Detection and quantification of glenohumeral joint effusion: reliability of ultrasound

Musculoskeletal ultrasound of the shoulder in patients with adhesive capsulitis

Adhesive capsulitis is a common pathological condition of the shoulder that affects the general population. The aim of the present study was to explore shoulder ultrasonographic findings in patients with adhesive capsulitis. A cross-sectional descriptive study was conducted on 96 patients with adhesive capsulitis. Abnormal shoulder ultrasonographic findings were found in all participants. The top three abnormal ultrasonographic imaging features were biceps tendon effusion (71.8%), positive dynamic supraspinatus impingement (56.2%) and subdeltoid-subacromial bursitis (47.9%). By assessing the relationship between limited functional shoulder range of motion (ROM) and abnormal shoulder ultrasonographic findings, limited passive ROM (PROM) with shoulder flexion of ≤120 degrees was found to be significantly associated with positive dynamic supraspinatus impingement. Similarly, limited PROM in shoulder abduction of ≤130 degrees was found to be significantly associated with subdeltoid and subacromial bursitis, as well as positive dynamic supraspinatus impingement. In addition, limited PROM with shoulder internal rotation of ≤60 degrees was significantly associated with positive dynamic supraspinatus impingement. Varying abnormal shoulder ultrasonographic findings were obtained in patients with adhesive capsulitis. Therefore, it should be cautioned that relying solely on physical examination may not accurately indicate true shoulder pathology and it is suggested that the final diagnosis should be based on a combination of the patients' clinical and overall ultrasonographic findings.

Skin, Soft Tissue, and Musculoskeletal Ultrasound

Point-of-care ultrasound may be used to assist in the diagnosis of skin, soft tissue, and musculoskeletal concerns in the emergency department. Frequently, linear or curvilinear probes are used to perform these studies and ultrasound may be used to assist in common emergency department procedures related to these conditions.

Rice bodies in a shoulder bursa: a cadaveric and histologic case report

INTRODUCTION

The subacromial/subdeltoid bursa can develop inflammation and effusion related to autoimmune, infectious, and musculoskeletal disorders. Rice bodies, or loose bodies within bursa, have been described as an uncommon complication of bursitis and have been the subject of case studies over a number of years. However, they have not been described in anatomical or physical therapy-related literature.

METHODS

A donor body dissected for a physical therapy anatomy course was found to have an enlarged subacromial/subdeltoid bursa. This bursa, along with the biceps brachii tendon sheath, and the subscapularis muscle bursa, were filled with numerous rice-like bodies. The bursal wall was well developed and thickened. Tissue specimens were obtained of the suspected rice bodies, the subacromial/subdeltoid bursal wall, and the biceps brachii tendon sheath. The tissue was embedded, sectioned, and processed with hematoxylin and eosin or Masson's Trichrome staining for blinded histologic assessment.

RESULTS

The tissue samples from within the bursa were identified as tissue similar to that in prior descriptions of rice bodies. Tissue samples from the bursal wall and tendon sheath were identified as similar to synovial membranes.

CONCLUSIONS

Rice bodies found within the cadaveric body were similar histologically to those described in rheumatology, radiology, and orthopedic literature. Anatomists teaching future health-care providers and practicing physical therapists should be familiar with rice bodies as a potential finding in cadavers, and patients.

Glenohumeral joint effusion assessment with point-of-care ultrasound

ABSTRACT

Ultrasound has favorable diagnostic accuracy for detecting glenohumeral joint effusions. This article describes an easy-to-learn and interpret limited glenohumeral joint ultrasound examination that can help guide further evaluation and treatment. We report on a patient ultimately diagnosed with septic arthritis of the glenohumeral joint, the associated joint effusion having been detected on bedside ultrasound. This ultrasound examination is applicable to generalist PAs and those working in orthopedics and acute care settings.

