Association of Range of Motion Deficit and Recurrence of Pain After Treatment of Adhesive Capsulitis

INTRODUCTION

We evaluated the factors influencing the duration of significant pain reduction after conservative management for adhesive capsulitis (AC).

METHODS

Follow-up for 6-8 months was performed with 141 patients with AC who experienced significant pain reduction after treatment. Clinical and demographic factors, numeric rating scale (NRS) scores, and shoulder range of motion (ROM) were collected and assessed pretreatment (T0), at 5 weeks post-treatment (T1), and at 6-8 months post-treatment (T2). Patients were divided into successful (n = 96) and unsuccessful (n = 45) NRS groups according to the degree of pain reduction at T2. We assessed post-treatment NRS and ROM improvement scores within each group and compared these parameters between the two groups.

RESULTS

Significant NRS and ROM improvements were achieved in all patients who participated in our study. The unsuccessful NRS group demonstrated a lack of significant improvement in abduction at T1 and T2. All T1 and shoulder ROM measurements among the unsuccessful NRS group were significantly smaller than those among the successful NRS group.

CONCLUSIONS

Failure to achieve a significant improvement in abduction angle after conservative management of AC was significantly associated with pain recurrence.

Evidence for Combining Conservative Treatments for Adhesive Capsulitis

Background: Adhesive capsulitis, also known as frozen shoulder, is a challenge to treat clinically. Common first-line treatment options are suprascapular nerve block (SSNB), intra-articular corticosteroid (IACS) injection, hydrodilatation, and physical therapy. This literature review summarizes each of these conservative treatments and discusses the evidence base for combining treatment options for potential additive benefits to improve patient outcomes (ie, pain, range of motion [ROM], and shoulder function). Methods: The PubMed and Google Scholar databases were searched using the search terms "adhesive capsulitis," "frozen shoulder," "corticosteroids," "physical therapy," "suprascapular nerve block," "hydrodilatation," and "conservative care." Pertinent articles were identified and synthesized to provide a comprehensive review of 4 common conservative treatments for adhesive capsulitis. Results: Combining SSNB with physical therapy and/or IACS injection and combining IACS injection with physical therapy have support in the literature for improving shoulder pain, ROM, and function, while hydrodilatation and physical therapy seem to offer some additive benefits for improving shoulder ROM when used as adjunct treatments for adhesive capsulitis. Conclusion: Adhesive capsulitis remains a challenge to treat clinically with much still unknown regarding treatment optimization. For the foreseeable future, first-line conservative management will continue to be the mainstay of managing adhesive capsulitis. Thus, knowing how to best use and optimize these various options-both individually and in combination-is vital for effective treatment.

A prospective study of 100 patients with rotator cuff tendinopathy showed no correlation between subacromial bursitis and the efficacy of ultrasound-guided corticosteroid injection

OBJECTIVES

The objective of this study was to determine whether the presence of subacromial bursitis in patients with rotator cuff tendinopathy (RCT) was associated with a better outcome after ultrasound (US)-guided subacromial corticosteroid injection.

METHODS

A single-center prospective study was performed including patients referred for subacromial injection to manage RCT. At baseline, all patients received an US-guided intra-bursal injection of betamethasone (1 ml). The primary endpoint was reduced pain 3 months (M3) after the procedure: a good responder was defined by a decrease in Visual Analogue Scale pain of more than 30%. Secondary endpoints included functional recovery assessed by the Oxford Shoulder Score (OSS) and clinical success at 6 weeks (W6). We also explored the association between good clinical response and other factors, such as US or X-ray features.

RESULTS

One hundred patients were included and 49 presented with subacromial bursitis. At M3, 60% of patients (54/100) were considered good responders. The rate of good responders did not differ between the bursitis and non-bursitis groups (p = 0.6). During follow-up, OSS improved over time whether bursitis was present or not. We did not find any US or X-ray features significantly associated with a favorable clinical outcome.

CONCLUSION

The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial injection in patients suffering from RCT.

CLINICAL RELEVANCE STATEMENT

The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial corticosteroid injection in patients with rotator cuff tendinopathy. For patient management, looking for ultrasonographic signs of bursitis does not appear relevant for the indication of the injection.

KEY POINTS

• Ultrasound-guided subacromial corticosteroid injections led to a significant improvement in 60% of patients suffering from rotator cuff tendinopathy. • The presence of subacromial bursitis was not associated with better improvement at 3 months post-injection. • Except for the Minnesota score referring to job satisfaction, we did not find any baseline clinical, X-ray, or ultrasound characteristics associated with a successful outcome.

Efficacy of Platelet-Rich Plasma Injection on Range of Motion, Pain, and Disability in Patients With Adhesive Capsulitis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of platelet-rich plasma (PRP) injection on range of motion, pain, and disability in patients with adhesive capsulitis (AC).

DATA SOURCES

The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases in February 2023.

STUDY SELECTION

Prospective studies comparing the outcomes of PRP with other intervention in patients with AC.

DATA EXTRACTION

The quality of included randomized trials was assessed using the revised Cochrane Risk of Bias (RoB 2.0) tool. The Risk of Bias in Non-Randomized Studies of Interventions tool was applied to assess the quality of nonrandomized trials. The mean difference (MD) or standardized mean difference (SMD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs).

