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Welch M, Rankin S, How Saw Keng M, Woods D. A systematic review of the treatment of primary acromioclavicular joint osteoarthritis. Shoulder Elbow 2024; 16:129-144. [PMID: 38655415 PMCID: PMC11034467 DOI: 10.1177/17585732231157090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/16/2023] [Accepted: 01/21/2023] [Indexed: 04/26/2024]
Abstract
Background This systematic review aims to comprehensively summarise and present the available evidence for the treatment of primary acromioclavicular joint (ACJ) osteoarthritis (OA). Methods Five databases were searched for studies investigating the management of ACJ OA. Included were studies with participants with clinical/radiological signs of primary ACJ OA, an intervention and included a functional outcome measure. Results Forty-eight studies were included. Treatments consisted of physiotherapy (n = 1 study), medical only (n = 11) and operative management (n = 36). Operative studies included five comparative trials - physiotherapy versus surgery (n = 1) and open versus arthroscopic resection (n = 4). A total of 1902 shoulders were treated for ACJ OA, mean age (51 years), 58% male and mean follow-up (28.5 months). Treatment with injection showed a mean improvement of 50% in pain levels at follow-up (mean = 7.5 months). The commonest surgical procedure was arthroscopic excision of the distal clavicle and operative studies averaged 6 months of conservative management and a mean functional outcome of 87.8%. Conclusion Studies varied in indication, intervention and quality but it did not provide evidence that both non-operative and operative interventions are effective. There was no significant difference between open or arthroscopic distal clavicle excision (DCE). Participants having between 0.5 and 2 cm of clavicle excised had good outcomes and those requiring concomitant shoulder procedures had similarly good outcomes.
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Affiliation(s)
- Matthew Welch
- Trauma & Orthopaedics, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Sally Rankin
- Trauma & Orthopaedics, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Matthew How Saw Keng
- Trauma & Orthopaedics, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - David Woods
- Trauma & Orthopaedics, Great Western Hospitals NHS Foundation Trust, Swindon, UK
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2
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Sakthivelnathan V, Somerson JS, Alijanipour P. Clinical Diagnosis of Common Overlapping Shoulder and Cervical Spine Disorders: A Review of Current Evidence. JBJS Rev 2023; 11:01874474-202311000-00006. [PMID: 37976388 DOI: 10.2106/jbjs.rvw.23.00164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
» Pain in the shoulder is a common orthopaedic complaint that can be caused by shoulder or neck pathologies.» Shoulder and neck pathologies often coexist, among which one may be a predisposing factor for the other.» History, physical examination, and diagnostic injections can be used to discern the cause of shoulder pain and guide treatment.
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Affiliation(s)
| | - Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Pouya Alijanipour
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
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3
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Peebles LA, Akamefula RA, Kraeutler MJ, Mulcahey MK. Management of Acromioclavicular Joint Injuries: A Historic Account. Clin Sports Med 2023; 42:539-556. [PMID: 37716720 DOI: 10.1016/j.csm.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
There has been a rapid evolution in best practice management of acromioclavicular (AC) joint injuries. AP, Zanca, scapular Y, and dynamic axillary radiographic views provide optimal visualization of the joint and may assess for the presence of horizontal AC instability. Severity of AC joint pathology is classified according to the 6-tier Rockwood scoring system. Over 160 surgical techniques have been described for AC joint repair and reconstruction in the last decade; as a result, determining the optimal treatment algorithm has become increasingly challenging secondary to the lack of consistently excellent clinical outcomes.
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Affiliation(s)
- Liam A Peebles
- Tulane University School of Medicine, 1430 Tulane Avenue, #2070, New Orleans, LA, USA
| | - Ramesses A Akamefula
- Tulane University School of Medicine, 1430 Tulane Avenue, #2070, New Orleans, LA, USA
| | - Matthew J Kraeutler
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, 6445 Main Street, #2300, Houston, TX, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA.
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4
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Dimitriou D, Winkler E, Zindel C, Grubhofer F, Wieser K, Bouaicha S. Is routine magnetic resonance imaging necessary in patients with clinically diagnosed frozen shoulder? Utility of magnetic resonance imaging in frozen shoulder. JSES Int 2022; 6:855-858. [PMID: 36081696 PMCID: PMC9446195 DOI: 10.1016/j.jseint.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Dimitris Dimitriou
- Corresponding author: Dimitris Dimitriou, MD, Balgrist University Hospital, Orthopaedic Department, University of Zurich, Forchstrasse 340, Zurich CH-8008, Switzerland.
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5
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Joo Y, Moon JY, Han JY, Bang YS, Kang KN, Lim YS, Choi YS, Kim YU. Usefulness of the acromioclavicular joint cross-sectional area as a diagnostic image parameter of acromioclavicular osteoarthritis. World J Clin Cases 2022; 10:2087-2094. [PMID: 35321173 PMCID: PMC8895195 DOI: 10.12998/wjcc.v10.i7.2087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/06/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acromioclavicular joint (ACJ) space narrowing has been considered to be an important diagnostic image parameter of ACJ osteoarthritis (ACJO). However, the morphology of the ACJ space is irregular because of osteophyte formation, subchondral irregularity, capsular distention, sclerosis, and erosion. Therefore, we created the ACJ cross-sectional area (ACJCSA) as a new diagnostic image parameter to assess the irregular morphologic changes of the ACJ.
AIM To hypothesize that the ACJCSA is a new diagnostic image parameter for ACJO.
METHODS ACJ samples were obtained from 35 patients with ACJO and 30 healthy individuals who underwent shoulder magnetic resonance (S-MR) imaging that revealed no evidence of ACJO. Oblique coronal, T2-weighted, fat-suppressed S-MR images were acquired at the ACJ level from the two groups. We measured the ACJCSA and the ACJ space width (ACJSW) at the ACJ on the S-MR images using our imaging analysis program. The ACJCSA was measured as the cross-sectional area of the ACJ. The ACJSW was measured as the narrowest point between the acromion and the clavicle.
