial sensors. Shoulder abduction of thirteen older adults suffering from shoulder dysfunction was recorded with two inertial sensors placed on the humerus and scapula. Movement variables (maximum angular mobility, angular peak of velocity, peak of acceleration) were used to explain the functionality of the upper limb assessed using the Upper Limb Functional Index (ULFI). The abduction movement of the shoulder was explained by six variables related to the mobility of the shoulder joint complex. A multivariate analysis of variance (MANOVA) was used to explain the results obtained on the functionality of the upper limb. Results: The MANOVA model based on angular mobility explained 69% of the variance of the ULFI value (r-squared = 0.69). The most relevant variables were the abduction-adduction of the humerus and the medial/lateral rotation of the scapula. Conclusions: The method used in the present study reveals the potential importance of the analysis of the scapular and humeral movements for comprehensive evaluation of the upper limb. Further research should include a wider sample and may seek to use this assessment technique in a range of potential clinical applications.

The Role of Imaging

Chapter

Feb 2025

Filip Struyf

Imaging can play an important role in the evaluation of patients with shoulder pain, especially when the diagnosis of the pathology is not apparent from clinical examination. It provides healthcare providers with valuable additional information about the anatomical structures of the shoulder, which can assist in diagnosing and planning the appropriate treatment. The imaging techniques we will discuss include X-rays, ultrasound, CT scans, and magnetic resonance imaging (MRI) scans, each with its own advantages and disadvantages. These images can serve as objective information to help make a proper diagnosis.

Codman Maneuver for Biceps Tendonitis: A Prospective Evaluation of a Forgotten Examination Maneuver

Article

Jan 2025

Neck or Shoulder? Establishing Consensus for Spine Screening in Patients With Shoulder Pain: An International Modified Delphi Study

Article

Sep 2024
PHYS THER

Objective There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. Methods A modified Delphi study was conducted through use of an international shoulder physical therapist’s expert panel. Three domains (clinical reasoning, history, physical examination) were evaluated using a Likert scale, with consensus defined as Aiken Validity Index ≥0.7. Results Twenty-two physical therapists participated. Consensus was reached on a total of 30 items: clinical reasoning (n = 9), history (n = 13), and physical examination (n = 8). The statement that spinal and shoulder disorders can coexist, sometimes influencing each other and at other times remaining independent issues, along with the concept of radiating pain as an explanatory phenomenon for the spine contribution to shoulder pain, achieved the highest degree of consensus. Conclusion International physical therapists shoulder experts reached consensus on key aspects when screening the spine in people with shoulder pain, including consideration of the distal location of symptoms relative to the shoulder, the presence or previous history of neck pain, the changes in symptoms related to neck movements, and the presence of neuropathic-like symptoms. They also acknowledged the importance of assessing active cervical or cervicothoracic movements and the usefulness of the Spurling test and symptom modification techniques applied to the spine.

Prevalence of OA-related imaging abnormalities in asymptomatic healthy adults

Article

Jul 2024
OSTEOARTHR CARTILAGE

It has been recognized that imaging findings associated with osteoarthritis (OA) are common in asymptomatic healthy joints, including the knee, hip and spine as shown in Fig. 1. These incidental imaging findings, if not interpreted in the appropriate clinical context, may result in unnecessary and possibly harmful additional imaging tests and treatments. In addition, when an osteoarthritic joint is symptomatic, the extent of radiographic markers of OA does not always correlate well with the severity of patient symptoms. As is the case in all areas of medical imaging, OA management should not be dictated by imaging results alone. Despite these limitations, imaging continues to be frequently used in the investigation of clinically suspected OA, with resultant resource implications and potential for delays in commencing management. The 2022 National Institute for Health and Care Excellence (NICE) guidance recommended that there is no evidence to support the use of imaging in addition to clinical assessment for people with typical initial clinical presentations with OA. Under this scenario, Ibounig et al. reported in their systematic review that 17% of asymptomatic shoulders had imaging findings consistent with shoulder OA when the data from 2 population studies [846 shoulders; 846 X-ray, 20 Magnetic resonance imaging (MRI)] were pooled (low certainty evidence). When pooling nine studies with asymptomatic non-population-based samples (633 shoulders; 258 X-ray, 375 MRI), 15% of shoulder joints had OA-relevant findings. The study samples of these papers included various study populations such as volunteers, athletes and healthcare populations.

Partial Rotator Cuff Tears

Chapter

May 2024

Partial-thickness rotator cuff tears (PTRCTs) are a common cause of shoulder pain and dysfunction in the adult population. PTRCTs are being increasingly diagnosed with MRI and arthroscopy. Initial treatment of symptomatic PTRCTs is usually nonoperative, including a period of physiotherapy accompanied by pain medication. If and when symptoms persist, surgical treatment may be indicated. Arthroscopic techniques with minimally invasive approach have become the gold standard. According to the evidence available, the use of arthroscopic repair has been associated with positive results in the short term, both with the transtendon in situ repair and tear completion with subsequent repair techniques. In addition, clinical outcomes do not seem to be significantly altered by the location of the lesions (articular or bursal), regardless of which method is used. Concerning the surgical technique chosen, in cases where the tear completion with subsequent repair technique is used, future research should define whether the single- or the double-row technique is more appropriate and analyze their results. Particularly in the subgroup of competitive and overhead athletes who have undergone repair of rotator cuff tears and have had unfavorable outcomes, leading to a low rate of return to sport at the same level prior to the injury.

Shoulder pathology on advanced imaging in asymptomatic non-athlete individuals: A narrative review

Article

Jun 2024

The prevalence of asymptomatic shoulder pathology has been shown to be high on both ultrasound and magnetic resonance imaging (MRI). The most common shoulder pathologies identified in asymptomatic, non‐athlete individuals include rotator cuff pathology, acromioclavicular (AC) joint pathology, labral tears, subacromial bursitis, and calcific tendinitis. The data in the current literature suggest that asymptomatic rotator cuff tears are diagnosed on ultrasound and MRI at high rates, suggesting that rotator cuff tears may be considered an age‐related, normal, degenerative change. However, there are data to suggest that the presence of an asymptomatic rotator cuff tear on imaging may predispose a patient to shoulder pain in the future, although the data remain inconclusive. AC joint arthritic changes are also common in older individuals on advanced imaging. Recent studies have reported that labral tears are common in asymptomatic shoulders, although at less frequent rates than in athletes, but more research is required on this topic. In addition, the presence of subacromial bursitis on imaging has not been found to accurately differentiate between symptomatic and asymptomatic shoulders. Finally, calcific tendinitis has been diagnosed asymptomatically, with most individuals remaining asymptomatic. Individuals who did develop pain developed severe pain, although the risk factors for developing symptomatic calcific tendinitis are unclear. In summary, given the high prevalence of shoulder pathology diagnosed on imaging, it is important to not over diagnose or complete an unnecessary workup for an asymptomatic person who is otherwise healthy.

