References: Shoulder Pain; Volume 3 Issue 7

1. AUTHOR	Bamji-A-N, Erhardt-C-C, Price-T-R, Williams-P-L
INSTITUTION	Queen Mary's Hospital, Sidcup, Kent.
TITLE	The painful shoulder: can consultants agree?
SOURCE	Br-J-Rheumatol 1996 Nov, VOL: 35 (11), P: 1172-4, ISSN: 0263-7103.
ABSTRACT	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. Author.

2. AUTHOR	Della-Sala-S-W, Bianchini-G.
INSTITUTION	U.O. di Radiologia, Ospedale S. Chiara, Trento.
TITLE	(Magnetic resonance in the study of the painful shoulder. The surgical comparison in 30 consecutive cases). TT La Risonanza Magnetica nello studio della spalla dolorosa. Raffronto chirurgico in 30 casi consecutivi.
SOURCE	Radiol-Med (Torino) 1996 Apr, VOL: 91 (4), P: 348-55, ISSN: 0033-8362.
ABSTRACT	Eighty patients complaining of shoulder pain were examined with MRI from January, 1993, through December, 1994. Thirty of them were submitted to surgery, with an exhaustive inspection of shoulder structures and the treatment of abnormal findings. In this subgroup of surgical patients, MRI had depicted 16 complete tears of the rotator cuff, 4 partial tears, 8 cases of subacromial impingement, I humeral head osteochondritis and, finally, I humeral head osteochondritis with complete rotator cuff tear. Surgical findings confirmed MR diagnosis in 97% of cases. MR findings were then compared with literature data and some atypical features were observed in our series. MRI was totally reliable in complete cuff tears (16/30 patients), always showing the involvement of supraspinatus tendons and, in some cases, of other cuff tendons. In partial cuff tears (4/30 patients), besides the classic pattern of a fissure in the deep/superficial supraspinatus tendon, we observed intra- and peritendinous changes, with no tendon interruption, due to diffuse microlesions. When impingement due to subacromial space narrowing, with no cuff tear, was present (8/30 patients), MRI depicted different causes--e.g., acromioclavear arthrosis, coracoacromial ligament hypertrophy and posttraumatic changes. MRI showed tendinosis in all patients but overestimated it in one case where partial cuff tear was not confirmed surgically--the only false positive in our series. At surgery, all these cases were classified as stage I-II impingement (according to Neer's classification). Finally, MRI was very reliable in the study of bone conditions (osteochondritis), both isolated and associated with cuff tears. The diagnostic accuracy of MRI in the study of the painful shoulder was very high (97%), in agreement with literature data. This is very important because many different causes of shoulder conditions (abnormal tendons, bones and mechanics) may present with similar clinical symptoms. MRI appears as the only imaging method yielding complete and accurate pieces of information in the patients with a painful shoulder. Author.

3. AUTHOR	Volpin-G, Stahl-S, Stein-H.
INSTITUTION	Dept. of Orthopedic Surgery, Rambam Medical Center, Haifa.
TITLE	(Impingement syndrome following direct injuries of the shoulder joint).
SOURCE	Harefuah 1996 Feb 15, VOL: 130 (4), P: 244-7; 295, ISSN: 0017-7768.
ABSTRACT	Impingement is the most common cause of pain and limitation of movement in the shoulder, with painful arc syndrome its major clinical sign. It usually becomes manifest at between 70 degrees-120 degrees of abduction, but in severe cases, this may be reduced to only 50 degrees-70 degrees. We studied 22 patients who had developed shoulder impingement following direct injuries and who had been treated by anterior acromioplasty and decompression, with an average follow-up of 32 months. 5 had sustained fractures of the greater tuberosity of the humerus at the time of injury, 14 had tears of the rotator cuff of various sizes (1 in both shoulders) and 3 had developed fibrotic scars of the subacromial bursa. Excellent or good results were achieved in 86.6%. Healing time was shorter, and there was return of full range of shoulder movement in those with subacromial scars, undisplaced fractures of the greater tuberosity, or those with a small tear of the rotator cuff. Recovery took longer in those with larger tears of the rotator cuff and in those with displaced fractures of the greater tuberosity. Recovery time was proportional to the size of the rotator cuff tear. It is concluded that direct trauma to the shoulder bears a direct relationship to the development of impingement syndrome, and that at surgery a concomitant tear in the rotator cuff is seen more than 2/3. Because of the high rate of success in surgical treatment of this syndrome, operation is indicated when a few months of physical therapy and analgesics fail to provide relief. In the presence of fractures, decompression surgery should be postponed until the fracture has united. Author.