DATA SYNTHESIS

Fourteen studies involving 1139 patients were included. Our meta-analysis revealed that PRP injection can significantly improve passive abduction (MD=3.91; 95% CI, 0.84-6.98), passive flexion (MD=3.90; 95% CI, 0.15-7.84), and disability (SMD=-0.50; 95% CI, -1.29 to -0.74) within 1 month after intervention. Moreover, PRP injection can significantly improve passive abduction (MD=17.19; 95% CI, 12.38-22.01), passive flexion (MD=17.74; 95% CI, 9.89-25.59), passive external rotation (MD=12.95; 95% CI, 10.04-15.87), pain (MD=-8.40; 95% CI, -16.73 to -0.06), and disability (SMD=-1.02; 95% CI, -1.29 to -0.74) 3 months after intervention. PRP injection can also significantly improve pain (MD=-18.98; 95% CI, -24.71 to -13.26), and disability (SMD=-2.01; 95% CI, -3.02 to -1.00) 6 months after intervention. In addition, no adverse effects of PRP injection were reported.

CONCLUSIONS

PRP injection may serve as an effective and safe treatment for patients with AC.

Non-surgical treatment of aseptic olecranon bursitis: A systematic review

OBJECTIVE

Olecranon bursitis (OB), characterized by inflammation and fluid collection in the olecranon bursa is a commonly encountered out-patient condition. The data is heterogeneous regarding a stepwise and standardized approach to aseptic OB treatment and the efficacy of intra-bursal corticosteroid injections (CSI). The objective of this review is to systematically evaluate the non-surgical treatment options for aseptic OB.

METHODS

This systematic review was conducted in accordance with PRISMA recommendations. The English and non-English literature search was performed in 5 medical databases to identify studies evaluating the treatment of OB. All included studies were evaluated for risk of bias (RoB) using the revised Cochrane RoB tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for case-control and cohort studies.

RESULTS

For the final analyses, 2 RCTs and 2 observational studies were included. The RoB for the RCTs was high and both failed to demonstrate a significant difference in terms of the resolution of OB and bursal tenderness among various invasive and non-invasive treatment options. Corticosteroid injection (CSI) was associated with a significant decline in the duration of symptoms. However, it was associated with a higher number of complications including bursal infection and skin atrophy.

CONCLUSION

Based on the available data, it appears that the clinical resolution of aseptic OB can occur with conservative methods if implemented earlier in the disease course. Although CSI is more effective than other treatments, it should be reserved for refractory cases because of a higher complication rate.

Cystic lesions and bursae around the knee: do they matter in knee osteoarthritis?

The cause of knee osteoarthritis (OA) and knee pain associated with OA is not well understood. Periarticular cystic lesions and bursae around the knee are among the most common morphologic features identified on MRI in the setting of OA. Despite widespread association of these lesions with knee OA and their inclusion in semiquantitative MRI scoring assessment systems for knee OA, the role that these lesions play in the development of knee pain and OA remains uncertain. In this discussion, we review the cystic lesions and bursae most commonly associated with OA of the knee, examine their relation and role in whole organ imaging assessments of OA, and present the literature investigating the associations of periarticular cysts and cyst-like lesions with knee pain and OA.

The reliability and validity of the Norwegian version of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire (VISA-G-Norwegian) for patients with greater trochanteric pain syndrome

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS) is a common chronic musculoskeletal condition that may affect physical function, quality of life and sleep. The Victorian Institute of Sport Assessment-Gluteal questionnaire (VISA-G) has been developed as a Patient-Reported Outcome Measurement (PROM) to address pain, everyday activities, physical activities, and difficulty with weight bearing activities. The aim of the study was to test the reliability, validity and floor and ceiling effects of the Norwegian version of the VISA-G (VISA-G-Norwegian) in a population with GTPS in a specialist health care setting.

METHODS

This psychometric evaluation of the VISA-G-Norwegian questionnaire were conducted with a prospective observational design. The VISA-G was translated into Norwegian following recommended guidelines. A subgroup repeated the VISA-G-Norwegian a week after the initial submission. For the reliability, the Intraclass Correlation Coefficient (ICC2.1), Standard Error of the Measurement (SEM) and the Smallest Detectable Change (SDC95%) were calculated. Internal consistency was measured using a Cronbach´s alpha. Floor and ceiling effects were evaluated, and construct validity was assessed with three a priori hypotheses.

RESULTS

78 participants were included in the study of which 47 stable participants undertook the test-retest reliability arm of the study. The ICC2.1 for the total score was 0.85 (95% CI 0.68, 0.92), SEM was 6.6 points and SDC95% 18.4 points. Cronbach`s alpha was 0.77 (95% CI 0.69, 0.84). No floor or ceiling effects were found in the total score, but ceiling effect was found in three of the eight items. For construct validity, one of the three hypotheses were confirmed. VISA-G-Norwegian correlated to the modified Harris Hip Score (mHHS), Oswestry Disability Questionnaire (ODI) and Numeric Pain Rating Scale (NPRS), 0.64, -0.75 and - 0.63 respectively.

CONCLUSION

The VISA-G-Norwegian has acceptable reliability and validity, despite ceiling effect of individual items. The large SDC95% should be considered when measuring change in similar cohorts with GTPS. For a potential future version, it would be recommended to consider response options for questions with ceiling effect and the comprehensibility of question eight.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov the 28/02/2020 (NCT04289922).

Post-traumatic ulcerated and chronic necrobiosis lipoidica of the elbow: A new entity?

BACKGROUND

Necrobiosis lipoidica (NL) is a chronic granulomatous dermatosis usually affecting the lower limbs, although less common sites have been described. Herein we report a series of cases of NL located on the elbow, with an unusual presentation and occurring after trauma or surgery.