RESULTS The average ACJCSA was 39.88 ± 10.60 mm2 in the normal group and 18.80 ± 5.13 mm2 in the ACJO group. The mean ACJSW was 3.51 ± 0.58 mm in the normal group and 2.02 ± 0.48 mm in the ACJO group. ACJO individuals had significantly lower ACJCSA and ACJSW than the healthy individuals. Receiver operating characteristic curve analyses demonstrated that the most suitable ACJCSA cutoff score was 26.14 mm2, with 91.4% sensitivity and 90.0% specificity.
CONCLUSION The optimal ACJSW cutoff score was 2.37 mm, with 88.6% sensitivity and 96.7% specificity. Even though both the ACJCSA and ACJSW were significantly associated with ACJO, the ACJCSA was a more sensitive diagnostic image parameter.
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Affiliation(s)
- Young Joo
- Department of Anesthesiology and Pain Medicine, CHA Ilsan Medical Center, School of Medicine, CHA University, Ilsan, Gyeonggi-do 10414, South Korea
| | - Jee Youn Moon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul 03080, South Korea
| | - Jung Youn Han
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, School of Medicine, Seongnam, Gyeonggi-do 13496, South Korea
| | - Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, School of Medicine, Seongnam, Gyeonggi-do 13496, South Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul 05715, South Korea
| | - Young Su Lim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary’s Hospital, Incheon 22711, South Korea
| | - Young-Soon Choi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary’s Hospital, Incheon 22711, South Korea
| | - Young-Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary’s Hospital, Incheon 22711, South Korea
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Garry CB, Adsit MH, Land V, Sanderson G, Sheppard SG, Balazs GC. Bony Edema and Clinical Examination Findings Predict the Need for Distal Clavicle Excision at the Time of Shoulder Arthroscopy. HSS J 2022; 18:63-69. [PMID: 35087334 PMCID: PMC8753536 DOI: 10.1177/15563316211008457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 02/03/2023]
Abstract
Background: Deciding to perform a distal clavicle excision for acromioclavicular joint arthritis, especially in conjunction with other arthroscopic shoulder procedures, is challenging for surgeons. Studies have reported mixed results on the value of magnetic resonance imaging (MRI) in decision making. Purpose: We sought to correlate MRI findings with clinical symptoms and the surgeon's decision to perform a distal clavicle excision. Methods: We compared MRI, clinical examination, and MRI findings of 200 patients who underwent distal clavicle excision for symptomatic acromioclavicular joint arthritis with 200 patients who underwent arthroscopic shoulder procedures for other reasons. Univariate statistics were used to determine correlations between physical examination findings, MRI findings, and the decision to perform distal clavicle excision. A binary logistic regression model was used to determine independent predictors of need for distal clavicle excision. Results: There was no difference in mean age, sex, and race between groups. Advanced acromioclavicular joint osteoarthritis was strongly correlated with positive physical examination findings. Bony edema correlated strongly with tenderness at the acromioclavicular joint but not pain with cross-body adduction testing. There was no association between higher MRI grade of osteoarthritis and the need for distal clavicle excision. Regression analysis identified both physical examination findings and bony edema on MRI as independent predictors of the need for distal clavicle excision. Conclusion: In the setting of positive clinical examination findings and bony edema of the distal clavicle, surgeons should feel reassured that distal clavicle excision is likely indicated.
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Affiliation(s)
- Conor B. Garry
- Bone & Joint Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | | | - Vaughn Land
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Galen Sanderson
- Bone & Joint Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Sean G. Sheppard
- Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | - George C. Balazs
- Bone & Joint Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, VA, USA,George C. Balazs, MD, Bone & Joint Sports Medicine Institute, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA 23708, USA.
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7
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Yiannakopoulos CK, Vlastos I, Theotokatos G, Galanis N. Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2021; 29:2090-2095. [PMID: 32556365 DOI: 10.1007/s00167-020-06098-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/10/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate the significance of untreated primary acromioclavicular joint (ACJ) osteoarthritis, encountered during arthroscopic rotator cuff repair (RCR), as a cause of persistent symptomatology and need for revision surgery. METHODS In a cohort of 811 consecutive patients older than 55 years who underwent RCR, the effect of primary ACJ osteoarthritis presence was prospectively examined. A total of 497 patients with mild/moderate and severe ACJ osteoarthritis based on preoperative MRI evaluation were allocated to Group A (n = 185, symptomatic ACJ) and Group B (n = 312, asymptomatic ACJ). Distal clavicle excision was not performed regardless of the presence of pain. The minimum follow-up was 28 months (28-46). The visual analogue scale (VAS) pain scores were assessed for ACJ pain on palpation, the cross body adduction test, the Constant-Murley, and the American Shoulder and Elbow Surgeons (ASES). RESULTS The overall loss to follow-up rate was 3.82% (19 patients: 11 in Group A and eight in Group B). The mean ASES score at the latest follow-up was 91.16 ± 9.3 and 92.37 ± 10.44 in Groups A and B, respectively, and the mean Constant-Murley score was 96.36 ± 5.7 and 95.76 ± 4.6 in Groups A and B, respectively. There was no statistical significance between regarding both scores. Localised ACJ pain on palpation and pain on cross body adduction were diminished in both the symptomatic and asymptomatic group. There were five cases (1%: two in Group A and three in Group B) with persistent ACJ pain who had failed the conservative treatment, and ACJ excision was necessary to alleviate the symptoms. All revision operations were uncomplicated with symptom resolution. CONCLUSION Untreated ACJ osteoarthritis, symptomatic or not, encountered during arthroscopic RCR is associated with a low percentage of failure. Routine distal clavicle excision is not absolutely necessary, even in patients with symptomatic ACJ osteoarthritis. LEVEL OF EVIDENCE II, Prospective cohort study.