Point-of-Care Ultrasound of a Shoulder Effusion in a Child With Septic Arthritis: A Case Report

ABSTRACT

Point-of-care musculoskeletal ultrasound can facilitate diagnosis of joint effusions and help guide management of suspected septic joints. This case report describes a previously healthy pediatric patient with acute onset shoulder pain and fever who was found to have leukocytosis and bacteremia. Point-of-care ultrasound (POCUS) demonstrated a unilateral shoulder joint effusion. After POCUS was performed, purulent fluid was aspirated from the joint, and she was diagnosed with a septic shoulder. We review the ultrasound technique, sonographic findings, and literature regarding POCUS for shoulder effusions.

Perforated flexible catheters improve joint fluid aspiration in shoulder cadavers

A fluoroscopically controlled anterior approach in supine position is often used for arthrocentesis of the shoulder, but can lead to a high rate of dry aspirations. The aim of this study was to compare the aspiration performance of rigid needles and flexible catheters used with this approach. We hypothesized that a flexible catheter can significantly improve the amount of the obtained fluid. The glenohumeral joint of ten human cadaveric shoulder specimens were sequentially filled with 5, 10, 20 and 30 mL of contrast agent. For each volume the maximum aspirated amount of contrast agent with 4 different aspiration devices (20 gauge needle, 16 gauge needle, 16 gauge flexible catheter and 16 gauge perforated flexible catheter) were compared. All aspirations were done in supine cadaver position from anterior under fluoroscopic control. The aspirated amount of fluid was significantly higher using the 16 gauge perforated flexible catheter (p = 0.002–0.028) compared with all other devices when 5, 10 and 20 mL of contrast agent were in the joint. This perforated flexible catheter aspirated 80–96% of the available fluid while the standard 20 gauge needle aspirated 40–60%. Using a 16 gauge perforated flexible catheter in a supine anterior arthrocentesis technique results in aspiration of most of the fluid in human cadaveric shoulder specimens, while standard needles aspirate only about 50% of it. This can be clinically relevant when there is very little synovial fluid available and might reduce the number of insufficient aspirations.

Biceps Tendon Sheath Injection: An Anatomical Conundrum

Objective

Long head biceps tendon peritendinous or sheath injections are routinely administered at or immediately distally to the bicipital groove. The main indication for injection remains the clinical diagnosis or treatment of biceps tendinopathy, although true inflammation of the tendon within the bicipital groove is rare. Because the tendon sheath is merely an extension of the joint cavity, it is plausible to assume that an injection into the sheath would result in intraarticular spread. Surprisingly, such an anatomical tenet has a vague confirmation in the published clinical literature. This experiment was undertaken to investigate patterns of injectate spread when peri-tendon injection at the bicipital groove is performed.

Design

An experimental cadaveric study.

Setting

An institutional clinical anatomy laboratory.

Methods

Twelve ultrasound-guided methylene blue injections of the bicep tendon sheath were performed on cadaver specimens. Dissections and gross examination of staining of the internal joint surfaces were performed. Visual confirmation of the intra- and/or extra-articular spread of the injectate was performed.

Results

In 11 specimens, injected contrast was found spreading onto the entire internal joint surface, including glenoid cartilage. One extraarticular injection was attributable to a technical issue.

Conclusions

The experiment confirmed continuity of the joint capsule and the biceps tendon sheath. These results suggest a low diagnostic utility of peritendinous injections at the level of the bicep groove. Such injections would likely result in intraarticular deposit of the injectate. Nonetheless, this approach may be utilized as an alternative simplified access to the glenohumeral joint.

Development and Reliability of the Joint Tissue Activity and Damage Examination for Quantitation of Structural Abnormalities by Musculoskeletal Ultrasound in Hemophilic Joints

OBJECTIVES

Musculoskeletal ultrasound (US) is used increasingly to examine hemophilic arthropathy. However, quantitative algorithms to document findings are lacking. We developed and sought to validate a protocol quantifying hemophilic joint abnormalities.