Multimodal positron emission tomography (PET) imaging in non-oncologic musculoskeletal radiology

Article

Mar 2024
SKELETAL RADIOL

Musculoskeletal (MSK) disorders are associated with large impacts on patient’s pain and quality of life. Conventional morphological imaging of tissue structure is limited in its ability to detect pain generators, early MSK disease, and rapidly assess treatment efficacy. Positron emission tomography (PET), which offers unique capabilities to evaluate molecular and metabolic processes, can provide novel information about early pathophysiologic changes that occur before structural or even microstructural changes can be detected. This sensitivity not only makes it a powerful tool for detection and characterization of disease, but also a tool able to rapidly assess the efficacy of therapies. These benefits have garnered more attention to PET imaging of MSK disorders in recent years. In this narrative review, we discuss several applications of multimodal PET imaging in non-oncologic MSK diseases including arthritis, osteoporosis, and sources of pain and inflammation. We also describe technical considerations and recent advancements in technology and radiotracers as well as areas of emerging interest for future applications of multimodal PET imaging of MSK conditions. Overall, we present evidence that the incorporation of PET through multimodal imaging offers an exciting addition to the field of MSK radiology and will likely prove valuable in the transition to an era of precision medicine.

Concordance of shoulder symptoms and imaging findings: a protocol for the Finnish Imaging of Shoulder (FIMAGE) study

Article

Full-text available

Dec 2023

Introduction Shoulder pain is a substantial medical and socioeconomic problem in most societies, affecting the ability to work or carry out leisure time activities as well as subsequently influencing physical and psychological well-being. According to a nationwide survey in Finland, 27% of the population reported shoulder pain within the last 30 days. In clinical practice, imaging findings of structural abnormalities are typically thought to explain symptoms, even though such findings are also prevalent in asymptomatic individuals, particularly with increasing age. Overall, there is a paucity of high-quality evidence on the prevalence, clinical relevance and prognosis of ‘abnormal’ imaging findings of the shoulder. The aim of the Finnish Imaging of Shoulder (FIMAGE) study is fourfold: to assess (1) the prevalence of shoulder symptoms and the most common anatomical variants and imaging abnormalities of the shoulder; (2) the concordance between shoulder symptoms, function and imaging abnormalities; (3) the most important determinants of symptoms, function and imaging abnormalities; and (4) the course of shoulder complaints over 5 years. Methods The FIMAGE target population of 600 participants, aged 40–75 years, will be randomly selected from a nationally representative general population sample of 9922 individuals originally recruited for the Finnish Health 2000 Survey. On giving informed consent, the participants will be invited to a clinical visit that includes assessment of general health, shoulder symptoms, bilateral shoulder examination and imaging of both shoulders with plain radiography and MRI. Ethics and dissemination The study has been approved by the Institutional Review Board of the Helsinki and Uusimaa Hospital District. The findings will be published according to the Strengthening the Reporting of Observational Studies in Epidemiology criteria. Trial registration number NCT05641415 .

Words matter: Kommunikation im klinischen Alltag

Article

Dec 2023

Fabian Pfeiffer

Kommunikation ist weit mehr als nur ein Mittel zum Zweck. Sie ist das Herzstück, das den therapeutischen Prozess lenkt, die therapeutische Beziehung stärkt und Behandlungsergebnisse verbessern kann. Mit den richtigen Techniken gelingt eine patientenzentrierte Kommunikation, die Placebo fördert und Nocebo meidet.

Ein Extremitätenschmerz, der keiner ist – Arm- und Beinschmerzen aus der Wirbelsäule

Article

Nov 2023

Georg Supp

Bei einem isolierten Schmerz an den Extremitäten empfiehlt die Literatur bisher kein Screening der Wirbelsäule. In der Praxis findet es schon gar nicht statt. Die EXPOSS-Studie zeigt nun, dass die Wirbelsäule sogar häufig für solche Beschwerden verantwortlich ist. Der Artikel zeigt, wie diese Erkenntnis in den Alltag umgesetzt werden kann.

Fully Automated Approach for Diagnosis of Supraspinatus Tendon Tear on Shoulder MRI by Using Deep Learning

Article

Oct 2023
ACAD RADIOL

Moving forward: A review of continuous kinetics and kinematics during handcycling propulsion

Article

Aug 2023
J BIOMECH

Propulsion kinetics of recumbent handcycling during high and moderate intensity exercise

Article

Jun 2023
J BIOMECH

People with spinal cord injuries (PwSCI) are at high risk of developing cardiovascular disease (CVD). While regular exercise can reduce risk of CVD, PwSCI face various barriers to exercise, including high rates of upper limb injuries, especially in the shoulder. Handcycling high intensity interval training (HIIT), which consists of periods of high intensity exercise followed by rest, is a potential exercise solution, but the musculoskeletal safety of HIIT is still unknown. In this study, we characterized three-dimensional continuous applied forces at the handle during handcycling HIIT and moderate intensity continuous training (MICT). These applied forces can give an early indication of joint loading, and therefore injury risk, at the shoulder. In all three directions (tangential, radial, and lateral), the maximum applied forces during HIIT were larger than those in MICT at all timepoints, which may indicate higher contact forces and loads on the shoulder during HIIT compared to MICT. The tangential and radial forces peaked twice in a propulsion cycle, while the lateral forces peaked once. Throughout the exercises, the location of tangential peak 2 and radial peak 1 was later in HIIT compared to MICT. This difference in maximum force location could indicate either altered kinematics or muscular fatigue at the end of the exercise protocol. These changes in kinematics should be more closely examined using motion capture or other modeling techniques. If we combine this kinetic data with kinematic data during propulsion, we can create musculoskeletal models that more accurately predict contact forces and injury risk during handcycling HIIT in PwSCI.

