The painful shoulder: can consultants agree?

As a two-phase exercise in inter-district audit, with the emphasis on critical evaluation of routine clinical practice, three rheumatologists each examined the same 44 patients with shoulder pain, and recorded their diagnosis and the investigations and treatment they would carry out. In the first phase, 26 patients were seen by each rheumatologist separately; there was complete diagnostic agreement in only 46%, with wide variation in the frequency of requests for standard investigations, but all three rheumatologists recommended steroid injections for most patients. In the second phase, all three rheumatologists examined a further 18 patients together, discussed the symptoms and signs, and recorded their diagnoses separately. There was complete agreement in 78%. The presence of more than one lesion, and differences in the interpretation of certain physical signs, partly explain the lack of agreement in Phase 1. Treatment of specific shoulder lesions is highly concordant, with injection the major treatment modality, followed by physiotherapy. Perhaps the different diagnoses reached, and the fact that treatment might therefore be administered for the wrong diagnosis, may explain some treatment failures. Also, recruitment of patients for studies of the treatment of shoulder lesions requires care to avoid selection of a heterogeneous group.     

Results of posterior inferior capsular shift in posterior shoulder instability

Today quality is not only in the economy but also in medicine a prime parameter in the evaluation of goods and services. To guarantee quality in a comprehensive way not only quality control but also quality assurance or even quality management are needed. One has to focus on its integral aspects which are structure, process and result. With laboratory analysis a preanalytic phase has to be distinguished from an analytic and a postanalytic one. According to the notion of the Deutscher Arztetag quality assurance is a common task of all physicians. A variety of organisations provide support. Guidelines of various types are pivotal. Some concerning dermatology have already been released by Deutsche Dermatologische Gesellschaft; others are in the process of formulation. A comprehensive monograph is under way.     

How much does inferior capsular shift reduce shoulder volume?

The purpose of this study was to quantitate the effect of inferior capsular shift on shoulder volume. Four fresh frozen cadaveric shoulders were analyzed. Volume before and after shift was determined using 3 techniques: (1) Magnetic resonance imaging sequences were digitized to computer and analyzed for volume via a 35-mm camera using Cue 2 software. The capsule was delineated by contrast between light and dark regions. Volume was calculated by summing the total area of respective slices. (2) Ultrasound images, obtained after surgical exposure of the capsule, were digitized. Volume was calculated using the formula for a prolate ellipsoid. (3) An 18-gauge needle was used to inject and evacuate saline via an anterior approach. Quantity of aspirated fluid provided a direct measure of volume. Inferior capsular shift was performed. After the operation, measurements were repeated. Inferior capsular shift reduced volume in all shoulders with each technique. On average, inferior capsular shift reduced joint volume by 57 %). A measurable reduction in shoulder joint volume is an effect of capsular shift. This measurement may have clinical application if volume is an indicator of instability or laxity.     

Atraumatic shoulder instability. Discussion of classification and results after capsular imbrication

AIMS/BACKGROUND: We studied the fate of hepatocytes in the rat liver after D-galactosamine injury by genetic labeling using recombinant retroviruses carrying the Escherichia coli lacZ gene coupled to a nuclear localization signal. METHODS: Hepatocytes were either labeled by direct injection of 2.5 ml high-titer retrovirus-containing medium in the regenerating liver parenchyma after administration of a single dose of D-galactosamine. Alternatively hepatocytes were pre-labeled, 24 h after a two-thirds hepatectomy, by injecting the same volume of retroviral solution in the portal vein and D-galactosamine was administered 15 days later. Gamma-glutamyl transpeptidase and beta-galactosidase activities were assessed on cryostat sections, along with localization of the hepatocyte-specific HES6 antigen. RESULTS: Morphological observations, as well as beta-galactosidase activity detection, showed that hepatocytes actively divide as early as 1 day after D-galactosamine injection. Gamma-glutamyl transpeptidase activity was detected in biliary cells, but also in mature hepatocytes, pre-labeled with beta-galactosidase before D-galactosamine administration. CONCLUSIONS: These experiments demonstrate that hepatocytes can divide to restore the liver mass after D-galactosamine liver injury. Furthermore, we also show that gamma-glutamyl transpeptidase, which has been reported to be expressed only by fetal or preneoplastic hepatocytes, can be re-expressed by mature hepatocytes during the recovery process.     