METHODS

Thirty-one patients with hemophilia were examined serially for 2 years with musculoskeletal US (≈600 joint examinations and ≈6000 images). Based on the spectrum of pathologies, a quantitative algorithm, named Joint Tissue Activity and Damage Examination (JADE), was developed for soft tissue and osteochondral measurements, including power Doppler, using nominal group techniques. To study intra- and inter-rater reliability, 8 musculoskeletal US-experienced hemophilia providers performed anatomic landmark recognition and tissue measurements on 86 images with arthropathic changes, with repetition 1 month later. Twenty-three musculoskeletal US-inexperienced providers performed similar assessments. Inter-operator reliability was established by 6 musculoskeletal US-experienced hemophilia providers, each acquiring images and JADE assessments of 3 hemophilic arthropathic joints. A radiologist and musculoskeletal sonographer functioned as adjudicators. The statistical analysis was performed with the intraclass correlation coefficient (ICC), Fleiss κ, and Cohen κ where appropriate.

RESULTS

The musculoskeletal US-experienced providers showed excellent intra-and inter-rater reliability for tissue measurements (ICCs, 0.94-0.96). Agreement was good to excellent for landmark recognition (Fleiss κ, 0.87-0.94). Inter-operator reliability was excellent for measurements and landmark recognition (ICC, 0.90; Fleiss κ, 1.0). Agreement with adjudicators was mostly good to excellent. Musculoskeletal US-inexperienced providers showed excellent inter-rater reliability for measurements (ICC, 0.96) and moderate agreement for landmark recognition (Fleiss κ, 0.58).

CONCLUSIONS

The JADE protocol appears feasible for quantifying hemophilic intra-articular abnormalities. Musculoskeletal US-trained hemophilia providers showed high intra-rater, inter-rater, and inter-operator reliability, supporting JADE as a protocol for clinical management and research.

Dynamic ultrasonography of the shoulder

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of shoulder pain. Its low cost, excellent diagnostic accuracy, and capability for dynamic evaluation are also advantages. To assess all possible causes of shoulder pain, it is better to follow a standardized protocol and to perform a comprehensive evaluation of the shoulder than to conduct a focused examination. Moreover, a proper dynamic study can enhance the diagnostic quality of US, especially when the pathology is not revealed by a static evaluation. The purpose of this article is to review the common indications for dynamic US of the shoulder, and to present the basic techniques and characteristic US findings.

Evaluation of the Effusion within Biceps Long Head Tendon Sheath Using Ultrasonography

BACKGROUND

Many shoulder diseases are related to glenohumeral joint synovitis and effusion. The purpose of the present study is to detect effusion within the biceps long head tendon sheath as the sign of glenohumeral joint synovitis using ultrasonography, and to evaluate the clinical meaning of effusion within the biceps long head tendon sheath.

METHODS

A consecutive series of 569 patients who underwent ultrasonography for shoulder pain were reviewed retrospectively and ultimately, 303 patients were included. The authors evaluated the incidence and amount of the effusion within the biceps long head tendon sheath on the ultrasonographic short axis view. Furthermore, the authors evaluated the correlation between the amount of effusion within the biceps long head tendon sheath and the range of motion and the functional score.

RESULTS

The effusion within the biceps long head tendon sheath was detected in 58.42% of the patients studied: 69.23% in adhesive capsulitis, 56.69% in rotator cuff tear, 41.03% in calcific tendinitis, and 33.33% in biceps tendinitis. The average amount of the effusion within the biceps long head tendon sheath was 1.7 ± 1.6 mm, and it was measured to be the largest in adhesive capsulitis. The amount of effusion within biceps long head tendon sheath showed a moderate to high degree of correlation with the range of motion, and a low degree of correlation with the functional score and visual analogue scale for pain in each type of shoulder disease.

CONCLUSIONS

The effusion within the biceps long head tendon sheath is closely related to the range of motion and clinical scores in patients with painful shoulders. Ultrasonographic detection of the effusion within the biceps long head tendon sheath might be a simple and easy method to evaluate shoulder function.