OBSERVATIONS

Our series includes three men and one woman, with a mean age of 64 years. Three had undergone surgery for elbow bursitis and one had had trauma after a fall from a horse, with exposure of subcutaneous tissue prior to healing. Within 5 years, they had all developed an atrophic erythematous annular plaque with papular and telangiectatic edges, with recurrent episodes of ulceration and scarring. Repeated tests for infectious agents were negative. Histological examinations showed granulomas and necrobiosis with palisading or early-stage palisading. Partial healing was achieved in two patients after 6 months of doxycycline. Treatment with adalimumab resulted in disappearance of the ulcers at 6 months in one patient.

DISCUSSION

Unusual sites of NL impose consideration of other types of palisading granuloma or mycobacterial infections, which we were able to rule out. Two other cases of NL of the elbow similar to ours are reported in the literature. These cases, involving multiple ulcerations over a very long period of time, probably constitute a distinct entity because of the very distinct character of these 6 cases. Tetracyclines are partially active and tumour necrosis factor alpha (TNF)-alpha inhibitors may offer an option.

Effect of Transfer Energy Capacitive and Resistive Therapy on Shoulder Pain, Disability, and Range of Motion in Patients With Adhesive Capsulitis: A Study Protocol for a Randomized Controlled Trial

Objective

We describe a protocol to evaluate the effectiveness of transfer energy capacitive and resistive (TECAR) therapy on shoulder passive range of motion, shoulder pain, and disability index in patients with adhesive capsulitis.

Methods

This study will be a double-blinded randomized clinical trial with a 1-month follow-up. For the purpose of this research, 30 patients with a 3-month history of shoulder pain and disability diagnosed as adhesive capsulitis will be selected and then randomized into 2 groups, including conventional physiotherapy consisting of electrophysical modalities and therapeutic exercises, which will be given to the control group. In the intervention group, after conventional physiotherapy, 10 minutes of TECAR therapy in resistive mode will be applied on both the anterior and inferior aspects of the shoulder joint. Outcome measures will be related to shoulder passive range of abduction, flexion, and external rotation that will be measured using a digital inclinometer, as well as shoulder pain and disability index that will be assessed by the validated questionnaire. Assessment will be done at baseline, 1 day after the intervention, and by passing 1 month.

Results

The statistical analysis will describe within-group and between-group comparisons; the findings will be illustrated in tables and charts.

Conclusion

Given the reason that the effectiveness of TECAR therapy has not been widely evaluated in adhesive capsulitis, the findings of this pilot study would provide baseline information on the effectiveness and complications of this treatment method and possibly propose a more appropriate protocol for patients with adhesive capsulitis.

Tendon injections - upper extremity

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

Overuse-Related Injuries of the Knee

Overuse-related injuries of the knee joint and periarticular soft tissues include a heterogenous group of sports and nonsports-related injuries. These conditions include friction and impingement syndromes, bone stress injuries, bursitis, and tendon-related pathology such as tendinopathy and snapping. Traction apophysitis are also discussed as commonly seen in the pediatric population. Although multiple imaging modalities can be used, this review focuses on MR imaging, which is the most common and, often, the only modality used.

INCIDENCE AND EPIDEMIOLOGY OF ADHESIVE CAPSULITIS DURING THE COVID-19 PANDEMIC

Objective

To evaluate a possible increase of adhesive capsulitis incidence during the COVID-19 pandemic.

Methods

A total of 1,983 patients with shoulder disorders were retrospectively analyzed regarding gender, age, development of adhesive capsulitis and comorbidities (systemic arterial hypertension, diabetes mellitus, dyslipidemia, hypothyroidism, hyperthyroidism, depression, and anxiety) in two different periods: from March 2019 to February 2020 and from March 2020 to February 2021. Descriptive and quantitative variables were statistically analyzed. The program used for the calculations was SPSS 17.0 for Windows.

Results

During the pandemic, there was a 2.41-fold increase (p < 0.001) in cases of adhesive capsulitis (compared to the previous year). Patients with depression and anxiety had a significantly increased risk by 8.8 (p < 0.001) and 14 (p < 0.001) times, respectively, of developing frozen shoulder (regarding the two periods studied).

Conclusion

A significant increase in the incidence of frozen shoulder was observed after the onset of the COVID-19 pandemic in addition to a simultaneous increase of psychosomatic disorders. Prospective studies would help to ratify the idea contained in this research. Level of Evidence III, Observational Cross-Sectional Study.

[CME Sonography 107: Ultrasound Elbow Cases]

CME Sonography 107: Ultrasound Elbow Cases Abstract. In this article, we discuss exemplary sonographic pathologies at the anterior, lateral, medial, and posterior elbow, highlighting important structures that should be systematically examined in the corresponding elbow region.

Clicking shoulder due to snapping Subacromial subdeltoid (SASD) bursitis: a case report of an unusual presentation in clinical practice with imaging features

A spectrum of pathologies can cause clicking, popping or snapping of the shoulder joint. These can lead to a patient seeking attention in clinical practice due to pain, discomfort and impact on activities of daily living. Traditionally these can originate from pathologies which involve biceps tendon, tears of the rotator cuff or the glenoid labrum, articular cartilage or due to loose bodies and scapulothoracic joint dysfunction [Guillin et al. in Br J Radiol 85:1343-1353, 2012; Vidoni et al. in Indian J Musculoskelet Radiol 4:61-69, 2022]. Subacromial subdeltoid (SASD) bursitis is a well-described entity and one of the commonest causes of shoulder pain. We present SASD bursitis as an unusual cause of clicking/snapping in the shoulder without associated pain in a healthy young male. The clinical presentation, diagnostic strategy with complementary imaging and the role of interventional radiology in its effective management is highlighted to support clinicians faced with a diagnostic dilemma.

