Ultrasound-Guided Treatments for the Painful Shoulder

: Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Scapular Retraction under Adduction Load: An Alternative to Overhead Exercises to Activate Infraspinatus, Upper, and Lower Trapezius in Subjects with and without Shoulder Pain

Exercises for lower trapezius (LT) often use overhead positions, causing compressive forces to the subacromial space. Scapular retraction would be an alternative to activate LT muscle. The present study aimed to assess the excitation levels of infraspinatus, upper trapezius, and lower trapezius muscles during a scapular retraction exercise under progressive adduction loads in subjects with and without painful shoulder. Electromyography of infraspinatus (IS), upper trapezius (UT), and LT was recorded during scapular retraction under progressive adduction loads of 42 participants, divided into two groups: with (SP, n = 26) and without shoulder pain (nSP, n = 16). The adduction loads of 20%, 30%, 40%, and 50% of the maximal voluntary contraction (MVC) were applied using a load cell. Normalized electromyography and the ratio between UT and LT (UT:LT) were used for statistical analysis. No differences were observed between groups, but a condition effect occurred for all muscles: UT showed higher values at 50% vs. 20% of MVC (p = 0.004); LT showed higher values on 40% and 50% of MVC (p = 0.001; 0.006). Higher values for IS were noted at 40% of MVC (vs. 20% of MVC; p = 0.04) and at 50% of MVC (vs. 20% of MVC; p = 0.001, vs. 30% of MVC, p = 0.001; vs. 40% of MVC; p = 0.001). UT:LT showed lower values at 50% of MVC (vs. 20% of MVC; p = 0.001 and vs. 30% of MVC; p = 0.016). Scapular retraction with adduction loads at 40–50% is an alternative to overhead exercises aiming to activate the LT and the IS muscles. The exercise ensures higher levels of LT and IS excitation without increasing UT excitation.

CLINICAL OUTCOME OF BLIND VERSUS SONOGRAPHIC GUIDED INFILTRATION OF CORTICO STEROID FOR PAINFUL SHOULDER CONDITIONS IN ADULTS – A COMPARATIVE STUDY

Background: Painful shoulder is one of the commonest ailmaent encountered in the outpatient department of orthopedica now a days. One of the ways to get relief from the pain is to instill intraarticular corticosteroids. Corticosteroid injections can be performed blind or with image guidance. The objective of this study was to compare the accuracy and efcacy of image guided intraarticular corticosteroid injections in shoulder pain versus blind, with specic reference to pain relief as per VAS and functional improvement as per constant score. Objective : To compare the efcacy of image guided intra-articular corticosteroid injection in shoulder pain versus blind method of inltration, with specic reference to 1. pain relief as per visual analogue score. 2. To compare post inltration functional improvement of as per constant score with these two methods. Methods: The present Study included 50 adults with a history of pain around the shoulder of three or more than three months duration and were divided into two groups of 25 patients each by simple computer based allocation. Results: Both groups showed improvement as per CONSTANT SCORE, (26.64 to 72.00, an improvement of 45.36 in USG group and 27.48 to 58.60, an improvement of 31.12 in blind group with significant p value of 0.001). Conclusion: USG inltration of corticosteroids in shoulder pain is a superior method compared to blind inltration as clearly established by signicant improvement in pain and range of motion (ROM) of shoulder joint (more in ultrasonic group compared to blind group) probably due to accurate needle placement and proper dosage of drug is delivered at the required site.

A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway.Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators.Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.

POS0497 A RELIABILITY EXERCISE USING CONSENSUAL DEFINITIONS FOR THE ULTRASONOGRAPHY OF THE SHOULDER IN RHEUMATOID ARTHRITIS

Background:Although numerous clinical tests for the diagnosis of painful shoulder are available, differentiating articular from periarticular lesions may be difficult in daily practice. Fortunately, the precise diagnosis of shoulder pain in RA benefited from a reliable imaging modality to detect its exact origin as ultrasonography (US).Objectives:This study aimed to assess the intraobserver and interobserver reliabilities of the ultrasonographic findings for patients with established RA having shoulder pain in a patient-based exercise among maghrebian rheumatologists experts on US.Methods:A total of 7 operators examined 10 patients in 2 rounds independently and blindly of each other.Each patient underwent a US scanning of the painful shoulder in four sites based on US technical guidelines of the European society of musculoskeletal radiology: long head of Biceps (LHB), subscapularis recess, posterior recess and axillary recess. The presence of a subdeltoid or subcoracoid bursitis or the presence of transfixiant tear of the suprasupinatus were notified if present. Intra and inter-observer reliabilities were calculated.Results:Intraobserver reliability was excellent for GS synovitis in subscapularis and posterior recesses (k=0.91 for both) and for subcoracoid bursitis (k=0.81). It was good in case of presence of a subdeltoid bursitis (k=0.79), transfixiant tear of the suprasupinatus (k=0.65), GS synovitis and effusion in LHB (k=0.67 and 0.6 respectively) and subdeltoid bursitis (k= 0.79). Interobserver reliability was good for PD for LHB signals searched longitudinally (k=0.78) and transversally (k=0.78). It was moderate for GS for LHB synovitis (k=0.55). Interobserver agreement was poor for effusion and GS synovitis for subscapularis, posterior and axillary recesses. It was very poor and/or absent for PD signals in these recesses.Conclusion:US is a reliable imaging tool for shoulder in RA especially with regard to LHB effusion, GS and PD synovitis. Interobserver reliability of subscapularis, posterior and axillary recesses could be optimized by standardization of sites to assess.References:[1]Bruyn G a. W, Naredo E, Möller I, Moragues C, Garrido J, de Bock GH, et al. Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Ann Rheum Dis 2009;68:357–61.Disclosure of Interests:None declared

Acupuntura para Tratamento do Ombro Doloroso: Metanálise

Background: The painful shoulder is a very prevalent entity. Several treatment options are currently recommended, including acupuncture. Acupuncture is part of the arsenal of Traditional ChineseMedicine (TCM) and dates back to the 6th century BC, and consists of the application of needles in specific points of the body, in order to harmonize and allow the free flow of vital energy (Qi). Objective: To evaluate the effectiveness of acupuncture for the treatment of painful shoulder, as well as to compare the techniques and points used. Methods: Meta-analysis of 28 randomized, controlled clinical trials, comparing the effect of acupuncture and placebo intervention (Sham). Results: In all these studies, acupuncture proved to be superior to control group in the treatment of shoulder pain. Most articles were of good quality, with clear randomization criteria and few publication biases. Conclusion: The needling of local points and distance, described by TCM, is able to reduce shoulder pain safely and effectively. Level of Evidence I: Systematic Review of Level I Studies.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study

Background: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. Methods: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. Results: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6–72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9–95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. Conclusion: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.