Assessment of Shoulder Pain in Rheumatoid Arthritis Patients by using High Resolution Musculoskeletal Ultrasound

Article

Oct 2019

The prevalence of neovascularity in rotator cuff tendinopathy: comparing conventional Doppler with superb microvascular imaging

Article

Apr 2022
CLIN RADIOL

AIMS To determine the prevalence of neovascularity in the supraspinatus tendon of patients presenting with clinically painful unilateral rotator cuff tendinopathy (RCT) using conventional colour Doppler ultrasound (CDU), power Doppler ultrasound (PDU), and superb microvascular imaging (SMI). The association between Doppler findings and clinical scores was also assessed. METHODS The bilateral supraspinatus of consecutive patients presented with unilateral RCT clinically were evaluated with grey-scale ultrasound (tendon thickening, heterogeneous echotexture, and hypoechogenicity), CDU, PDU, and SMI. The prevalence of neovascularity and grey-scale changes on duplex imaging techniques were analysed. The relationship between neovascularity on CDU, PDU, SMI, and pain/disability as determined using a visual analogue scale (VAS) and the Oxford Shoulder Score (OSS) were assessed. RESULTS Fifty-nine patients (mean age 53 years, 39 women) were recruited. Of the symptomatic supraspinatus tendons, 42.4% (25/59) demonstrated neovascularity on SMI, compared to 6.8% (4/59) on PDU and 5.1% (3/59) on CDU. Of the asymptomatic supraspinatus tendons, 5.1% (3/59) depicted neovascularity on SMI but not on conventional Doppler techniques. SMI showed a significant correlation with the VAS (r² = 0.560, p<0.001) and OSS (r² = 0.62, p<0.001). PDU weakly correlated with the VAS and OSS (r² = 0.312, p=0.016; r² = 0.260, p=0.047, respectively) while CDU did not show a significant relationship. CONCLUSION SMI is superior in demonstrating neovascularity and shows better correlation with pain and functional deficit compared to conventional Doppler in patients with painful RCT. SMI also showed vascularity to a lesser degree in the asymptomatic tendon. Further large-scale studies are needed to prove the diagnostic value of SMI in the assessment of RCT.

Knee Myofascial Pain and Knee-Abdomen Syndromes; A Newly Identified Knee Disorders, Commonly Misdiagnosed as Arthritis, Multiple Case Study

Article

Full-text available

Feb 2022

Background: Knee osteoarthritis is a common orthopedic condition. Imaging based pathoanatomical findings are utilized as a cornerstone for diagnosis of the condition, 97% of asymptomatic knees demonstrate pathoanatomical findings, causing doubt of diagnosis and efficiency of intervention based on asymptomatically present pathoanatomical features. Purpose: This study explores myofascial dysfunctions as an alternative explanation to knee pain. Identifying new syndromes termed as knee myofascial pain and knee-abdomen syndromes. Therapeutic intervention: Describing 3 cases of knee osteoarthritis and one case of rheumatoid arthritis treated to full recovery as myofascial dysfunction. All of these cases were investigated and treated to complete recovery from specific myofascial continuity known as deep front line dysfunction, as a cause of knee pain. Results: Both syndromes demonstrated 50% to 100% pain reduction after one session of myofascial release, with no recurrence over long-term follow-up after discharge. Conclusion: Knee myofascial pain and knee-abdomen syndromes are clinically present commonly misdiagnosed as arthritic changes. Myofascial release produced an immediate major pain reduction ranging from 50 to 100%. High quality research is required to identify more accurate diagnostic criteria and consequently best treatment strategies.

Let's talk about shoulder osteoarthritis

Article

Feb 2022

Unintended Consequences: An Evaluation Quantifying Benefits, Iatrogenic Harms and Downstream Cascade Costs of Musculoskeletal Magnetic Resonance Imaging (MRI) in UK Primary Care

Article

Full-text available

Jul 2020

Objectives The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety. Methods Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation. Results Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered ‘low-value’ (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%–30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost–consequence or cost–utility analysis. Conclusion Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1–2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Cardiovascular Disease Risk Factors Predict the Development and Numbers of Common Musculoskeletal Disorders

Article

Full-text available

Jan 2020

Clinical decision-making for shoulder surgery referral: An art or a science?

Article

Sep 2020
J EVAL CLIN PRACT

Rationale: Decision-making in musculoskeletal health care is complex, with discrepancy among clinical providers and variation in the per cent of referrals for specialist care. To date, there is an increased focus on specialist referrals, risking overuse of expensive testing and contributing to unnecessary treatment. Aims and objectives: This report will considerer the difficulties of primary care musculoskeletal decision-making using shoulder injuries as an example, presenting a solution based on multi-criteria decision-making analysis with online software. The associated issues involved in clinical decision-making are complex. Contributing to the components of complexity are; the multifaceted aetiology of shoulders, the experience and knowledge of providers, and the burden of patient demands. Notwithstanding, funding considerations, resource allocation availability and other associated issues around clinical decision-making. Considering the many facets and complexities of clinical decision-making, this is an area where multi-criteria decision-making analysis (MCDM) may be appropriate. The MCDM analysis approach is increasingly being used in health care and can assist in the organizing and weighting of identified key clinical factors. MCDM could be applied to the challenges of musculoskeletal care with the potential to decrease decision-making variability. Furthermore, the significance of each key clinical factor that musculoskeletal decision-making is based on are to date unclear. Conclusion: Therefore, this preliminary report offers a start towards clarifying key factors and an approach for implementing improved shoulder clinical care decision-making which could then be adapted and applied to other body sites.

Comparison of shoulder muscle strength, cross-sectional area, acromiohumeral distance, and thickness of the supraspinatus tendon between symptomatic and asymptomatic patients with rotator cuff tears

Article

May 2020
J SHOULDER ELB SURG

Background The purpose of this study was to demonstrate the differences in shoulder muscle strength, cross-sectional area of the rotator cuff muscles, acromiohumeral distance, and supraspinatus tendon thickness between symptomatic and asymptomatic patients with rotator cuff tears. Methods Thirty-two symptomatic patients and 23 asymptomatic patients with rotator cuff tears participated in this study. Data of the patients with any type of tear and supraspinatus tear were analyzed. We evaluated the isometric torque, cross-sectional area of the rotator cuff muscles, supraspinatus tendon thickness, acromiohumeral distance, range of motion, and Western Ontario Rotator Cuff Index. Results Asymptomatic patients showed greater isometric torque of shoulder abduction and internal rotation than symptomatic patients with any type of tear (P ≤ .01). Asymptomatic patients also demonstrated greater cross-sectional area of the supraspinatus (P < .01); however, there was no significant difference in the cross-sectional area of the other cuff muscles. There was also no significant difference in the supraspinatus tendon thickness (P = .10). The acromiohumeral distance at 90° of shoulder abduction was larger (P = .04) in asymptomatic patients. Additionally, similar tendencies were observed in the results of patients with supraspinatus tears, except for the isometric torque of shoulder external rotation. This torque was greater (P < .01) in asymptomatic patients. Conclusion Asymptomatic patients showed greater shoulder range of motion, muscle strength of shoulder abduction and internal rotation, small occupation ratio of supraspinatus tendon thickness as a percentage of acromiohumeral distance, and large cross-sectional area of supraspinatus.