[CME-Sonography 106: Subacromial Bursa - A Myth]

CME-Sonography 106: Subacromial Bursa - A Myth Abstract. In everyday clinical practice, we frequently encounter bursitis. It can occur in practically any joint region, for example in local mechanical overload situations, after a trauma or in the context of an inflammatory systemic disease. In this review we focus on the location of bursitis in the shoulder region and would like to contribute to get away from the "myth" called subacromial bursitis.

Adventitial bursitis of the dorsal foot presenting as soft tissue masses in patients with autism spectrum disorder

Autism spectrum disorder (ASD) is an increasingly common neurodevelopmental disorder associated with impairments in postural control and repetitive patterns of behavior. Here, we describe two cases of adventitial bursitis of the dorsolateral feet in patients with ASD presenting as mass-like lesions. Both patients habitually sat in the W-position and were treated with ultrasound-guided aspirations with immediate relief of symptoms.

Management of septic and aseptic prepatellar bursitis: a systematic review

BACKGROUND

Despite contributing to significant morbidity in working-age adults, there is no consensus on the optimal treatment for prepatellar bursitis. Much of the existing literature combines prepatellar and olecranon bursitis. This systematic review aims to determine the optimal management of prepatellar bursitis.

STUDY DESIGN AND METHODS

A primary search of electronic published and unpublished literature databases from inception to November 2019 was completed. Articles over 25 years old, case reports with less than four patients, paediatric studies, and non-English language papers were excluded. Our primary outcome was recurrence after 1 year. Comparisons included endoscopic vs open bursectomy, duration of antibiotics. Methodological quality was assessed using the Institute of Health Economics and Revised Cochrane Risk of Bias scoring systems. Meta-analyses were conducted where appropriate.

RESULTS

In total 10 studies were included (N = 702). Endoscopic and open bursectomy showed no difference in recurrence after 1 year (OR 0.41, 95% CI 0.05-3.53, p = 0.67), and surgical complications (OR 1.44, 95% CI 0.34-6.08, p = 0.44). 80% endoscopically-treated patients were pain free after 1 year. Patients treated with antibiotics for less than 8 days were not significantly more prone to recurrence (2/17 vs 10/114, OR 0.66, 95% CI 0.13-3.29, p = 0.64) compared to 8 days plus at minimum 1 year post injury.

CONCLUSIONS

Our study represents the largest cohort of patients evaluating management strategies for prepatellar bursitis, and includes data not previously published. Endoscopic bursectomy is non-inferior to open bursectomy, enabling a shorter hospital stay. It also offers a relatively low risk of post-operative pain. Endoscopic bursectomy is a viable option to treat both septic and aseptic prepatellar bursitis. Our small cohort suggests recurrence and hospital stay are not improved with antibiotic treatment exceeding 7 days for septic prepatellar bursitis.

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment

QUESTION

What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease?

DESIGN

2×2 factorial online randomised experiment.

PARTICIPANTS

People with shoulder pain.

INTERVENTION

Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery.

OUTCOME MEASURES

Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work.

RESULTS

A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome.

CONCLUSION

Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition).

TRIAL REGISTRATION

ACTRN12621001370897.

[Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis]

Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis Abstract. Bursitis olecrani is a common clinical diagnosis that can have systemic, infectious and traumatic causes. In this article we want to present the diagnostics, possible differential diagnoses, complications and the current therapy recommendations as a practical guide.

The effects of complex decongestive therapy on pain and functionality in individuals with breast cancer who developed adhesive capsulitis due to lymphedema: an evaluation by an isokinetic computerized system

Background

This study aimed to determine the impact of complex decongestive therapy applications on upper extremity function in breast cancer patients who developed adhesive capsulitis after lymphedema.

Methods

Thirty patients who developed adhesive capsulitis due to lymphedema were divided into two groups as study (n = 15) and control (n = 15) groups. Both groups received 20 minutes of exercise five days a week for three weeks using a Biodex isokinetic dynamometer, as well as a hot pack and TENS (Transcutaneous Electrical Nerve Stimulation) treatment to the shoulder joint. The study group received 45 minutes of intensive decongestive therapy along with the adhesive capsulitis treatment. The visual analogue scale was used to assess pain, circumference, and volumetric measurements were used to assess edema, and the Arm, Shoulder, and Hand Problems Questionnaire (DASH: Disabilities of the Arm, Shoulder, and Hand) was used to assess upper extremity functionality. The shoulder range of motion was evaluated.

Results

Both groups had improvements in pain (P < 0.001), shoulder joint range of motion (P < 0.001), and upper extremity functionality (P < 0.001) after the treatment. There was a significant decrease in circumference and volumetric measurements in the study group (P < 0.001). However, no differences were seen in measurements in the control group.

Conclusions

The results showed that complex decongestive therapy was beneficial in reducing lymphedema in breast cancer patients who acquired adhesive capsulitis due to lymphedema. Consequently, the authors believe that supplementing conventional physiotherapy with complex decongestive therapy will benefit patients.

Effectiveness of graded motor imagery in subjects with frozen shoulder: a pilot randomized controlled trial

Background

Subjects with frozen shoulder (FS) might not be comfortable with vigorous physical therapy. Clinical trials assessing the effect of graded motor imagery (GMI) in FS are lacking. The aim of this study was to determine the effect of GMI as an adjunct to conventional physiotherapy in individuals with painful FS.