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Affiliation(s)
- Christos K Yiannakopoulos
- Metropolitan General Hospital, Athens, Greece. .,School of Physical Education and Sport Science, National and Kapodistrian University of Athens, Athens, Greece.
| | - Iakovos Vlastos
- Metropolitan General Hospital, Athens, Greece.,School of Physical Education and Sport Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Theotokatos
- School of Physical Education and Sport Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikiforos Galanis
- Orthopaedic Department, Medical School, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
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8
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Abstract
The aim of this article is to review the use of magnetic resonance imaging (MRI) for the evaluation of shoulder pain, which is a common clinical complaint of the musculoskeletal system. MRI is an essential auxiliary tool to evaluate these patients because of its high resolution and high sensitivity in depicting the soft tissues. This article will review the imaging technique, normal imaging anatomy, and most common imaging findings of disorders of tendons, labrum, and ligaments of the shoulder. It will also discuss common systemic diseases that manifest in the shoulder as well as disorders of the acromioclavicular joint and bursae. New advances and research in MRI have provided additional potential uses for evaluating shoulder derangements.
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9
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Flores DV, Goes PK, Gómez CM, Umpire DF, Pathria MN. Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment. Radiographics 2020; 40:1355-1382. [PMID: 32762593 DOI: 10.1148/rg.2020200039] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The acromioclavicular joint is an important component of the shoulder girdle; it links the axial skeleton with the upper limb. This joint, a planar diarthrodial articulation between the clavicle and the acromion, contains a meniscus-like fibrous disk that is prone to degeneration. The acromioclavicular capsule and ligaments stabilize the joint in the horizontal direction, while the coracoclavicular ligament complex provides vertical stability. Dynamic stability is afforded by the deltoid and trapezius muscles during clavicular and scapular motion. The acromioclavicular joint is susceptible to a broad spectrum of pathologic entities, traumatic and degenerative disorders being the most common. Acromioclavicular joint injury typically affects young adult males and can be categorized by using the Rockwood classification system as one of six types on the basis of the direction and degree of osseous displacement seen on conventional radiographs. MRI enables the radiologist to more accurately assess the regional soft-tissue structures in the setting of high-grade acromioclavicular separation, helping to guide the surgeon's selection of the appropriate management. Involvement of the acromioclavicular joint and its stabilizing ligaments is also important for understanding and classifying distal clavicle fractures. Other pathologic processes encountered at this joint include degenerative disorders; overuse syndromes; and, less commonly, inflammatory arthritides, infection, metabolic disorders, and developmental malformations. Treatment options for acromioclavicular dysfunction include conservative measures, resection arthroplasty for recalcitrant symptoms, and surgical reconstruction techniques for stabilization after major trauma.
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Affiliation(s)
- Dyan V Flores
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Paola Kuenzer Goes
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Catalina Mejía Gómez
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Darwin Fernández Umpire
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Mini N Pathria
- From the Institute of Radiology, St. Luke's Medical Center Global City, Department of Radiology, Philippine Orthopedic Center, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); Department of Musculoskeletal Radiology, Ayudas Diagnósticas Sura, Medellín, Colombia (C.M.G.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
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10
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Precerutti M, Formica M, Bonardi M, Peroni C, Calciati F. Acromioclavicular osteoarthritis and shoulder pain: a review of the role of ultrasonography. J Ultrasound 2020; 23:317-325. [PMID: 32671655 DOI: 10.1007/s40477-020-00498-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/27/2022] Open
Abstract
Acromioclavicular joint osteoarthritis is often a cause of shoulder pain. On the other hand, imaging frequently leads to such a diagnosis, especially in elderly patients, and some authors believe it to have a poor correlation with the clinical picture. It is, however, widely accepted that such a condition can be the cause of rotator cuff impingement. In the case of shoulder pain, it is important to distinguish between symptomatic acromioclavicular osteoarthritis and other causes, especially rotator cuff pathology, which is more common. Sometimes, the clinical picture does not allow for differential diagnosis; in these cases, the injection of a local anesthetic into the acromioclavicular joint or into the subacromial bursa can be of great help. Ultrasonography can easily detect acromioclavicular osteoarthritis and rotator cuff pathology, and it is highly effective in guiding the articular or bursal injection of a local anesthetic to assess the origin of the pain. In addition, in conservative therapy, ultrasonography can guide the articular or bursal injection of corticosteroids and hyaluronic acid.
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Affiliation(s)
- Matteo Precerutti
- Servizio Di Diagnostica Per Immagini, ICS Maugeri Spa SB, IRCCS Montescano, Montescano, Italy
| | - Manuela Formica
- Servizio Di Diagnostica Per Immagini, ICS Maugeri Spa SB, IRCCS Montescano, Montescano, Italy
| | - Mara Bonardi
- UO Radiodiagnostica, IRCCS Policlinico S. Matteo Pavia, Pavia, Italy
| | - Caterina Peroni
- Servizio Di Diagnostica Per Immagini, ICS Maugeri Spa SB, IRCCS Pavia, Pavia, Italy
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11
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Abstract
Acromioclavicular joint (ACJ) pathology is a common source of shoulder girdle pain, frequently coexisting with and sharing overlapping clinical features of rotator cuff and glenohumeral articular lesions. ACJ trauma and osteoarthritis dominate clinical presentation; however, an array of pathologies can affect the joint. MR imaging of the ACJ is a powerful secondary diagnostic tool in early diagnosis of ACJ pathology and in accurate assessment of ACJ injuries, helping to resolve clinically challenging cases and allowing for individualized treatment planning. Knowledge of ACJ anatomy, biomechanics, and pathology is fundamental to interpreting and providing a clinically relevant ACJ MR imaging report.
