Rotator cuff tears and shoulder impingement: a tale of two diagnostic test accuracy reviews

Isolated bursal-side infraspinatus tear diagnosed by computed tomography bursography: a case series

Background

Partial-thickness rotator cuff tears are commonly found in the articular-side tendon of the supraspinatus; however, isolated lesions, except those occurring in the supraspinatus tendons, are rare. We report three cases of isolated bursal-side infraspinatus tears that were difficult to detect by magnetic resonance imaging but could be visualized by computed tomography bursography.

Case presentation

Three Asian patients (59–71 years old) with shoulder pain ranging from 1 month to 3 years in duration were each diagnosed with shoulder impingement syndrome. Magnetic resonance imaging studies failed to show a tear of the rotator cuff tendon complex. However, computed tomography bursography showed a longitudinal infraspinatus partial-thickness tear on the bursal side in each case. Arthroscopic decompression of the subacromial space and debridement of the infraspinatus tendon tear successfully alleviated the shoulder pain in two of the three patients; the third patient did not undergo surgery and remained symptomatic at follow-up.

Conclusions

In patients with chronic shoulder pain but normal magnetic resonance imaging findings, computed tomography bursography should be considered, as bursal-side infraspinatus tears may be found in these patients. Furthermore, our findings provide a basis for larger studies to further establish the accuracy of computed tomography bursography for these lesions.

Clinical outcomes and cost-utility of rotator cuff repair surgery by open and arthroscopic techniques: study protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff injuries account for up to 70% of pain in the shoulder. However, there remains no consensus on the best surgical treatment for patients with rotator cuff injuries, in terms of the cost-effectiveness and cost-utility of open and arthroscopic methods for rotator cuff repair. The objective of this trial is to compare the efficacy, cost-effectiveness and cost-utility of open and arthroscopic procedures for rotator cuff repair.

METHODS AND ANALYSIS

The trial is a two-group, parallel-design, randomised controlled trial. A total of 100 patients with symptomatic rotator cuff lesions will be allocated in either open or arthroscopic technique in a 1:1 ratio, considering smoking (yes or no), lesion size (≤3 cm or >3 cm) and diabetes (present or absent) as stratification factors. All patients will be included in the same rehabilitation programme after the intervention. The primary outcome measure will be the Constant-Murley Score and the EuroQol-5D-3L score at 48 weeks postsurgery. Secondary outcomes include cost-effectiveness, cost-utility, pain, complications and clinical analysis, using the Simple Shoulder Test, Visual Analogue Pain Scale (VAS), integrity of the repair evaluated through MRI, and complications and failures of the proposed methods. For the cost-effectiveness analysis, we will use the VAS and the Constant-Murley Score as measures of effectiveness. For the cost-utility analysis, we will use the EuroQol-5D-3L as a measure of utility in terms of incremental cost per quality-adjusted life-years.

ETHICS AND DISSEMINATION

The study has been approved by the local research ethics committee of both institutions: Hospital Israelita Albert Einstein and Hospital Alvorada Moema/Hospital Pró-Cardíaco. The results will be published in a peer-reviewed, open access journal.

TRIAL REGISTRATION NUMBER

NCT04146987.

Towards an integrated clinical framework for patient with shoulder pain

Background

Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment.

Objectives

The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP.

Conclusion

The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient.

Preoperative NSAIDs, non-acute onset and long-standing symptoms predict inferior outcome at long-term follow-up after rotator cuff repair

PURPOSE

To evaluate mid- to long-term results after arthroscopic rotator cuff repair and to explore possible predictors of inferior outcome.

METHODS

Patients treated for full-thickness supraspinatus and/or infraspinatus tears from 2004 to 2008, using a uniform single-row arthroscopic technique, were included in the study. Pre- and post-operative QuickDASH were used as the primary outcome measure, and VAS of pain, function and satisfaction were also collected. An additional questionnaire explored demographic and preoperative factors like onset and duration of symptoms, preoperative treatment and smoking habits.

RESULTS

One hundred and forty-seven patients (82 %) were available at 6-9 years after surgery. All outcomes improved significantly from the preoperative values. A total of 8 % of patients had undergone additional surgery to the same shoulder during the follow-up period. Long-standing symptoms (>12 months) (P < 0.01), non-acute onset of symptoms (P < 0.01) and preoperative use of NSAIDs (P = 0.01) were correlated with inferior outcome at follow-up. No other factors investigated (i.e. gender, age, smoking and steroid injections) were found to affect the primary outcome (QuickDASH).

CONCLUSION

The current study is one of few reports of mid- to long-term outcomes after arthroscopic single-row repair of full-thickness rotator cuff tears. Global improvement in symptoms and function was found between the preoperative and the 6-9 years evaluation, and the technique therefore seems like a viable approach for treating tears of the supra- and the infraspinatus tendon. Several predictors of inferior long-term outcome after rotator cuff repair were, however, identified: preoperative use of NSAIDs, long-standing symptoms before surgery and non-acute onset of shoulder symptoms. In light of the current findings, accurate diagnosis and prompt treatment seem important in optimizing outcomes after rotator cuff surgery.

LEVEL OF EVIDENCE

IV.