Methods

Twenty subjects aged 40–65 years having stage I and II of FS were randomly divided into two study groups. The conventional physiotherapy group (n = 10) received electrotherapy and exercises while the GMI group (n = 10) received GMI along with the conventional physiotherapy thrice a week for 3 weeks. Pre- (Session 1) and post- (Session 9) intervention analysis for flexion, abduction, and external rotation range of motion (ROM) using a universal goniometer, fear of movement using the fear avoidance belief questionnaire (FABQ), pain with the visual analogue scale, and functional disability using the shoulder pain and disability index (SPADI) was done by a blinded assessor.

Results

Statistically significant difference was seen within both the groups for all the outcomes. In terms of increasing abduction ROM as well as reducing fear of movement, pain, and functional disability, the GMI group was significantly better than control group. However, both groups were equally effective for improving flexion and external rotation ROM.

Conclusions

Addition of GMI to the conventional physiotherapy proved to be superior to conventional physiotherapy alone in terms of reducing pain, kinesiophobia, and improving shoulder function for stage I and II of FS.

[CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI)]

CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI) Abstract. Pain in the shoulder can have its origin in different structures of the shoulder joint or in affected periarticular structures. Therefore, it is important to be able to make a specific diagnosis and identify the exact pathology behind it in order to initiate the most appropriate individually precise treatment. In this review, we discuss possible causes of impingement of the shoulder.

[CME Rheumatology 26: Rheumatological Cases]

CME Rheumatology 26: Rheumatological Cases Abstract. Special rheumatological cases are illustrated using various examples. On the one hand we present differential diagnoses and causes of a "Baker's cyst", on the other hand a case of involvement of the cervical spine in rheumatoid arthritis. Usually, the medical history and precise clinical examination will lead us in the right diagnostic direction. Further clarifications such as laboratory analyses or imaging procedures are used in a targeted manner, taking into account the clinic.

Chronic inflammation and extracellular matrix-specific autoimmunity following inadvertent periarticular influenza vaccination

BACKGROUND

Viral infections may trigger autoimmunity in genetically predisposed individuals. Immunizations mimic viral infections immunologically, but only in rare instances vaccinations coincide with the onset of autoimmunity. Inadvertent vaccine injection into periarticular shoulder tissue can cause inflammatory tissue damage ('shoulder injury related to vaccine administration, SIRVA). Thus, this accident provides a model to study if vaccine-induced pathogen-specific immunity accompanied by a robust inflammatory insult may trigger autoimmunity in specific genetic backgrounds.

METHODS

We studied 16 otherwise healthy adults with suspected SIRVA occurring following a single work-related influenza immunization campaign in 2017. We performed ultrasound, immunophenotypic analyses, HLA typing, and influenza- and self-reactivity functional immunoassays. Vaccine-related bone toxicity and T cell/osteoclast interactions were assessed in vitro.

FINDINGS

Twelve of the 16 subjects had evidence of inflammatory tissue damage on imaging, including bone erosions in six. Tissue damage was associated with a robust peripheral blood T and B cell activation signature and extracellular matrix-reactive autoantibodies. All subjects with erosions were HLA-DRB1*04 positive and showed extracellular matrix-reactive HLA-DRB1*04 restricted T cell responses targeting heparan sulfate proteoglycan (HSPG). Antigen-specific T cells potently activated osteoclasts via RANK/RANK-L, and the osteoclast activation marker Trap5b was high in sera of patients with an erosive shoulder injury. In vitro, the vaccine component alpha-tocopheryl succinate recapitulated bone toxicity and stimulated osteoclasts. Auto-reactivity was transient, with no evidence of progression to rheumatoid arthritis or overt autoimmune disease.

CONCLUSION

Vaccine misapplication, potentially a genetic predisposition, and vaccine components contribute to SIRVA. The association with autoimmunity risk allele HLA-DRB1*04 needs to be further investigated. Despite transient autoimmunity, SIRVA was not associated with progression to autoimmune disease during two years of follow-up.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

The efficacy of physiotherapy interventions in the treatment of adhesive capsulitis: A systematic review

BACKGROUND

Adhesive capsulitis is a debilitating condition which causes the capsule of the gleno-humeral joint to thicken and contract progressively. The effectiveness of various non-operative methods has been demonstrated to improve the pain, range of motion (ROM) and functional status of patients with adhesive capsulitis.

OBJECTIVE

This study aims to review recent evidence on the efficacy of physiotherapy interventions in the treatment of adhesive capsulitis.

METHODS

PubMed, Physiotherapy Evidence Database (PEDro), Science Direct and Cochrane databases were searched for studies published since 2013. The search terms included: Frozen shoulder, adhesive capsulitis, physical therapy, rehabilitation, manual therapy, mobilization, exercise, education, and electrotherapy. The search was limited to studies published in English and studies that used human subjects.

RESULTS

Quality scores of 33 articles were reviewed according to the Sackett's critical appraisal criteria and the grades of recommendation were determined for physiotherapy interventions used in the studies.

CONCLUSION

The empirical evidence suggests that certain physical therapy techniques and modalities are strongly recommended for pain relief, improvement of ROM, and functional status in patients with adhesive capsulitis, while others are either moderately or mildly recommended. However, the efficacy of one treatment modality over another is uncertain. The poor methodological rigors demonstrated in most of the reviewed studies emphasize the urgent need of properly conducted, adequately sampled randomized controlled trials with adequate follow up to determine the superior combination of treatment.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses

PURPOSE

No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses.

METHODS

Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes.

RESULTS

Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters.