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Affiliation(s)
- Terence Patrick Farrell
- Department of Radiology, Thomas Jefferson University Hospitals, 132 South 10th Street, 10 Main, Philadelphia, PA 19107, USA.
| | - Adam Zoga
- Department of Radiology, Thomas Jefferson University Hospitals, Sidney Kimmel Medical Center, 132 South 10th Street, Suite 1096, Philadelphia, PA 19107, USA
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12
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Matcuk GR, Moin P, Cen S. Shoulder measurements on MRI: Statistical analysis of patients without and with rotator cuff tears and predictive modeling. Clin Anat 2019; 33:173-186. [PMID: 31177567 DOI: 10.1002/ca.23422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 11/10/2022]
Abstract
This study aims to determine significant differences between various measurements of shoulder structures and relationships in patients with and without rotator cuff tears and identify a subset of these measurements that may merit further investigation. Shoulder MRIs of 120 patients with rotator cuff tears (RCT group) and 80 patients with normal examinations (No RCT group) were retrospectively identified. Numerous measurements of shoulder anatomy and relationships and pathology characterization were performed for each study. The mean and ranges of measurements for each group were identified, and P-values were calculated to assess differences between the two groups. Classification and Regression Tree (CART) identified prediction models for separating the two groups based on these shoulder MRI measurements. Statistically significant differences were observed for 9 of 18 of the shoulder measurements between the two groups (P < 0.05). Using long head of biceps tendon tear, tendinosis, and subacromial-subdeltoid bursal fluid, the prediction model from CART demonstrated 99.5% accuracy in separating the two groups. Subacromial distance, subacromial spur size, and acromioclavicular osteophyte could also separate the two groups with 97.5% accuracy. Other measures less commonly associated with impingement and rotator cuff tears could also be used to separate the two groups with up to 81.5% accuracy. This study introduces new measures and clarifies ranges for existing measurements on shoulder MRI. Abnormalities of some of these measurements may be associated with subacromial impingement, and combinations of these parameters may be useful for separating patients with or without rotator cuff tears. Clin. Anat. 33:173-186, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- George R Matcuk
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Paymann Moin
- Department of Radiology, Kaiser Permanente, Panorama City Medical Center, Panorama City, California
| | - Steven Cen
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California
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13
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Veen EJD, Donders CM, Westerbeek RE, Derks RPH, Landman EBM, Koorevaar CT. Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis. J Shoulder Elbow Surg 2018; 27:e252-e258. [PMID: 29501222 DOI: 10.1016/j.jse.2018.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/26/2017] [Accepted: 01/07/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND A magnetic resonance imaging (MRI) scan of the shoulder can have added value in diagnosing symptomatic osteoarthritis of the acromioclavicular (AC) joint. Specific MRI signs have been recognized but not analyzed extensively before. This study aims to identify predictive MRI signs in patients with symptomatic AC osteoarthritis. METHODS The MRI scans of 70 patients with symptomatic AC osteoarthritis were compared with those of 70 patients with subacromial pain syndrome and no clinical signs of symptomatic AC osteoarthritis. Seven variables were evaluated on the MRI scans of the AC joint: joint space narrowing, inferior osteophytes, joint effusion, osteolysis, bone marrow edema, impression on the supraspinatus, and inferior joint distension. Logistic regression analysis of these variables was performed. RESULTS The presence of inferior osteophytes, bone marrow edema, impression on the supraspinatus, and inferior joint distension was individually associated with symptomatic AC osteoarthritis. Bone marrow edema was observed only in patients with symptomatic AC osteoarthritis. Multivariate analysis showed a significant association between inferior joint distension, as well as impression on the supraspinatus muscle, and symptomatic AC osteoarthritis. The area under the receiver operating characteristic curve in the multivariate logistic model was 0.839 (95% confidence interval, 0.771 to 0.907). Interobserver and intraobserver variability showed good to excellent κ values (range, 0.68 to 0.88). CONCLUSION We identified predictive MRI signs in patients with symptomatic AC osteoarthritis. These findings, including bone marrow edema, inferior joint distension, and impression on the supraspinatus muscle, showed good discriminative ability. They are practical and easy to use and can assist the physician in diagnosing symptomatic AC osteoarthritis.
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Affiliation(s)
- Egbert J D Veen
- Department of Orthopaedic Surgery and Traumatology, Deventer Hospital, Deventer, The Netherlands; Department of Orthopaedic Surgery, University Medical Center, University of Groningen, Groningen, The Netherlands.
| | - Cornelia M Donders
- Department of Orthopaedic Surgery and Traumatology, Deventer Hospital, Deventer, The Netherlands
| | | | - Rosalie P H Derks
- Department of Radiology, Deventer Hospital, Deventer, The Netherlands
| | - Ellie B M Landman
- Department of Orthopaedic Surgery and Traumatology, Deventer Hospital, Deventer, The Netherlands
| | - Cornelis T Koorevaar
- Department of Orthopaedic Surgery and Traumatology, Deventer Hospital, Deventer, The Netherlands
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14
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Abstract
Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.
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Cadogan A, McNair PJ, Laslett M, Hing WA. Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain. PLoS One 2016; 11:e0167738. [PMID: 27936246 PMCID: PMC5147961 DOI: 10.1371/journal.pone.0167738] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/19/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP. METHODS AND FINDINGS In a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR. CONCLUSION Combinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP.
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Affiliation(s)
- Angela Cadogan
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
- * E-mail:
| | - Peter J. McNair
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
| | - Mark Laslett
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
| | - Wayne A. Hing
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
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Heterogeneous MR arthrography findings in patients with subacromial impingement syndrome – Diagnostic subgroups? J Electromyogr Kinesiol 2016; 29:64-73. [DOI: 10.1016/j.jelekin.2015.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 03/28/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022] Open
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Edelson G, Saffuri H, Obid E, Lipovsky E, Ben-David D. Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up. J Shoulder Elbow Surg 2014; 23:e243-50. [PMID: 24725899 DOI: 10.1016/j.jse.2014.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/08/2014] [Accepted: 01/12/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections. METHOD Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results. RESULTS Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders. CONCLUSION This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.