Desmoid tumor of the thoracic wall. A case manifesting as painful stiffness of the shoulder

BACKGROUND: Desmoid tumors are uncommon fibromatous tumors arising from musculoaponeurotic tissue characterized by spindle cell fibroblast and myofibroblast proliferation. The cause is unknown (trauma, hormonal factors, genetic anomaly...). Locally invasive, they tend to recur increasing morbidity or even mortality. CASE REPORT: Stiff shoulder resulting from blockage of the scapulothoracic articulation was the inaugural sign. Three-phase bone scintigraphy demonstrated early uptake in the soft tissue in contact with the scapula. Magnetic resonance imaging and biopsy confirmed the diagnosis of desmoid tumor. Complete resection was performed. No adjuvant radiotherapy nor hormone treatment were given since no antiestrogen receptor antibodies were identified on the surgical specimen. DISCUSSION: The clinical manifestation (stiff shoulder) and the scapular localization observed in this case are unusual for desmoid tumors. Initially tendinopathy of the shoulder, acromio-clavicular arthropathy and capsular retraction of the shoulder joint had been entertained. Early diagnosis and wide surgical resection are indicated in desmoid tumors.     

Bone-scintigraphy in painful bipartite patella

We report the scintigraphic-appearances of painful bipartite patella in 25-year-old man a 2 1/2 years history of unexplained patellar pain. Painful bipartite patella is a rare cause of chronic post-traumatic patellar pain. Bone scintigraphy, by demonstrating increased uptake by the painful accessory bipartite fragment, appears to be an imaging method of choice in the diagnosis of this condition.     

A painful inflammation of the thyroid

Four women aged 30, 29, 52 and 43 years presented with what appeared to be subacute thyroiditis (De Quervain's thyroiditis). This disease is characterized by fatigue, a painful thyroid gland and thyrotoxic manifestations. The diagnosis is further based on a high erythrocyte sedimentation rate and low tracer uptake during thyroid scintigraphy. Only the first patient showed a typical course. In the second and third ones the painful thyroid was associated with nodular enlargement. Fine needle aspiration cytology was at first consistent with subacute thyroiditis but a repeated aspiration showed papillary carcinoma in the second and anaplastic carcinoma in the third patient. In the fourth one, subacute thyroiditis was accompanied by normochromic anaemia, a low serum albumin concentration and liver function disorders. She made a full recovery without treatment. Thyroid malignancies can mimic subacute thyroiditis. Persistent nodular enlargement of the thyroid is suspicious and requires careful investigation.     

Ultrasonography in the management of painful hips in children

It has been suggested that nitric oxide could be implicated in the pathogenesis of Alzheimer's disease (AD). Recently Kuiper et al. reported decreased CSF nitrate levels (oxidation product that provides an indirect estimation of nitric oxide) in AD patients, assessed with a colorimetric method. However other group, using a microplate version of the Griess reaction, did not confirm these findings. We studied the CSF and plasma levels of nitrate with kinetic cadmium-reduction method in 32 AD patients and 36 matched controls. The CSF and plasma nitrate levels did not differ significantly between the two study groups. CSF and plasma nitrate levels did not correlate with age at onset and duration in the patient group. These data suggest that CSF and plasma levels of nitrate are apparently unrelated with the risk for AD.     

Impingement syndrome in the athletic shoulder

The repetitive overhead use of the arm required by many sports may lead to impingement in the vulnerable avascular region of the supraspinatus and biceps tendons. The impingement syndrome may spill over at any time to involve the adjacent biceps tendon, subacromial bursa, and acromioclavicular joint and, as a continuum, with the passage of time, may eventuate in degeneration and partial, even complete thickness, rotator cuff tears later in life. Physical findings, particularly a positive impingement sign, confirm the diagnosis. In the young competing athlete, therapeutic measures consist of careful warm-up exercises, occasional rest by avoidance of the offending movement, and local modalities of ice, ultrasound, and transcutaneous stimulation along with anti-inflammatory medications. Surgical decompression achieved by resecting the coracoacromial ligament or a more definitive anterior acromioplasty may rarely be indicated.     

Renal insufficiency in the neonatal period

The fatty acid composition of plasma membranes in the placenta of induced-pregnancy females with ovarian hypofunction was studied Palmitic, stearic, and oleic acids were prevalent in the placental membranes. The content of arachidonic acid was higher that of linoleic acid which was in greater qualities in the membranous lipids of other tissues than arachidonic acid. The changes found in the fatty acid composition of placental membranous phospholipids were associated with the deviations in the levels of this organ-specific hormones progesterone and placental lactogen.     

Pseudothrombophlebitis in neuropathic arthropathy of the shoulder

The syndrome of pseudothrombophlebitis is a well-known complication of popliteal cysts. We report the case of a patient with a neuropathic arthropathy of the shoulder in whom pseudothrombophlebitis of the upper extremity subsequently developed. To our knowledge, this is the first such case that has been reported.     