CONCLUSION

Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

Evaluation of patients admitted with musculoskeletal tuberculosis: sixteen years' experience from a single center in Turkey

Background

The aim of our study was to describe musculoskeletal system tuberculosis (TB) as a single-center experience.

Methods

This is a retrospective observational study conducted at a TB Dispensary in the east Mediterranean part of Turkey between 2004 and 2020. The clinical and demographic characteristics including age, gender, involvement location and duration of illness, presenting complaint, local examination findings, treatment outcome were retrieved and analyzed from the case files. Statistical analyses were performed using SPSS Statistics version 17.0 (IBM). The normality of data analysed by using Kolmogorov-Smirnov. The descriptive statistics were reported as mean ± standard deviation, medians, and ranges (min-max).

Results

Overall, 31 patients (3.2 % of all TB cases) with a mean age of 44.2 ± 16.7 years had musculoskeletal tuberculosis. The mean duration of treatment was 12.9 ± 5.5 months. Of the 31 patients, six (19.4 %) had concomitant pulmonary TB. One of the patients was in the pediatrics age group, and two of them were in the geriatric group. The most affected area was the vertebra. The most common complaint of the patients was back pain and seen in 22 patients (70.9 %).

Conclusions

The physicians should be suspicious about the diagnosis of musculoskeletal TB disease. If the diagnosis and treatment are delayed, spinal damage and other consequences might be incurable.

Bursitis of the coccyx in an adult with rheumatoid arthritis mimicking a sacrococcygeal meningocele

Background

Bursitis is a chronic inflammatory condition characterized by the deposition of cholesterol, macrophage infiltration, and bursal wall calcification. Bursitis is, however, rarely found in the sacrococcygeal region where it may present as a space-occupying mass.

Case Description

A 64-year-old male with rheumatoid arthritis presented with 3 years' duration of difficulty sitting and walking due to a soft-tissue mass involving the coccyx region. Once the patient's MR demonstrated a cystic lesion with erosion of the coccyx, the patient underwent gross total resection of the lesion that proved to be pathologically consistent with bursitis. Postoperatively, the patient's complaints fully resolved.

Conclusion

Bursitis may present as a soft-tissue tumor-like lesion in the coccyx that favorably responds to gross total surgical excision.

Factors associated with revision surgery for olecranon bursitis after bursectomy

BACKGROUND

The primary aim of our study was to identify the factors associated with revision surgery after bursal excision in patients with olecranon bursitis. The secondary aims were to describe the revision rate after bursectomy and to assess which factors are associated with flap surgery after bursectomy and describe the most common complications after bursectomy of the olecranon bursa.

METHODS

We included 191 adult patients with olecranon bursitis who underwent olecranon bursa excision between January 2002 and October 2018. Patients who were pregnant, patients with incomplete records of the primary surgical procedure, and patients who underwent bursectomy during elbow arthroplasty were excluded. After manual chart review, we found that 22 patients had undergone revision surgery. Bivariate analysis was performed to assess the association between revision surgery and patient characteristics, comorbidities, and clinical characteristics. Additionally, we collected data regarding postoperative complications and intraoperative variables such as the use of drains, vacuum assisted closure therapy, and flap surgery.

RESULTS

The overall revision rate in our cohort was 11.5% (22 of 191 patients). Bivariate analysis showed that patients who underwent revision surgery were more frequently women (P = .004), more often had a history of ipsilateral (P = .020) or contralateral (P = .012) olecranon bursitis, and more often received a diagnosis of rheumatoid arthritis (P = .001) or diabetes mellitus (P = .019). The most common complications were delayed wound healing (n = 8, 4.2%) and osteomyelitis (n = 8, 4.2%). Flap surgery was performed in 5 patients (2.6%). Bivariate analysis showed that patients with rheumatoid arthritis underwent flap surgery more frequently (P = .011).

CONCLUSION

The revision rate after bursectomy for olecranon bursitis was 11.5% (22 of 191 patients). Patients with rheumatoid arthritis, diabetes mellitus, or a history of ipsilateral and contralateral olecranon bursitis and female patients underwent revision surgery after bursectomy for olecranon bursitis more frequently. In addition, patients with rheumatoid arthritis underwent flap surgery after bursectomy more frequently.

Two rare cases of fungal bursitis due to Phialemoniopsis pluriloculosa

Fungal infections due to Phialemoniopsis spp. are rarely reported in the medical literature. We report the first two cases of fungal bursitis of the knee by Phialemoniopsis pluriloculosa, which has not been previously reported. Both patients were successfully treated with a six-month course of posaconazole.

Disseminated intravascular coagulation as a complication of bursitis: angiogenesis and repetitive bleeding as potential factors for disseminated intravascular coagulation: a case report

Background

Malignant tumors, such as acute leukemia and solid cancers, frequently cause disseminated intravascular coagulation. However, cases of disseminated intravascular coagulation as a complication of bursitis were not reported previously.

Case presentation

A 72-year-old Japanese woman was scheduled to undergo resection of a rapidly growing subcutaneous tumor-like lesion on her left back. Preoperative blood tests suggested disseminated intravascular coagulation. The resected lesion was cystic tumor containing a hematoma. After the operation, the patient completely recovered from disseminated intravascular coagulation, indicating that disseminated intravascular coagulation in this case was caused by the tumor. Pathological examination of the resected tumor revealed considerable fibrin deposition and angiogenesis on the cyst wall, which was presumably a response to inflammation and indicated presence of repetitive intratumoral bleeding, subsequently leading to a diagnosis of chronic hemorrhagic bursitis.