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Affiliation(s)
- Gordon Edelson
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel.
| | - Husam Saffuri
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel
| | - Elias Obid
- Orthopedic Department, Poriya Government Hospital, Tiberias, Israel
| | | | - Doron Ben-David
- Radiology Department, Poriya Government Hospital, Tiberias, Israel
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Clinical identifiers for early-stage primary/idiopathic adhesive capsulitis: are we seeing the real picture? Phys Ther 2014; 94:968-76. [PMID: 24652474 DOI: 10.2522/ptj.20130398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Adhesive capsulitis is often difficult to diagnose in its early stage and to differentiate from other common shoulder disorders. OBJECTIVE The aim of this study was to validate any or all of the 8 clinical identifiers of early-stage primary/idiopathic adhesive capsulitis established in an earlier Delphi study. DESIGN This was a cross-sectional study. METHODS Sixty-four patients diagnosed with early-stage adhesive capsulitis by a physical therapist or medical practitioner were included in the study. Eight active and 8 passive shoulder movements and visual analog scale pain scores for each movement were recorded prior to and immediately following an intra-articular injection of corticosteroid and local anesthetic. Using the local anesthetic as the reference standard, pain relief of ≥70% for passive external rotation was deemed a positive anesthetic response (PAR). RESULTS Sixteen participants (25%) demonstrated a PAR. Univariate logistic regression identified that of the proposed identifiers, global loss of passive range of movement (odds ratio [OR]=0.26, P=.03), pain at the end of range of all measured active movements (OR=0.06, P=.02), and global loss of passive glenohumeral movements (OR=0.23, P=.02) were associated with a PAR. Following stepwise removal of the variables, pain at the end of range of all measured active movements remained the only identifier but was associated with reduced odds of a PAR. LIMITATIONS The lack of a recognized reference standard for diagnosing early-stage adhesive capsulitis remains problematic in all related research. CONCLUSIONS None of the clinical identifiers for early-stage adhesive capsulitis previously proposed by expert consensus have been validated in this study. Clinicians should be aware that commonly used clinical identifiers may not be applicable to this stage.
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[Magnetic resonance imaging of the shoulder: impingement and instability related abnormalities--update 2013]. Radiologe 2014; 53:917-34. [PMID: 24068294 DOI: 10.1007/s00117-013-2565-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Magnetic resonance imaging (MRI) plays an important role in the diagnosis and differentiation of numerous shoulder abnormalities and chronic shoulder pain. Important indications for MRI are assessment of the rotator cuff and the labrocapsular complex. The assessment of the rotator cuff muscles is crucial. The value of MR arthrography is discussed. The potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities, shoulder instability-related lesions and the assessment of pathological conditions of the long biceps tendon. The following article describes the most common pathological findings of the shoulder joint and gives a description of the relevant findings for the orthopedic shoulder surgeon. The current article represents an update of an article previously published in 2006 with the same title (Zanetti and Saupe, Radiologe 46:79-89, 2006).
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Mall NA, Foley E, Chalmers PN, Cole BJ, Romeo AA, Bach BR. Degenerative joint disease of the acromioclavicular joint: a review. Am J Sports Med 2013; 41:2684-92. [PMID: 23649008 DOI: 10.1177/0363546513485359] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities. This most commonly occurs in middle-aged individuals because of degeneration to the fibrocartilaginous disk that cushions the articulations. Diagnosis relies on history, physical examination, imaging, and diagnostic local anesthetic injection. Diagnosis can be challenging given the lack of specificity with positive physical examination findings and the variable nature of AC joint pain. Of note, symptomatic AC osteoarthritis must be differentiated from instability and subtle instability, which may have similar symptoms. Although plain radiographs can reveal degeneration, diagnosis cannot be based on this alone because similar radiographic findings can be seen in asymptomatic individuals. Nonoperative therapy can provide symptomatic relief, whereas patients with persistent symptoms can be considered for resection arthroplasty by open or arthroscopic technique. Both techniques have proven to provide predictable pain relief; however, each has its own unique set of potential complications that may be minimized with an improved understanding of the anatomical and biomechanical characteristics of the joint along with meticulous surgical technique.
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Affiliation(s)
- Nathan A Mall
- Brian J. Cole, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison, Suite 300, Chicago, IL 60612.
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Saccomanni B. A new test for acromio-clavicolar pathology. J Clin Orthop Trauma 2013; 4:75-9. [PMID: 26403628 PMCID: PMC3880508 DOI: 10.1016/j.jcot.2013.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 03/01/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND A prospective study was established to assess the sensitivity and specificity of the new Saccomanni (SAC) test for isolated AC pathology, and compare with 4 commonly used clinical tests. MATERIALS AND METHODS The Saccomanni (Sac) test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the Saccomanni test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The Saccomanni test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of true positive tests. STUDY DESIGN Case series. RESULTS The SAC test showed a sensitivity of 98% and specificity is 91.7%. All 4 other tests were less sensitive. CONCLUSION The SAC test is a highly sensitive test in patients presenting with isolated AC related symptoms. This study is an innovation for clinical tests in the world. The primary aim of this study was to assess the diagnostic sensitivity of my newly described SAC test. From the present study, it can be concluded that the easy-to use SAC is a highly sensitive test to evaluate AC joint pathology, when compared to other standard tests. CLINICAL RELEVANCE Level III, Diagnostic Study of Nonconsecutive Patients.