Anatomic relationships in the shoulder impingement syndrome

Impingement syndrome of the shoulder may be produced by compression of the subacromial structures against the coracoacromial arch. The anterior tip of the acromion, the coracoacromial ligament, and the coracoid process have been implicated as sources of impingement. Anatomic specimens were examined to determine the anatomic sites on the coracoacromial arch that result in compression of the subacromial structures during specific shoulder motions that are known to produce impingement pain. The relationships of the supraspinatus tendon, the biceps tendon, and the greater tuberosity of the humerus with the coracoacromial arch were demonstrated through various arcs of shoulder motion in autopsy subjects. Biceps tendon impingement occurred predominantly against the lateral free edge of the coracoacromial ligament. Impingement of the supraspinatus tendon and greater tuberosity was demonstrated primarily against the acromial end of the coracoacromial ligament and the anterior tip of the acromion during arcs of flexion and internal rotation. The coracoacromial ligament was stretched by the greater tuberosity passing beneath it. This may explain the formation of traction osteophytes on the anterior acromion in patients with chronic impingement symptoms.     

Multidirectional instability of the shoulder in the athlete

Laxity of the inferior glenohumeral ligament is the essential lesion in involuntary multidirectional instability of the shoulder. Most important in the diagnosis, which is difficult to make, is the physical examination. Treatment consists of strengthening the muscles in the direction of the greatest instability. If this fails after a year, surgery is indicated.     

Nociceptor hyper-responsiveness during vincristine-induced painful peripheral neuropathy in the rat

Neuropathic pain accompanies peripheral nerve injury after a wide variety of insults including metabolic disorders, traumatic nerve injury, and neurotoxic drugs. Chemotherapy-induced neuropathic pain, caused by drugs such as vincristine and taxol, occurs in cancer patients who receive these drugs as antineoplastic agents. Although a variety of remediations have been attempted, the absence of knowledge concerning mechanisms of chemotherapy-induced neuropathic pain has hindered the development of treatment strategies. Vincristine, a widely used chemotherapeutic agent, produces painful peripheral neuropathy in humans and mechanical hyperalgesia in rats. To test the hypothesis that alterations in C-fiber nociceptor function occur during vincristine-induced painful peripheral neuropathy, we performed in vivo extracellular recordings of single neurons from the saphenous nerve of vincristine-treated rats. Forty-one percent of C-fiber nociceptors were significantly hyper-responsive to suprathreshold mechanical stimulation. As a population, these mechanically hyper-responsive nociceptors also had significantly greater responses to suprathreshold heat stimulation; however, heat hyper-responsiveness was found only in a subset of these nociceptors and was never detected in the absence of mechanical hyper-responsiveness. In addition, mean conduction velocities of A-fibers and C-fibers in vincristine-treated rats were significantly slowed. Mean heat and mechanical activation thresholds of C-fiber nociceptors, their distribution among subclasses, and the percentage of spontaneously active neurons in vincristine-treated rats were not statistically different from controls. Vincristine does not, therefore, cause generalized impairment of C-fiber nociceptor function but rather specifically interferes with mechanisms underlying responsiveness to suprathreshold stimuli. Furthermore, vincristine-induced nociceptor hyper-responsiveness may involve alterations specifically in mechanotransduction in some nociceptors and alterations in general cellular adaptation mechanisms in others.     

Ultrasound diagnosis of the shoulder

Sonography of the shoulder joint is a well-established technique in the hands of the experienced examiner, when using a standardized protocol. It has proved invaluable in assessing pathological soft tissue changes, especially after trauma. The static evaluation of anatomy and dynamic assessment of function are especially helpful in both preoperative staging and postoperative follow-up. The normal anatomy, examination techniques, including our own variations, and pathological conditions are discussed. The findings and various classifications of impingement syndrome, rotator cuff injuries, biceps tendon lesions and inflammatory changes are examined. Review of the major articles in the literature shows excellent correlation with our results, the overall sensitivity in the case of rotator cuff lesions being over 90%. A well-performed ultrasound examination in most cases obviates the need for the more invasive arthroscopy and the more cumbersome and expensive MRI examinations.     

Neuropathic arthropathy of the shoulder

We retrospectively reviewed the records of six men (seven shoulders) with neuropathic arthropathy of the shoulder who were referred to our shoulder service during a twenty-eight-year period (from 1969 through 1997). The etiology of the neuropathic condition was syringomyelia in five patients (six shoulders) and chronic alcoholism in one patient. Five patients (six shoulders) were initially misdiagnosed, and seven operative procedures that were unrelated to the etiology of the neuropathic condition were performed in four of these patients. Radiographs revealed destruction of the shoulder joint and marked resorption of the humeral head in all patients. Magnetic resonance images revealed a syrinx of the central cord in all of the patients except for the one who had chronic alcoholism.     

Clinical examination of the shoulder

If the treatment of shoulder problems is to be successful, an accurate diagnosis is required. To achieve this, it is necessary to pay attention to some peculiarities of the shoulder joint. Because of the great importance of the soft tissues in dynamic and static stabilization, bony lesions will occur late when massive dysfunction of the shoulder has maybe just occurred. Imaging techniques as CT or X-ray will not give a diagnosis in the early phases. Therefore, an exact clinical evaluation with a history and assessment of motion and special muscle testing will permit an early diagnosis.