Conclusions

Clinicians should note that, despite being benign, soft-tissue tumors accompanied by inflammation with angiogenesis and repetitive intratumoral bleeding can cause disseminated intravascular coagulation, albeit rarely.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02773-x.

Heel fat pad involvement in rheumatoid arthritis: a review and case series

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease affecting not only the synovial joints but also multiple extra-articular sites, including ankle and foot soft tissue. Hindfoot abnormalities usually follow those in the forefoot, with up to 4 out of 10 patients experiencing talalgia during their disease course. Enthesophytosis, retrocalcaneal bursitis, and plantar fasciitis are among the most common etiologies, while heel fat pad abnormalities like subcalcaneal bursitis are rare. Here, we report two cases of subcalcaneal bursitis, and the first case of heel fat pad and subcalcaneal bursa herniation in patients with established RA, along with a comprehensive literature review of subcalcaneal bursitis and other heel fat pad abnormalities in RA. Subcalcaneal bursitis, also referred to as panniculitis, inflammatory-edematous lesion, or adventitial (adventitious) bursitis has been reported in up to 10% of patients with RA. It appears as a compressible, heterogeneous, and hypoechoic subcalcaneal mass on ultrasound (US), with peripheral vascularization on Doppler US. Patients may present with heel discomfort. Ultrasonographic assessment is usually sufficient to confirm the presence of heel fat pad pathologies. Rest, analgesics, and mechanical aids with or without addition of disease-modifying antirheumatic drugs are usually employed, while intervention is rarely required.

[CME Sonography 97: Ultrasound Pathologies of the Hip]

CME Sonography 97: Ultrasound Pathologies of the Hip Abstract. Hip pain has a broad differential diagnosis. A clinical examination is not enough to determine the underlying cause. In most cases, sonography helps to narrow the differential diagnosis or to make a specific diagnosis. Furthermore, ultrasound allows a targeted and anatomically precise diagnostic aspiration or therapeutic infiltration. Examples are used to illustrate different pathologies by region.

[CME Sonography 97/Answers: Ultrasound Pathologies of the Hip]

CME Sonography 97/Answers: Ultrasound Pathologies of the Hip Abstract. Abstract: Hip pain has a broad differential diagnosis. A clinical examination is not enough to determine the underlying cause. In most cases, sonography helps to narrow the differential diagnosis or to make a specific diagnosis. Furthermore, ultrasound allows a targeted and anatomically precise diagnostic aspiration or therapeutic infiltration. Examples are used to illustrate different pathologies by region.

Unusual, but important, peri- and extra-articular manifestations of rheumatoid arthritis: a pictorial essay

Ultrasonography is a useful technique to detect soft tissue changes of rheumatoid arthritisnot only synovitis, but also tenosynovitis, bursitis, and enthesitis-even at a subclinical stage. However, radiologists tend to focus on synovitis in daily practice, and unusual peri- or extra-articular manifestations of rheumatoid arthritis are difficult to detect at the initial presentation. This pictorial essay describes a broad spectrum of ultrasonographic findings in tendons, bursae, ligaments, subcutaneous tissues, bones, and nerves to assist in the accurate diagnosis of rheumatoid arthritis.

Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA)

Vaccination injection site adverse reactions are usually mild and transient, and post-vaccination musculoskeletal symptoms, such as myalgia and arthralgia, are very common. Shoulder injury related to vaccine administration (SIRVA), defined as shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm, is a well-established condition in the medical literature, yet underreported. In such cases, subacromial-subdeltoid bursitis may occur, leading to shoulder dysfunction and ongoing pain. Millions of doses of vaccines for the prevention of COVID-19 have been administered to adults worldwide during the pandemic. We report a case of subacromial-subdeltoid bursitis after COVID-19 vaccination, related to the unintentional injection of vaccine solution into the bursa resulting in a robust immune-mediated inflammatory reaction.

Pterygoid hamulus elongation syndrome

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Pterygoid hamulus elongation syndrome is an extremely rare condition, existed around in 1% of humanity.

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Pain in the soft palate and pharynx can originate from numerous related pathological or anatomical structures.

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The diagnosis of hamular elongation should be based on the detailed history, clinical examination, and correlation with radiographic imaging.

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Management of hamular elongation is preferably to be done with surgical resection, and the conservative solution should be used in limited circumstances.

Introduction

Pain in the soft palate and pharynx can originate from numerous related anatomical structures. Therefore, the diagnosis of patients who complain of pain in these areas is also difficult and challenging. One of the anatomic disorders that causes pain and discomfort in this region is pterygoid hamulus elongation syndrome.

Presentation of case

We report a rare case of pterygoid hamulus elongation with persistent sharp localized pain in the hamular region radiating to the temporal area for four years that was treated successfully by surgical resection of elongated hamulus.

Discussion

Pterygoid Hamulus elongation syndrome is a unique disease presenting many symptoms in the palatal and pharyngeal areas. May caused by injury, infection, or a pre-existing condition. The diagnosis of hamular elongation should be based on detailed history, clinical examination, and correlation with radiographic imaging.

Conclusion

Due to the rarity, PHE syndrome should be diagnosed accurately. Management of hamular elongation is either surgical or conservative but resection of the pterygoid hamulus is usually preferred.

Increased frequency of intermetatarsal and submetatarsal bursitis in early rheumatoid arthritis: a large case-controlled MRI study

Background

The forefoot is a preferential location for joint and tendon sheath inflammation in rheumatoid arthritis (RA). It also contains bursae, of which the intermetatarsal bursae have a synovial lining. Some small imaging studies suggested that intermetatarsal bursitis (IMB) and submetatarsal bursitis (SMB) are involved in RA, but their association has not been thoroughly explored. Healthy control studies suggested that lesion size might be relevant. We studied the relation between IMB and SMB in early RA, compared to other arthritides and healthy controls, and the relevance of lesion sizes.