4. AUTHOR	van-der-Heijden-G-J, van-der-Windt-D-A, de-Winter-A-F.
INSTITUTION	Institute for Rehabilitation Research, Hoensbroek, Netherlands.
TITLE	Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials.
SOURCE	BMJ 1997 Jul 5, VOL: 315 (7099), P: 25-30, ISSN: 0959-8138 45 Refs.
ABSTRACT	OBJECTIVE: To assess the effectiveness of physiotherapy for patients with soft tissue shoulder disorders. DESIGN: A systematic computerised literature search of Medline and Embase, supplemented with citation tracking, for relevant trials with random allocation published before 1996. SUBJECTS: Patients treated with physiotherapy for disorders of soft tissue of the shoulder. MAIN OUTCOME MEASURES: Success rates, mobility, pain, functional status. RESULTS: Six of the 20 assessed trials satisfied at least five of eight validity criteria. Assessment of methods was often hampered by insufficient information on various validity criteria, and trials were often flawed by lack of blinding, high proportions of withdrawals from treatment, and high proportions of missing values. Trial sizes were small: only six trials included intervention groups of more than 25 patients. Ultrasound therapy, evaluated in six trials, was not shown to be effective. Four other trials favoured physiotherapy (laser therapy or manipulation), but the validity of their methods was unsatisfactory. CONCLUSIONS: There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders. Due to small trial sizes and unsatisfactory methods, evidence for the effectiveness of other methods of physiotherapy is inconclusive. For all methods of treatment, trials were too heterogeneous with respect to included patients, index and reference treatments, and follow up to merit valid statistical pooling. Future studies should show whether physiotherapy is superior to treatment with drugs, steroid injections, or a wait and see policy. Author.

5. AUTHOR	Brox-J-I, Brevik-J-I.
INSTITUTION	Department of Physical Medicine and Rehabilitation, Ullevaal University Hospital, Oslo, Norway.
TITLE	Prognostic factors in patients with rotator tendinosis (stage II impingement syndrome) of the shoulder.
SOURCE	Scand-J-Prim-Health-Care 1996 Jun, VOL: 14 (2), P: 100-5, ISSN: 0281-3432.
ABSTRACT	OBJECTIVE: To evaluate prognostic factors in patients with rotator tendinosis (stage II impingement syndrome) of the shoulder. DESIGN: Analytic retrospective study of factors associated with success or failure of treatment. SETTING: Departments of orthopaedics and physical medicine and rehabilitation. PARTICIPANTS: 125 patients aged 18-66 who had rotator tendinosis resistant to treatment in primary health care; some had active treatment (arthroscopic surgery or a supervised exercise regimen), some not (placebo laser or withdrawal from active treatment). PREDICTORS: Medication, sickness leave, physical and psychosocial measures at baseline. RESULTS: Active treatment, not on sickness leave, and not on regular medication were the best independent prognostic factors, with an estimated odds ratio for success of 4.8 (1.7 to 13.6), 4.4 (1.6 to 12.1), and 4.2 (1.5 to 11.1), respectively. Reported shoulder-related work demands did not alter the impact of sickness leave. The influence of regular medication was particularly high in those who had no disease apart from the painful shoulder (odds ratio 17.0). Patients who had taken medication for the painful shoulder regularly during the previous year, usually chose two or three agents from the following groups: analgesics, benzodiazepines, muscle relaxants, and antiinflammatory drugs. CONCLUSION: Prognosis for rotator tendinosis is improved by active treatment and a more restricted prescription of medication and sick leave. Polymedication should be avoided. Author.