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Affiliation(s)
- Bernardino Saccomanni
- Medical Doctor, Orthopaedic and Trauma Surgery, Ambulatorio di Ortopedia, via della Conciliazione, 65, 74014 Laterza (TA), Italy
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Choo HJ, Lee SJ, Kim JH, Cha SS, Park YM, Park JS, Lee JW, Oh M. Can symptomatic acromioclavicular joints be differentiated from asymptomatic acromioclavicular joints on 3-T MR imaging? Eur J Radiol 2013; 82:e184-91. [DOI: 10.1016/j.ejrad.2012.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/26/2012] [Accepted: 10/29/2012] [Indexed: 11/25/2022]
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Borbas P, Kraus T, Clement H, Grechenig S, Weinberg AM, Heidari N. The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. J Shoulder Elbow Surg 2012; 21:1694-7. [PMID: 22475721 DOI: 10.1016/j.jse.2011.11.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/21/2011] [Accepted: 11/28/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections. MATERIALS AND METHODS A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound. RESULTS The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement (P = .025). DISCUSSION The use of ultrasound significantly improves the accuracy of ACJ injection.
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Affiliation(s)
- Paul Borbas
- Department of Orthopedics, University of Zurich, Balgrist, Zurich, Switzerland.
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van Riet RP, Goehre T, Bell SN. The long term effect of an intra-articular injection of corticosteroids in the acromioclavicular joint. J Shoulder Elbow Surg 2012; 21:376-9. [PMID: 21700479 DOI: 10.1016/j.jse.2011.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 04/27/2011] [Accepted: 05/07/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND A prospective study was established to assess the effect of an intra-articular injection of corticosteroid and local anaesthetic into the acromioclavicular (AC) joint. METHODS Fifty-eight patients with isolated AC joint symptoms were included. Clinical tests were repeated immediately following the injection, as well as at 1-month follow-up. If symptoms failed to improve at this time, arthroscopic surgery was offered. All other patients were dismissed from standard care and contacted for this study. Both American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores were obtained at final follow-up. RESULTS Sixteen patients had improved sufficiently. Between the 1 month and average final follow-up of 42 months, 1 patient had arthroscopic resection of the distal clavicle. Four of the 15 patients reported occasional mild pain. Average visual analogue scale (VAS) score for pain was 0.5 (0-3). Average ASES score was 94.1 (70-100) and average UCLA score was 33.9 (28-35). DISCUSSION Pain relief achieved with an injection into the AC joint has both a diagnostic and therapeutic value. The decrease of pain with clinical testing affirms the correct position of the injection. Only a minority of patients has sufficient pain relief from the injection at 1 month follow-up; however, this is sustained at the longer-term follow-up in the patients that have a positive reaction. CONCLUSION The diagnostic value of the injection of a local anaesthetic in the AC joint is immediate. Only 28% have a clear positive result at 1 month; but, this result is sustained at long-term follow-up. There were no complications.
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Affiliation(s)
- Roger P van Riet
- Department of Orthopaedics and Traumatology, Monica Hospital, Deurne, Antwerp, Belgium.
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Cadogan A, Laslett M, Hing WA, McNair PJ, Coates MH. A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks. BMC Musculoskelet Disord 2011; 12:119. [PMID: 21619663 PMCID: PMC3127806 DOI: 10.1186/1471-2474-12-119] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 05/28/2011] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND 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). METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Angela Cadogan
- Health & Rehabilitation Research Institute, AUT University, Northcote, Auckland, New Zealand.
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van Riet RP, Bell SN. Clinical evaluation of acromioclavicular joint pathology: sensitivity of a new test. J Shoulder Elbow Surg 2011; 20:73-6. [PMID: 20850994 DOI: 10.1016/j.jse.2010.05.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Revised: 05/20/2010] [Accepted: 05/25/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND A prospective study was established to assess the sensitivity of the newly described Bell-van Riet (BvR) test for isolated AC pathology, and compare with 4 commonly used clinical tests. MATERIALS AND METHODS The BvR test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the BvR test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The BvR test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of truly positive tests. RESULTS The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive. CONCLUSION The BvR test is a highly sensitive test in patients presenting with isolated AC related symptoms, and demonstrates AC joint pathology better than other accepted tests.
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Affiliation(s)
- Roger P van Riet
- Department of Orthopedic Surgery and Traumatology, Monica Hospital, Deurne (Antwerp), Belgium.
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Peck E, Lai JK, Pawlina W, Smith J. Accuracy of Ultrasound-Guided Versus Palpation-Guided Acromioclavicular Joint Injections: A Cadaveric Study. PM R 2010; 2:817-21. [DOI: 10.1016/j.pmrj.2010.06.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 06/08/2010] [Accepted: 06/14/2010] [Indexed: 11/29/2022]
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Docimo S, Kornitsky D, Futterman B, Elkowitz DE. Surgical treatment for acromioclavicular joint osteoarthritis: patient selection, surgical options, complications, and outcome. Curr Rev Musculoskelet Med 2010; 1:154-60. [PMID: 19468890 PMCID: PMC2684214 DOI: 10.1007/s12178-008-9024-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Osteoarthritis is one of the most common causes of pain originating from the acromioclavicular (AC) joint. An awareness of appropriate diagnostic techniques is necessary in order to localize clinical symptoms to the AC joint. Initial treatments for AC joint osteoarthritis, which include non-steroidal anti-inflammatory drugs (NSAIDS) and corticosteroids, are recommended prior to surgical interventions. Distal clavicle excision, the main surgical treatment option, can be performed by various surgical approaches, such as open procedures, direct arthroscopic, and indirect arthroscopic techniques. When choosing the best surgical option, factors such as avoidance of AC ligament damage, clavicular instability, and post-operative pain must be considered. This article examines patient selection, complications, and outcomes of surgical treatment options for AC joint osteoarthritis.
