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

Abstract

BackgroundThe 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).MethodsConsecutive 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.ResultsIn 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).ConclusionsRotator 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.

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care

“…Sample size was estimated using methods for estimates for diagnostic accuracy studies described by Flahault et al 44 and details are provided elsewhere. 1 Ethical approval was granted by the New Zealand Ministry of Health Regional Ethics Committee. All participants provided written informed consent prior to participation in the study.…”

“…The diagnostic ultrasound procedure is described in detail elsewhere. 1 Sonographers and radiologists recorded diagnostic information on a standardized worksheet that included recording pathological findings affecting the subacromial bursa, rotator cuff, long head of biceps tendon, acromioclavicular joint and whether a glenohumeral joint effusion was present. Rotator cuff tears were classified according to size (tear width and length in mm), location (intrasubstance, articular or bursal surface) and grade classification (high-grade, more than 50% of tendon thickness; low grade, less than 50% of tendon thickness; or full thickness tear including retraction).…”

“…1 Rotator cuff tears can result in considerable pain, functional disability, reduced quality of life and loss of independence. [2][3][4] They may also result in loss of productivity and high costs of associated workrelated compensation for those unable to continue in high-demand occupations.…”

Prolotherapy: A Non-Invasive Approach to Lesions of the Glenoid Labrum; A Non-Controlled Questionnaire Based Study

“…In a retrospective study of 544 arthroscopies, labral lesions were diagnosed in 44% of cases [4]. In the majority of cases, labral lesions are found in association with other intra-articular pathologies, including rotator cuff tears, instability, impingement syndrome, HillSachs lesions, osteoarthritis and paralabral cysts [3][4][5]. Since definitive diagnosis of many of these conditions is not possible preoperatively, management of these patients is a challenge for the primary care provider.…”

“…Among the many pathologies that can give rise to shoulder pain, labral lesions are among the most prevalent findings. In a prospective study of 208 consecutive cases of shoulder pain in primary care, magnetic resonance arthrograms were performed on 93 patients, of whom 44 (47%) were found to have glenoid labral tear [3]. In a retrospective study of 544 arthroscopies, labral lesions were diagnosed in 44% of cases [4].…”