Associations of sonographic abnormalities of the shoulder with various grades of biceps peritendinous effusion (BPE)

Bicipital peritendinous effusion (BPE), a common ultrasonographic finding of the long head of the biceps tendon, may be associated with shoulder joint derangement, but supporting evidence from large-scale studies is lacking. The aim of this cross-sectional study was to determine the strength of the association between BPE and sonographic abnormalities of the shoulder joint. We reviewed the sonographic reports of patients with suspected shoulder disorders investigated ultrasonographically between January 2011 and January 2012. BPE was graded according to its measured thickness as absent (<1 mm), mild (1-2 mm), moderate (2-3 mm) or severe (>3 mm). The associations between BPE and sonographic abnormalities were examined using multinomial logistic regression adjusted for age, gender, affected side and clinical diagnosis of frozen shoulder. The prevalence rates of absent, mild, moderate and severe BPE among the 907 shoulders examined were 64.1%, 17.8%, 10.4% and 7.7%, respectively. Frozen shoulder was associated with mild BPE (relative risk [RR] vs. participants without BPE = 1.83, 95% confidence interval [CI] = 1.28-2.50). Sonographic findings of biceps tendinopathy, subdeltoid bursitis and full-thickness tears of the supraspinatus tendon were significantly associated with the entire spectrum of BPE, whereas subscapularis tendon tears were significantly associated with moderate (RR = 2.47, 95% CI = 1.29-4.69) and severe (RR = 3.11, 95% CI = 1.51-6.33) BPE. Severe BPE was associated with articular-sided partial-thickness tears of the supraspinatus tendon (RR = 14.32, 95% CI = 4.30-34.35), posterior recess effusion (RR, 7.98, 95% CI = 1.44-34.93) and biceps medial subluxation (RR = 7.25, 95% CI = 1.90-22.33). Our study indicates that BPE is related to various shoulder abnormalities and that the strengths of these associations depend on the severity of BPE. Clinicians encountering BPE should grade its severity and be alert for hidden lesions of the shoulder joint.

Limited subacromial gliding of the supraspinatus tendon during dynamic ultrasonography can predict a decrease in capacity and MR arthrographic features of the shoulder joint

OBJECTIVES

The aim of this prospective study was to compare the painful subacromial gliding limitation of the supraspinatus tendon (SGLS) during dynamic ultrasonography, the features of magnetic resonance arthrography (MRA), and the maximum intra-articular injection volume to predict decreased joint capacity of the shoulder joint.

METHODS

Between January 2003 and August 2011, 67 patients prospectively underwent ultrasonography including dynamic examination and MRA. Ultrasonography and ultrasonography-guided injection of contrast medium was performed before MRA, and each SGLSdU was compared with injected contrast volume, which was assumed as the maximum joint capacity and MRA features.

RESULTS

Forty-seven patients (70.1%) were revealed as SGLS-positive, and 20 patients (29.9%) were revealed as SGLS-negative by dynamic ultrasonography. Pearson's correlation coefficient between SGLS and the injection volume was -0.764 (P < 0.001). The value between SGLS and MRA features was 0.711 (P < 0.001). The mean injected volume of the SGLS-positive (22.0 ml) and negative group (10.7 ml) was significantly different (P < 0.001).

CONCLUSIONS

SGLS at ultrasonography correlated well with MRA features and the maximum intra-articular injection volume. This sign could predict the decreased capacity of the shoulder joint, an important feature of adhesive capsulitis, and increase the usefulness of dynamic ultrasonography.

KEY POINTS

• Dynamic ultrasound is increasingly used in the evaluation of the shoulder. • This can assess subacromial gliding limitation of the supraspinatus tendon (SGLS) • SGLS appeared inversely proportional to the maximum volume of intra-articular injection. • Dynamic ultrasonography findings correlated well with MR arthrographic features of adhesive capsulitis.

Magnetic resonance imaging of shoulder arthropathies

The role of magnetic resonance imaging in evaluating shoulder arthropathies is evolving. This article reviews 4 of the major arthropathies: septic arthritis, rheumatoid arthritis, calcium pyrophosphate dihydrate (CPPD) deposition disease, and hydroxyapatite disease (HAD), with special attention to their magnetic resonance imaging features. Comfort with identifying these entities allows appropriate and prompt treatment, which is critical for joint preservation in the case of infection, for maximal therapeutic efficacy of disease-modifying drugs in the case of rheumatoid arthritis, and for expediting symptomatic relief in the cases of CPPD deposition disease and HAD.