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Affiliation(s)
- Salvatore Docimo
- Anatomy and Pathology Academic Medicine Fellow, New York College of Osteopathic Medline, Old Westbury, NY USA
- Department of Pathology, New York College of Osteopathic Medicine, Old Westbury, NY USA
| | | | - Bennett Futterman
- Department of Anatomy, New York College of Osteopathic Medicine, Old Westbury, NY USA
| | - David E. Elkowitz
- Department of Pathology, New York College of Osteopathic Medicine, Old Westbury, NY USA
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Peterson C, Hodler J. Evidence-based radiology (part 2): Is there sufficient research to support the use of therapeutic injections into the peripheral joints? Skeletal Radiol 2010; 39:11-8. [PMID: 19727709 DOI: 10.1007/s00256-009-0784-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 08/14/2009] [Accepted: 08/17/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This review article addresses the best evidence currently available for the effectiveness of injection therapy for musculoskeletal conditions involving the peripheral joints. The research is presented by anatomical region and areas of controversy and the need for additional research are identified. DISCUSSION Randomized controlled trials, meta-analyses and systematic reviews are lacking that address the effectiveness of therapeutic injections to the sternoclavicular, acromioclavicular, ankle and foot joints. No research studies of any kind have been reported for therapeutic injections of the sternoclavicular joint. With the exception of the knee, possibly the hip and patients with inflammatory arthropathies, research does not unequivocally support the use of therapeutic joint injections for most of the peripheral joints, including the shoulder. Additionally, controversy exists in some areas as to whether or not corticosteroids provide better outcomes compared to local anesthetic injections alone. CONCLUSION When viscosupplementation injections are compared to corticosteroids in patients with osteoarthritis of the knee, the evidence supports the use of viscosupplementation for more prolonged improvement in outcomes, with corticosteroids being good for short-term relief.
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Affiliation(s)
- Cynthia Peterson
- Radiology, Orthopaedic University Hospital of Balgrist, Forchstrasse 340, 8008, Zürich, Switzerland.
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Ironman triathletes: MRI assessment of the shoulder. Skeletal Radiol 2008; 37:737-41. [PMID: 18542952 DOI: 10.1007/s00256-008-0516-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 04/24/2008] [Accepted: 04/25/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this paper was to demonstrate the prevalence of shoulder magnetic resonance imaging (MRI) abnormalities, including abnormal bone marrow signal at the acromioclavicular (AC) joint in symptomatic and asymptomatic Ironman Triathletes. MATERIALS AND METHODS The shoulders of 23 Ironman Triathletes, seven asymptomatic (group I) and 16 symptomatic (group II), were studied by MRI. A separate, non-triathlete group was evaluated specifically for AC joint marrow signal abnormalities to compare with the Ironman Triathletes. RESULTS Partial thickness tears of the rotator cuff, rotator cuff tendinopathy, and AC joint arthrosis were common findings in both groups of triathletes. Tendinopathy was the only finding that was more prevalent in the symptomatic group, but this was not a statistically significant difference (p = 0.35). There were no tears of the glenoid labrum seen in group I or II subjects. Of note is that 71% (5/7) of group I subjects and 62% (10/16) of group II subjects had increased signal changes in the marrow of the AC joint (p = 0.68). The comparison group showed a lower prevalence (35%, p = 0.06) of this finding. CONCLUSIONS No statistically significant difference was found among the findings for group 1, group 2, or the comparison group, although the difference between the comparison group and Ironman Triathletes approached statistical significance when evaluating for AC joint abnormal signal. Shoulder MRI of Ironman Triathletes should be interpreted with an appreciation of the commonly seen findings in asymptomatic subjects.
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The long-term effectiveness of steroid injections in primary acromioclavicular joint arthritis: a five-year prospective study. J Shoulder Elbow Surg 2008; 17:535-8. [PMID: 18359647 DOI: 10.1016/j.jse.2007.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 04/18/2007] [Accepted: 12/09/2007] [Indexed: 02/01/2023]
Abstract
We evaluated the long-term benefits of steroid injection in 25 shoulders in 20 consecutive patients (average age, 55 years) with primary acromioclavicular arthritis. Minimum follow-up was 5 years. The mean preinjection Constant score (61 points) improved at 6 months to 81 points, (mean difference, 19.36; P < .01). Improvement at 12 months (mean, 86 points) was also significant vs the 6-month score (P = .001). The mean score at 5 years (81 points) was a significant deterioration vs the 12-month score (P = .01) but still a significant improvement vs the preinjection scores (P < .0005). Younger patients had greater improvement in the objective score (range of movement and power; r = -0.47; P = .01), as did women (r = 0.405; P = .05). Local steroid injection is an effective treatment for primary isolated acromioclavicular arthritis. Improvement continues for at least 12 months. The benefit is felt up to 5 years. Pain relief tends to diminish long-term.
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Mellado JM, Calmet J. [The postsurgical rotator cuff: surgical techniques, clinical outcome, and MRI evaluation]. RADIOLOGIA 2008; 50:11-27. [PMID: 18275784 DOI: 10.1016/s0033-8338(08)71925-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Surgical treatment of rotator cuff tears significantly reduces painful symptoms and improves functional capacity in many patients. However, despite recent advances, up to 25% of patients remain symptomatic after surgery. This has led to research into the reasons for these poor outcomes, including how to identify them with imaging methods and how to avoid them through new therapeutic approaches. Based on our clinical experience, we review the available treatment alternatives for rotator cuff tears, analyzing the main areas of controversy and the possible causes of unsatisfactory outcome after surgery. Furthermore, we review the expectations, difficulties, and requirements of diagnostic imaging in the follow-up of surgically treated rotator cuffs, with special emphasis on the MRI findings and their clinical impact.
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Affiliation(s)
- J M Mellado
- Sección de Radiología. Hospital Reina Sofía. Tudela. Navarra. España.