A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks

Article

Full-text available

May 2011
BMC MUSCULOSKEL DIS

The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Cohort profile: The north west Adelaide health study (NWAHS)

Article

Full-text available

Dec 2009
INT J EPIDEMIOL

Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons

Article

Full-text available

Oct 2008
NEW ENGL J MED

Magnetic resonance imaging (MRI) of the knee is often performed in patients who have knee symptoms of unclear cause. When meniscal tears are found, it is commonly assumed that the symptoms are attributable to them. However, there is a paucity of data regarding the prevalence of meniscal damage in the general population and the association of meniscal tears with knee symptoms and with radiographic evidence of osteoarthritis. We studied persons from Framingham, Massachusetts, who were drawn from census-tract data and random-digit telephone dialing. Subjects were 50 to 90 years of age and ambulatory; selection was not made on the basis of knee or other joint problems. We assessed the integrity of the menisci in the right knee on 1.5-tesla MRI scans obtained from 991 subjects (57% of whom were women). Symptoms involving the right knee were evaluated by questionnaire. The prevalence of a meniscal tear or of meniscal destruction in the right knee as detected on MRI ranged from 19% (95% confidence interval [CI], 15 to 24) among women 50 to 59 years of age to 56% (95% CI, 46 to 66) among men 70 to 90 years of age; prevalences were not materially lower when subjects who had had previous knee surgery were excluded. Among persons with radiographic evidence of osteoarthritis (Kellgren-Lawrence grade 2 or higher, on a scale of 0 to 4, with higher numbers indicating more definite signs of osteoarthritis), the prevalence of a meniscal tear was 63% among those with knee pain, aching, or stiffness on most days and 60% among those without these symptoms. The corresponding prevalences among persons without radiographic evidence of osteoarthritis were 32% and 23%. Sixty-one percent of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month. Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age.

MR Imaging of the rotator cuff: Peritendinous and bone abnormalities in an asymptomatic population

Article

Full-text available

May 1996

MR imaging of the shoulder was performed in an asymptomatic population to determine the prevalence of MR-evident peritendinous and bone abnormalities. Findings were correlated with subject age and rotator cuff abnormalities. Dual-echo T2-weighted oblique coronal MR images of the shoulder were evaluated for 100 asymptomatic volunteers who were 19-88 years old. Twenty symptomatic patients with arthroscopic correlation were included as controls. Images were assessed independently by two reviewers with no knowledge of subject history or symptomatology. Bursal, peribursal, and bone findings were correlated with subject age and the appearance of the rotator cuff tendon. Changes characteristic of acromioclavicular joint osteoarthrosis were present in three fourths of the shoulders. One third had subacromial spurs. Changes in the peribursal fat plane and the presence of fluid in the subacromial-subdeltoid bursa paralleled the degree of MR-evident rotator cuff abnormalities. Joint fluid was observed in nearly all subjects. Our findings reveal a high prevalence of MR-evident bone and peritendinous shoulder abnormalities among asymptomatic individuals. The prevalence of subacromial spurs and humeral head cysts correlated closely with the severity of MR-evident rotator cuff abnormalities, as did changes in the bursa and peribursal fat. Acromioclavicular joint osteoarthrosis is seen in many shoulders independently of rotator cuff disease; therefore, its presence alone does not appear to be a reliable indicator of pain or tendon disease.

Predictors of chronic shoulder pain: A population based prospective study

Article

Full-text available

Sep 1998

To determine the natural history of shoulder pain in the population, and predictors of outcome on the basis of clinical and individual factors. In addition, to determine whether outcome is influenced by the definition of shoulder pain used. A prospective cohort study, over a 3 year period, of subjects recruited from a cross sectional population screening study of shoulder pain, conducted in the Greater Manchester area of the UK. Of 92 subjects classified as having shoulder pain in the cross sectional study, 50 (54%) reported shoulder pain at followup about 3 years later. In 90% of cases this was accompanied by some disability specifically relating to the symptoms. Baseline factors that predicted symptoms at followup were: pain (indicated on a manikin) within a more narrowly defined shoulder region, shoulder pain related disability, pain on the day of examination, symptoms lasting more than one year, and a high score on the General Health Questionnaire, a measure of psychological distress. Shoulder pain in the population is a longterm disabling symptom, although many subjects do not seek early medical consultation. Disability (independent of whether there was restriction of movement on examination) is a strong predictor of continuing symptoms. The outcome observed in epidemiological studies of shoulder pain will be influenced by the initial definition of symptoms.

Reliability of five method for assessing shoulder range of motion

Article

Full-text available

Feb 2001
AUST J PHYSIOTHER

In symptomatic subjects, the reliability of tests for shoulder joint range of motion has yet to be determined. For this reason, inter-rater and intra-rater agreement trials were undertaken to ascertain the reliability of visual estimation, goniometry, still photography, "stand and reach" and hand behind back reach for six different shoulder movements. Intra-class correlation coefficients (Rho) were derived by using a random effects model. For flexion, abduction and external rotation fair to good reliability was demonstrated for both trials using visual estimation (Inter-rater Rho = 0.57-0.70; Intra-rater Rho = 0.59-0.67), goniometry (Inter-rater Rho = 0.64-0.69; Intra-rater Rho = 0.53-0.65) and still photography (Inter-rater Rho = 0.62-0.73; Intra-rater Rho = 0.56-0.61). The tests had standard errors of measurement of between 14 and 25 degrees (inter-rater trial) and 11 and 23 degrees (intra-rater trial).

Radiographic classification of glenohumeral arthrosis

Article

Full-text available

May 2003
Acta Orthop Scand

We studied the interobserver agreement of two radiographic classification systems for evaluation of glenohumeral arthrosis in 40 patients at long-term follow-up after the Eden Hybbinette operation for habitual dislocation of the anterior shoulder. Both observers agreed that none of the patients had severe arthrosis. The Samilson-Prieto system showed agreement using the classification in 35 of 40 operated shoulders (kappa 0.76). The Kellgren-Lawrence system showed agreement using the classification in 23 of 40 operated shoulders (kappa 0.36). The rate of arthrosis in the operated shoulder ranged from 0.2 to 0.6, depending on the classification system and the observer. None of the patients without arthrosis, but one fifth of those with arthrosis reported pain. The Samilson-Prieto classification is preferable because it is simple to use and has excellent interobserver agreement.

Prevalence and incidence of shoulder pain in the general population: A systematic review

Article

Full-text available

Feb 2004

To investigate the incidence and prevalence of shoulder complaints in the general population. A systematic review of the literature was conducted. Medline, Embase, and Cinahl were searched for relevant studies. Eighteen studies on prevalence and one study on incidence met the inclusion criteria. Incidence figures of 0.9-2.5% were found for different age groups. Prevalence figures differed from 6.9 to 26% for point prevalence, 18.6-31%, for 1-month prevalence, 4.7-46.7% for 1-year prevalence and 6.7-66.7% for lifetime prevalence. Prevalence rates decreased when the case definition was restricted, in terms of duration of pain or the presence of limited movements, and increased when the location for pain was enlarged. The reported prevalence figures on shoulder complaints diverged strongly. Health professionals and policymakers who estimate the amount of medical care needed and related costs should be aware of the variations in prevalence rate and the underlying reasons for these differences.

The North West Adelaide Health Study: Detailed methods and baseline segmentation of a cohort for selected chronic diseases

Article

Full-text available

Feb 2006
Epidemiol Perspect Innovat

The North West Adelaide Health Study is a population-based biomedical cohort study investigating the prevalence of a number of chronic conditions and health-related risk factors along a continuum. This methodology may assist with evidence-based decisions for health policy makers and planners, and inform health professionals who are involved in chronic disease prevention and management, by providing a better description of people at risk of developing or already diagnosed with selected chronic conditions for more accurate targeting groups for health gain and improved health outcomes. Longitudinal data will provide information on progression of chronic conditions and allow description of those who move forward and back along the continuum over time. Detailed methods are provided regarding the random recruitment and examination of a representative sample of participants (n = 4060), including the rationale for various processes and valuable lessons learnt. Self-reported and biomedical data were obtained on risk factors (smoking, alcohol consumption, physical activity, family history, body mass index, blood pressure, cholesterol) and chronic conditions (asthma, chronic obstructive pulmonary disease, diabetes) to classify participants according to their status along a continuum. Segmenting this population sample along a continuum showed that 71.5% had at least one risk factor for developing asthma, chronic obstructive pulmonary disease or diabetes. Almost one-fifth (18.8%) had been previously diagnosed with at least one of these chronic conditions, and an additional 3.9% had at least one of these conditions but had not been diagnosed. This paper provides a novel opportunity to examine how a cohort study was born. It presents detailed methodology behind the selection, recruitment and examination of a cohort and how participants with selected chronic conditions can be segmented along a continuum that may assist with health promotion and health services planning.

A standardized protocol for measurement of range of movement of the shoulder using the Plurimeter-V inclinometer and assessment of its intrarater and interrater reliability

Article

Jan 1998

Objective. To develop a standardized protocol for measurement of shoulder movements using a gravity inclinometer designed for use in clinical trials, and to assess its intra- and interrater reliability in a group of manipulative physiotherapists. Methods. After instruction, 6 manipulative physiotherapists independently assessed 8 movements of the shoulder, including total and glenohumeral flexion (TF, GHF), total and glenohumeral abduction (TA, GHA), external rotation in neutral (ERN) and abduction (ERA), internal rotation in abduction (IRA), and hand behind back (HBB), in random order in 6 patients with shoulder pain and stiffness according to a 6 x 6 Latin square design using the standardized protocol. The assessments were then repeated. Analysis of variance was used to partition total variability into components of variance in order to calculate intraclass correlation coefficients (ICCs). Results. The intra- and interrater reliability of the different movements varied widely. Reliability was higher for TF and TA than for the corresponding glenohumeral movements (e.g., intrarater ICCs: TF = 0.80, GHF = 0.65, TA = 0.75, GHA = 0.62). Interrater reliability was higher in the second round suggesting a practice effect (e.g., round 1, 2 interrater ICCs TF = 0.62, 0.82; TA = 0.62, 0.88; ERN = 0.85, 0.95). Conclusion. The measurement of the active range of TF, TA, ERN, and HBB, measured by manipulative physiotherapists following the standardized protocol, has intra- and interrater reliability acceptable for use as an outcome measure in clinical trials assessing interventions for shoulder pain.

3235.0 - Population by Age and Sex, Regions of Australia

Book

Jan 2009

Australian Bureau Statistics

The clinical course of shoulder pain: Prospective cohort study in primary care

Article

Sep 1996

Current knowledge of the clinical course and efficacy of treatment for shoulder pain comes mainly from studies of hospital patients. However, only a few patients experiencing such pain require referral to a specialist. Although shoulder pain is common in the general population, the outcome of patients presenting in general practice is unknown.1 We conducted a prospective cohort study to determine the outcome of shoulder pain in primary care. Twelve general practitioners recruited 166 patients who consulted with a new episode of shoulder pain during one year. They recorded demographic information, diagnosis, management, and an assessment of passive elevation of the shoulder; patients assessed the disability associated with their symptoms with a validated 22 item disability questionnaire.2 To assess outcome, identical disability questionnaires were sent to patients six and 18 months after consultation, together with a question measuring self assessed change in symptoms …

A standardized protocol for measurement of range of movement of the shoulder using the Plurimeter‐V inclinometer and assessment of its intrarater and interrater reliability

Article

Dec 2005
ARTHRIT RHEUM-ARTHR

Objective. To develop a standardized protocol for measurement of shoulder movements using a gravity inclinometer designed for use in clinical trials, and to assess its intra‐ and interrater reliability in a group of manipulative physiotherapists. Methods. After instruction, 6 manipulative physiotherapists independently assessed 8 movements of the shoulder, including total and glenohumeral flexion (TE GHF), total and glenohumeral abduction (TA, GHA), external rotation in neutral (ERN) and abduction (ERA), internal rotation in abduction (IRA), and hand behind back (HBB), in random order in 6 patients with shoulder pain and stiffness according to a 6 × 6 Latin square design using the standardized protocol. The assessments were then repeated. Analysis of variance was used to partition total variability into components of variance in order to calculate intraclass correlation coefficients (ICCs). Results. The intra‐ and interrater reliability of the different movements varied widely Reliability was higher for TF and TA than for the corresponding glenohumeral movements (e.g., intmrater ICCs: TF = 0.80, GHF = 0.65, TA = 0.75, GHA = 0.62). Intererrater reliability was higher in the second round suggesting a practice effect (e.g., round 1,2 interrater ICCs TF = 0.62, 0.82; TA = 0.62, 0.88; ERN = 0.85, 0.95). Conclusion. The measurement of the active range of TF, TA, ERN, and HBB, measured by manipulative physiotherapists following the standardized protocol, has intra‐ and interrater reliability acceptable for use as an outcome measure in clinical trials assessing interventions for shoulder pain.

Development of a Shoulder Pain and Disability Index

Article

Dec 1991
ARTHRIT RHEUM-ARTHR

A shoulder pain and disability index (SPADI) was developed to measure the pain and disability associated with shoulder pathology. The SPADI is a self-administered index consisting of 13 items divided into two subscales: pain and disability. Thirty-seven male patients with shoulder pain were used in a study to examine the measurement characteristics of the SPADI. Test-retest reliability of the SPADI total and subscale scores ranged from 0.6377 to 0.6552. Internal consistency ranged from 0.8604 to 0.9507. SPADI total and subscale scores were highly negatively correlated with shoulder range of motion (ROM) supporting the criterion validity of the index. Principal components factor analysis with and without varimax rotation supported the construct validity of the total SPADI and its subscales. High negative correlations between changes in SPADI scores and changes in shoulder ROM indicated the SPADI delected changes in clinical status over short time intervals. The SPADI should prove useful for both clinical and research purposes.