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Modic changes, possible causes and relation to low back pain. Med Hypotheses 2007; 70:361-8. [PMID: 17624684 DOI: 10.1016/j.mehy.2007.05.014] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Accepted: 05/04/2007] [Indexed: 12/20/2022]
Abstract
UNLABELLED In patients with low back pain (LBP) it is only possible to diagnose a small proportion, (approximately 20%), on a patho-anatomical basis. Therefore, the identification of relevant LBP subgroups, preferably on a patho-anatomical basis, is strongly needed. Signal changes on MRI in the vertebral body marrow adjacent to the end plates also known as Modic changes (MC) are common in patients with LBP (18-58%) and is strongly associated with LBP. In asymptomatic persons the prevalence is 12-13%. MC are divided into three different types. Type 1 consists of fibro vascular tissue, type 2 is yellow fat, and type 3 is sclerotic bone. The temporal evolution of MC is uncertain, but the time span is years. Subchondral bone marrow signal changes associated with pain can be observed in different specific infectious, degenerative and immunological diseases such as osseous infections, osteoarthritis, ankylosing spondylitis and spondylarthritis. In the vertebrae, MC is seen in relation to vertebral fractures, spondylodiscitis, disc herniation, severe disc degeneration, injections with chymopapain, and acute Schmorl's impressions. The aim of this paper is to propose two possible pathogenetic mechanisms causing Modic changes. These are: A mechanical cause: Degeneration of the disc causes loss of soft nuclear material, reduced disc height and hydrostatic pressure, which increases the shear forces on the endplates and micro fractures may occur. The observed MC could represent oedema secondary to the fracture and subsequent inflammation, or a result of an inflammatory process from a toxic stimulus from the nucleus pulposus that seeps through the fractures. A bacterial cause: Following a tear in the outer fibres of the annulus e.g. disc herniation, new capilarisation and inflammation develop around the extruded nuclear material. Through this tissue it is possible for anaerobic bacteria to enter the anaerobic disc and in this environment cause a slowly developing low virulent infection. The MC could be the visible signs of the inflammation and oedema surrounding this infection, because the anaerobic bacteria cannot thrive in the highly aerobic environment of the MC type 1. PERSPECTIVES One or both of the described mechanisms can - if proven - be of significant importance for this specific subgroup of patients with LBP. Hence, it would be possible to give a more precise and relevant diagnosis to 20-50% of patients with LBP and enable in the development of efficient treatments which might be antibiotics, special rehabilitation programmes, rest, stabilizing exercise, or surgical fixation, depending on the underlying cause for the MC.
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Zanetti M, Saupe N. [MR imaging of the shoulder. Impingement and instability-related abnormalities]. Radiologe 2005; 46:79-89; quiz 90-1. [PMID: 16328210 DOI: 10.1007/s00117-005-1306-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.
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Affiliation(s)
- M Zanetti
- Radiologie, Universitätsklinik Balgrist, Zürich, Schweiz.
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Fialka C, Krestan CR, Stampfl P, Trieb K, Aharinejad S, Vécsei V. Visualization of Intraarticular Structures of the Acromioclavicular Joint in an Ex Vivo Model Using a Dedicated MRI Protocol. AJR Am J Roentgenol 2005; 185:1126-31. [PMID: 16247120 DOI: 10.2214/ajr.04.1433] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to develop an MRI protocol that could visualize the intraarticular structures of the acromioclavicular (AC) joint. MATERIALS AND METHODS Using six fresh specimens from cadaveric shoulders, several MRI sequences were performed on 1.0-T scanners with a superficial coil (the temporomandibular joint coil). After the radiologic examination, the specimens were prepared for histology and 300-microm-thick, toluidine blue-stained sections were prepared that corresponded to the MR images. In each series of sections, immunohistochemistry using a type II collagen antibody was performed to further characterize the intraarticular structures. RESULTS The coronal 3D T1-weighted fast-field echo water-selective sequence allowed the identification of the intraarticular disk in all cases. Determination on MRI of other intraarticular structures--adipose tissue, synovial fluid, and the borders between neighboring tissues of different types--that corresponded to the histologic sections was possible. The use of a second plane in the 1.0-T sequences did not reveal additional information. CONCLUSION The described MRI protocol allows the visualization of the intraarticular fibrocartilaginous disk and the border between articular cartilage and the disk. Future clinical studies will indicate the diagnostic value of this protocol. We assume that this MRI protocol could help us to better understand AC joint disorders, in particular those located intraarticularly, and dislocations.
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Affiliation(s)
- Christian Fialka
- Department of Traumatology, Medical University of Vienna and Vienna General Hospital, Waehringer Guertel 18-20, Vienna A-1090, Austria
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Abstract
Shoulder pain is a frequent presenting complaint to physiatrists. Commonly encountered pathogeneses include rotator cuff pathology, bursitis, biceps tendonitis, and labral tears. Because the majority of shoulder pain originates within the subacromial region and the glenohumeral joint, the acromioclavicular, sternoclavicular, and scapulothoracic articulations may be overlooked. Osteoarthritis of the acromioclavicular joint is a common source of shoulder pain that is often neglected by clinicians and researchers. The proper diagnosis of acromioclavicular joint osteoarthritis requires a thorough physical exam, plain-film radiograph, and a diagnostic local anesthetic injection. Current treatment options are rather limited. Initial therapies are similar to that of osteoarthritis in other joints and include oral analgesics or anti-inflammatories and an emphasis on activity modification. Physical therapy, unfortunately, has little to offer, as therapeutic exercise and range of motion play only a minor role. If a diagnostic local anesthetic injection provides relief, there may be a role for corticosteroid injections. It seems that the administration of local corticosteroids into the acromioclavicular joint may provide short-term pain relief. The judicious administration of such injections remains controversial, and most experts agree that steroid injections do not alter the natural progression of the disease. Surgical options, indicated typically after a minimum of 6 mos of unsuccessful conservative treatment consist of open or arthroscopic distal clavicle resection.
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Affiliation(s)
- Charles J Buttaci
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
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Jost B, Gerber C. What the shoulder surgeon would like to know from MR imaging. Magn Reson Imaging Clin N Am 2004; 12:161-8, vii. [PMID: 15066599 DOI: 10.1016/j.mric.2004.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Bernhard Jost
- Department of Orthopaedics, University of Zürich, Uniklinik Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland
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