Comparison of risk factors for shoulder pain and rotator cuff syndrome in the working population

Article

Jul 2012
AM J IND MED

To compare risk factors for shoulder pain without and with rotator cuff syndrome (RCS). A total of 3,710 workers of a French region were randomly included in the cross-sectional study between 2002 and 2005. Personal and occupational risk factors were assessed during a physical examination and by a self-administered questionnaire. Multinomial logistic modeling was used for the following outcomes: no shoulder pain and no RCS (reference), shoulder pain without RCS (called "shoulder pain") and RCS, separately for men and women. The prevalence rates of "shoulder pain" for men and women were 28.0% and 31.1%, respectively, and the prevalence rates of RCS were 6.6% and 8.5%, respectively. In men, "shoulder pain" and RCS were associated with age, high-perceived physical exertion, and arm abduction. Automatic work pace and low supervisor support were associated with "shoulder pain," and high psychological demand and low skill discretion with RCS. In women, "shoulder pain" and RCS were associated with age, repetitiveness of tasks, and low supervisor support. High perceived physical exertion and exposure to cold temperatures were associated with "shoulder pain." Age was more strongly associated with RCS than with shoulder pain without RCS for both genders. Biomechanical and psychosocial factors were associated with "shoulder pain" and RCS and differed between genders.

Ultrasound of the Shoulder: Asymptomatic Findings in Men

Article

Oct 2011
AM J ROENTGENOL

The purpose of this study was to examine the range and prevalence of asymp tomatic findings at sonography of the shoulder. The study sample comprised 51 consecutively enrolled subjects who had no symptoms in either shoulder. Ultrasound of one shoulder per patient was performed by a musculoskeletal sonographer according to a defined protocol that included imaging of the rotator cuff, tendon of the long head of the biceps brachii muscle, subacromial-subdeltoid bursa, acromioclavicular joint, and posterior labrum. The shoulder imaged was determined at random. The 51 scans were retrospectively analyzed by three fellowship-trained musculoskeletal radiologists in consensus, and pathologic findings were recorded. Subtle or questionable findings of mild tendinosis, bursal prominence, and mild osteoarthritis were not recorded. Twenty-five right and 26 left shoulders were imaged. The subject age range was 40-70 years. Ultrasound showed subacromial-subdeltoid bursal thickening in 78% (40/51) of the subjects, acromioclavicular joint osteoarthritis in 65% (33/51), supraspinatus tendinosis in 39% (20/51), subscapularis tendinosis in 25% (13/51), partial-thickness tear of the bursal side of the supraspinatus tendon in 22% (11/51), and posterior glenoid labral abnormality in 14% (7/51). All other findings had a prevalence of 10% or less. Asymptomatic shoulder abnormalities were found in 96% of the subjects. The most common were subacromial-subdeltoid bursal thickening, acromioclavicular joint osteoarthritis, and supraspinatus tendinosis. Ultrasound findings should be interpreted closely with clinical findings to determine the cause of symptoms.

Reliability of radiologic classification for cuff tear arthropathy

Article

Mar 2011

Several classification schemes have been proposed for cuff tear arthropathy and used for scientific and clinical purposes, even though their reliability has not been established and compared as of yet. Two observers (O1 and O2) twice independently classified 52 shoulder radiographs into the cuff arthropathy schemes of Favard, Visotsky-Seebauer, Hamada, and Sirveaux. The schemes of Samilson and Prieto as well as Kellgren and Lawrence, commonly used for osteoarthritis of the shoulder, were also used for comparison. Reliability was tested with the κ coefficient. The intraobserver and interobserver reliabilities were 0.812 for O1, 0.710 for O2, and 0.305 for O1 versus O2 for the Favard classification; 0.868, 0.583, and 0.551, respectively, for the Visotsky-Seebauer classification; 1.000, 0.491, and 0.407, respectively, for the Hamada classification; and 0.852, 0.602, and 0.598, respectively, for the Sirveaux classification. For comparison, the Samilson-Prieto classification reached 0.815, 0.710, and 0.507, respectively, and the Kellgren-Lawrence scheme reached 0.815, 0.713, and 0.430, respectively. Of the classification schemes tested, the Sirveaux classification displayed the best reliability overall. The Sirveaux classification only respects alterations of the glenoid, however. Among the schemes respecting both the glenoid and the humerus, the Hamada and Visotsky-Seebauer schemes showed similar reliability compared with the Samilson-Prieto and Kellgren-Lawrence systems, whereas the Favard classification was not as reliable. We therefore recommend the Visotsky-Seebauer or Hamada classification scheme.

Symptomatic Progression of Asymptomatic Rotator Cuff Tears A Prospective Study of Clinical and Sonographic Variables

Article

Nov 2010
J BONE JOINT SURG AM

The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic. A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period. With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment. Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function.

Comparison of Bloks and Worms Scoring Systems Part II. Longitudinal Assessment of Knee MRIs for Osteoarthritis and Suggested Approach Based on their Performance: Data from the Osteoarthritis Initiative

Article

Nov 2010
OSTEOARTHR CARTILAGE

There are two widely used scoring systems for knee magnetic resonance imaging (MRI) in osteoarthritis (OA) and the strengths and weaknesses of each system in terms of ease of use and association with known risk factors and outcomes are unknown. To compare Whole Organ Magnetic Resonance Imaging Score (WORMS) and Boston Leeds Osteoarthritis Knee Score (BLOKS) scales using longitudinal MRI and X-ray data. In the Osteoarthritis Initiative (OAI), knee radiographs, long limb films for alignment and MRI's were acquired in the interval from 0 to 24 months follow-up. OAI MRI's from baseline and 24 months were read separately using BLOKS and WORMS scales. X-rays were scored semiquantitatively for joint space loss and long limb films were measured for alignment angle. We evaluated which of the WORMS or BLOKS cartilage loss scores best correlated with joint space loss on the X-ray and which was best predicted by varus malalignment on long limb film. To examine the validity of bone marrow lesion (BML) and meniscal scales, we tested which of WORMS or BLOKS baseline scores for BML or meniscus best predicted cartilage loss from baseline to 24 months. We critically evaluated strengths and weaknesses of each scoring system also. Of 113 knees read longitudinally, 33 showed any cartilage loss using BLOKS and 30 using WORMS with high agreement between the scales. In the medial compartment, both BLOKS and WORMS picked up only 42% of the knees with X-ray joint space loss with similar specificity (88 vs 86%). Varus knees were more likely to be a risk factor for medial cartilage loss in BLOKS [adj odds ratio (OR) 5.9 (95% confidence intervals (CIs) 1.5, 24.0)] than in WORMS [adj OR 2.1 (95% CI 0.7, 6.3)]. WORMS BML scores predicted cartilage loss more strongly than any BLOKS BML variables and some BLOKS BML measures did not affect risk of cartilage loss at all. However, across the range of scores, meniscal tear scores in BLOKS predicted cartilage loss better for each abnormality than did WORMS meniscal tear scores and the meniscal signal abnormality scored in BLOKS but not in WORMS, predicted cartilage loss. BLOKS took longer and was more difficult to score longitudinally especially for BML scores. In a comparison of instruments limited by small numbers of knees compared, BLOKS meniscal score was preferable to WORMS meniscal scale in predicting cartilage loss most likely because it includes potentially important pathology missed by WORMS. On the other hand, BML scoring in WORMS was preferable in that it better predicted later cartilage loss, was easier to score and did not include potentially extraneous measures. Neither method was definitively better for cartilage scoring.

Magnetic Resonance Imaging Abnormalities in the Shoulder and Wrist Joints of Asymptomatic Elite Athletes

Article

Mar 2009

To characterize abnormalities on magnetic resonance images (MRI) in the shoulder and wrist joints of asymptomatic elite athletes to better define the range of "normal" findings in this population. Cohort study. Academic medical center. Division IA collegiate volleyball players (n=12), swimmers (n=6), and gymnasts (n=15) with no history of injury or pain and normal physical examination results. None. Grade of severity of MRI changes of the shoulder and wrist joints. A 3- to 4-year follow-up questionnaire was administered to determine the clinical significance of the asymptomatic findings. All athletes demonstrated at least mild imaging abnormalities in the joints evaluated. Shoulder: Volleyball players had moderate and severe changes primarily in the labrum (50% moderate, 8% severe), rotator cuff (25% moderate, 17% severe), bony structures (33% moderate), and tendon/muscle (25% moderate, 8% severe). Swimmers had moderate changes primarily in the labrum (83% moderate) and ligament (67% moderate). Wrist: All gymnasts had changes in the wrist ligaments (40% mild, 60% moderate), tendons (53% mild, 47% moderate), and cartilage (60% mild, 33% moderate, 7% severe). Most gymnasts exhibited bony changes (20% normal, 47% mild, 26% moderate, 7% severe), the presence of cysts/fluid collections (80%), and carpal tunnel changes (53%). Swimmers had no wrist abnormalities. At follow-up interview, only 1 swimmer and 1 volleyball player reported shoulder problems during the study. Additionally, only 1 gymnast reported a wrist injury during their career. Asymptomatic elite athletes demonstrate MRI changes of the shoulder (swimmers and volleyball players) and wrist (gymnasts) similar to those associated with abnormalities for which medical treatment and sometimes surgery are advised. Given the somewhat high frequency of these asymptomatic findings, care must be taken to correlate clinical history and physical examination with MRI findings in these patients with symptoms.

Adhesive Capsulitis: Establishing Consensus on Clinical Identifiers for Stage 1 Using the Delphi Technique

Article

Aug 2009
PHYS THER

Adhesive capsulitis often is difficult to diagnose in its early stage and to differentiate from other commonly seen shoulder disorders with the potential to cause pain and limited range of movement. The purpose of this study was to establish consensus among a group of experts regarding the clinical identifiers for the first or early stage of primary (idiopathic) adhesive capsulitis. A correspondence-based Delphi technique was used in this study. Three sequential questionnaires, each building on the results of the previous round, were used to establish consensus. A total of 70 experts from Australia and New Zealand involved in the diagnosis and treatment of adhesive capsulitis completed the 3 rounds of questionnaires. Following round 3, descriptive statistics were used to screen the data into a meaningful subset. Cronbach alpha and factor analysis then were used to determine agreement among the experts. Consensus was achieved on 8 clinical identifiers. These identifiers clustered into 2 discrete domains of pain and movement. For pain, the clinical identifiers were a strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, and pain easily aggravated by movement. For movement, the clinical identifiers included a global loss of active and passive range of movement, with pain at the end-range in all directions. Onset of the disorder was at greater than 35 years of age. This is the first study to use the Delphi technique to establish clinical identifiers indicative of the early stage of primary (idiopathic) adhesive capsulitis. Although limited in differential diagnostic ability, these identifiers may assist the clinician in recognizing early-stage adhesive capsulitis and may inform management, as well as facilitate future research.

Abnormal Findings on Magnetic Resonance Images of Asymptomatic Shoulders

Article

Feb 1995

Magnetic resonance images of the shoulders of ninety-six asymptomatic individuals were evaluated to determine the prevalence of findings consistent with a tear of the rotator cuff. The scans were reviewed independently by two diagnostic radiologists who are experienced in the interpretation of magnetic resonance images of the shoulder. The over-all prevalence of tears of the rotator cuff in all age-groups was 34 per cent (thirty-three). There were fourteen full-thickness tears (15 per cent) and nineteen partial-thickness tears (20 per cent). The frequency of full-thickness and partial-thickness tears increased significantly with age (p < 0.001 and 0.05, respectively). Twenty-five (54 per cent) of the forty-six individuals who were more than sixty years old had a tear of the rotator cuff: thirteen (28 per cent) had a full-thickness tear and twelve (26 per cent) had a partial-thickness tear. Of the twenty-five individuals who were forty to sixty years old, one (4 per cent) had a full-thickness tear and six (24 per cent) had a partial-thickness tear. Of the twenty-five individuals who were nineteen to thirty-nine years old, none had a full-thickness tear and one (4 per cent) had a partial-thickness tear. Magnetic resonance imaging identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings.

Returning to the Bedside: Using the History and Physical Examination To Identify Rotator Cuff Tears

Article

Dec 2000

To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT). Retrospective chart review Orthopedic practice limited to disorders of the shoulder 448 consecutive patients with suspected RCT referred for arthrography over a 4-year period Presence of partial or complete RCT on arthrogram 301 patients (67.2%) had evidence of complete or partial RCT. Clinical findings in the univariate analysis most closely associated with rotator cuff tear included infra- and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), arc of pain (P = .004), and impingement sign (P = .01). Stepwise logistic regression based on a derivation dataset (n = 191) showed that weakness with external rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age > or = 65 (AOR 4.05(2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five-point scoring system developed from this model was applied in the remaining patient sample (n = 216) to test validity. No significant differences in performance were noted using ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT to the diagnostic prediction of an expert clinician. This score had specificity equivalent to magnetic resonance imaging or ultrasonography in diagnosis of RCT. The presence of three simple features in the history and physical examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromising sensitivity or specificity.

The Association of Bone Marrow Lesions with Pain in Knee Osteoarthritis

Article

Apr 2001

The cause of pain in osteoarthritis is unknown. Bone has pain fibers, and marrow lesions, which are thought to represent edema, have been noted in osteoarthritis. To determine whether bone marrow lesions on magnetic resonance imaging (MRI) are associated with pain in knee osteoarthritis. Cross-sectional observational study. Veterans Affairs Medical Center. 401 persons (mean age, 66.8 years) with knee osteoarthritis on radiography who were drawn from clinics in the Veterans Administration health care system and from the community. Of these persons, 351 had knee pain and 50 had no knee pain. Knee radiography and MRI of one knee were performed in all participants. Those with knee pain quantified the severity of their pain. On MRI, coronal T(2)-weighted fat-saturated images were used to score the size of bone marrow lesions, and each knee was characterized as having any lesion or any large lesion. The prevalence of lesions and large lesions in persons with and without knee pain was compared; in participants with knee pain, the presence of lesions was correlated with severity of pain. Bone marrow lesions were found in 272 of 351 (77.5%) persons with painful knees compared with 15 of 50 (30%) persons with no knee pain (P < 0.001). Large lesions were present almost exclusively in persons with knee pain (35.9% vs. 2%; P < 0.001). After adjustment for severity of radiographic disease, effusion, age, and sex, lesions and large lesions remained associated with the occurrence of knee pain. Among persons with knee pain, bone marrow lesions were not associated with pain severity. Bone marrow lesions on MRI are strongly associated with the presence of pain in knee osteoarthritis.

Bone Marrow Edema and Its Relation to Progression of Knee Osteoarthritis

Article

Oct 2003
ANN INTERN MED

While factors affecting the course of knee osteoarthritis are mostly unknown, lesions on bone scan and mechanical malalignment increase risk for radiographic deterioration. Bone marrow edema lesions on magnetic resonance imaging correspond to bone scan lesions. To determine whether edema lesions in the subarticular bone in patients with knee osteoarthritis identify knees at high risk for radiographic progression and whether these lesions are associated with limb malalignment. Natural history study. A Veterans Administration hospital in Boston, Massachusetts. Persons 45 years of age and older with symptomatic knee osteoarthritis. Baseline assessments included magnetic resonance imaging of the knee and fluoroscopically positioned radiography. During follow-up at 15 and 30 months, patients underwent repeated radiography; at 15 months, long-limb films were obtained to assess mechanical alignment. Progression was defined as an increase over follow-up in medial or lateral joint space narrowing, based on a semi-quantitative grading. Generalized estimating equations were used to evaluate the relation of medial bone marrow edema lesions to medial progression and lateral lesions to lateral progression, before and after adjustment for limb alignment. Of 256 patients, 223 (87.1%) participated in at least one follow-up examination. Medial bone marrow lesions were seen mostly in patients with varus limbs, and lateral lesions were seen mostly in those with valgus limbs. Twenty-seven of 75 knees with medial lesions (36.0%) showed medial progression versus 12 of 148 knees without lesions (8.1%) (odds ratio for progression, 6.5 [95% CI, 3.0 to 14.0]). Approximately 69% of knees that progressed medially had medial lesions, and lateral lesions conferred a marked risk for lateral progression. These increased risks were attenuated by 37% to 53% after adjustment for limb alignment. Bone marrow edema is a potent risk factor for structural deterioration in knee osteoarthritis, and its relation to progression is explained in part by its association with limb alignment.

Interobserver Reproducibility of the Visual Estimation of Range of Motion of the Shoulder

Article

Aug 2005
ARCH PHYS MED REHAB

To assess interobserver reproducibility (agreement and reliability) of visually estimated shoulder range of motion (ROM) and to study the influence of clinical characteristics on the reproducibility. Test-retest analyses. Various health care settings in the Netherlands. Consecutive patients with shoulder complaints (N = 201) referred by 20 general practitioners, 2 orthopedic physicians, and 20 rheumatologists. Not applicable. Independent visual estimation by 2 physiotherapists of the ROM. Agreement was calculated as the mean difference in visual estimation between examiners +/-1.96 x standard deviations of this mean difference. The intraclass correlation coefficient (ICC) was calculated as a measure of reliability, based on a 2-way random effects analysis of variance. The lowest level of agreement was for visual estimation of active and passive elevation (limits of agreement, -43.4 to 39.8 and -46.7 to 41.5, respectively, for the difference between the affected and contralateral sides), for which the level of agreement was most clearly associated with pain severity and disability. The ability to differentiate between subjects was acceptable for all movements for the difference between the affected and contralateral sides (ICCs, > .70) except for horizontal adduction (ICC = .49). Interobserver agreement was low for the assessment of active and passive elevation, especially for patients with a high pain severity and disability. Except for horizontal adduction, visual estimation seems suitable for distinguishing differences between affected and contralateral ROM between subjects.

The Demographic and Morphological Features of Rotator Cuff Disease

Article

Aug 2006

Very little comparative information is available regarding the demographic and morphological characteristics of asymptomatic and symptomatic rotator cuff tears. This information is important to provide insight into the natural history of rotator cuff disease and to identify which factors may be important in the development of pain. The purpose of the present study was to compare the morphological characteristics and prevalences of asymptomatic and symptomatic rotator cuff disease in patients who presented with unilateral shoulder pain. Five hundred and eighty-eight consecutive patients in whom a standardized ultrasonographic study had been performed by an experienced radiologist for the assessment of unilateral shoulder pain were evaluated with regard to the presence and size of rotator cuff tears in each shoulder. The demographic factors that were analyzed included age, gender, side, and cuff thickness. All of these factors were evaluated with regard to their correlation with the presence of pain. Of the 588 consecutive patients who met the inclusion criteria, 212 had an intact rotator cuff bilaterally, 199 had a unilateral rotator cuff tear (either partial or full thickness), and 177 had a bilateral tear (either partial or full thickness). The presence of rotator cuff disease was highly correlated with age. The average age was 48.7 years for patients with no rotator cuff tear, 58.7 years for those with a unilateral tear, and 67.8 years for those with a bilateral tear. Logistic regression analysis indicated a 50% likelihood of a bilateral tear after the age of sixty-six years (p < 0.01). In patients with a bilateral rotator cuff tear in whom one tear was symptomatic and the other tear was asymptomatic, the symptomatic tear was significantly larger (p < 0.01). The average size of a symptomatic tear was 30% greater than that of an asymptomatic tear. Overall, patients who presented with a full-thickness symptomatic tear had a 35.5% prevalence of a full-thickness tear on the contralateral side. There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms, we recommend surveillance at yearly intervals for patients with known rotator cuff tears that are treated nonoperatively.

Detection and quantification of rotator cuff tears. Comparison of US, MRI, and arthroscopic findings in 71 consecutive cases

Jan 2004
708

Teefey

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults

Abstract

No full-text available

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