Methods

Six hundred and thirty-four participants were studied: 157 consecutive patients presenting with early RA, 284 other arthritides, and 193 healthy controls. All underwent unilateral contrast-enhanced MRI of the forefoot at presentation. Two readers independently scored IMB and SMB and measured transverse and dorsoplantar diameters, blinded to clinical data. Subsequently, consensus was reached. Intra-reader ICC was 0.89. Logistic regression models were used, and test characteristics were calculated.

Results

IMB and SMB associated with RA independent of each other (P < 0.001) and independent of age, gender, BMI, RA-MRI inflammation, and anti-CCP-antibodies (P = 0.041). Sensitivity for RA of IMB was 69%, and for SMB 25%. Specificity for IMB was 70% compared to other arthritides, and 84% compared to healthy controls. For SMB, this was 94% and 97% respectively. Regarding lesion size, the groups had considerable overlap: no cut-off size for RA could be distinguished with high sensitivity and specificity.

Conclusion

Intermetatarsal and submetatarsal bursitis associated with early rheumatoid arthritis, contributing to the emerging evidence that inflammation of juxta-articular soft tissues is an early feature of RA.

Treatment of a rotator cuff tear combined with iatrogenic glenoid fracture and shoulder instability: A rare case report

BACKGROUND

The brisement manipulation is an effective treatment for refractory shoulder stiffness. Rotator cuff tears can sometimes exist in combination with adhesive capsulitis. Arthroscopic capsular release combined with rotator cuff repair has achieved good outcomes in published reports.

CASE SUMMARY

We report the case of a patient with right shoulder pain for more than 1 year that was suspected to have adhesive capsulitis and a rotator cuff tear that was treated with brisement manipulation and arthroscopic management. An iatrogenic glenoid fracture with shoulder instability occurred during the manipulation. Arthroscopic treatment for fracture fixation, capsular release, and rotator cuff repair was performed, and the functional results are reported.

CONCLUSION

Arthroscopic fixation for iatrogenic glenoid fracture and repairing coexisting rotator cuff tear can provide the stability needed for early rehabilitation.

[CME Sonography 95: Sonographic Differential Diagnosis of Anterior Shoulder Pain]

CME Sonography 95: Sonographic Differential Diagnosis of Anterior Shoulder Pain Abstract. Anterior shoulder pain is common, and, compared to high-resolution dynamic sonography, the clinical examination is usually not precise enough for the exact classification of the cause of the pain. In this review we discuss possible causes of anterior shoulder pain with special emphasis on the ultrasound diagnosis of causes of subcoracoidal impingement and of anterior snapping syndrome. We use high-resolution ultrasound images to illustrate various possible underlying pathologies in anterior shoulder pain.

The use of pelvic radiographs as a predictor for gluteal tendinopathy and bursitis

AIM

To evaluate the relationship between radiographic measurements of the hip and sonographic evidence of gluteal tendinopathy and bursitis in patients with lateral hip pain.

METHODS AND MATERIALS

Patients with lateral hip pain referred for ultrasound of the hip in our institution over a 5-year period were identified. Findings of gluteal tendinopathy and subgluteal or trochanteric bursitis on ultrasound were recorded. Radiographs of the hip were also evaluated and femoral offset (FO), global offset (GO), abductor lever arm (ALA) and trochanteric impingement distance (TID) were recorded. The mean of each measurement was compared between patients with gluteal tendinopathy and subgluteal or trochanteric bursitis.

RESULTS

273 patients were included in the study. 107 patients (39.2%) had a THA. In the asymptomatic hip, a range of normal measurements were obtained: FO 22.4-76.5 mm, GO 40.1-116.1 mm, ALA 45.0-98.4 mm and TID 13.8-63.1 mm. In the native hip and post THA, there was no statistically significant relationship between FO, GO, ALA and TID in patients with gluteal tendinopathy or trochanteric or subgluteal bursitis.

CONCLUSIONS

Lateral hip pain is a common presenting complaint in patients with hip pain and is reported in a small proportion of patients post THA. No statistically significant relationship was found between radiographic measurements and ultrasound findings in our patient cohort. However, we describe the range of measurements obtained from the normal asymptomatic hip in this large cohort of patients, which may aid in the evaluation and management of patients with lateral hip pain.

Intra-articular distension preceded by physical therapy versus intra-articular distension followed by physical therapy for treating adhesive capsulitis of the shoulder

BACKGROUND

Intra-articular distension is a validated treatment in adhesive capsulitis of the shoulder and is commonly followed by intensive in-patient physical therapy. A recent meta-analysis found that physical therapy is as effective as intra-articular distension (IAD) and that an early distension could be the primary choice for treating frozen shoulder. The question of the additional contribution of physical therapy prior to IAD compared with IAD followed by physical therapy has not been raised.

OBJECTIVES

We compared IAD preceded by physical therapy to that followed by physical therapy in terms of pain relief and functional outcome.

METHODS

We enrolled patients with primitive adhesive capsulitis of the shoulder. The eligible patients were randomized into three groups: A, B and C. Group A received intra-articular distension followed by physical therapy, group B received intra-articular distension in the middle of physical therapy and group C received physical therapy alone. Patients were assessed at the beginning of the protocol (T0), after 6 weeks (T1) and after 12 weeks (T2). The main outcome measures were pain using a Visual Analog Scale and the Disabilities of Arm, Shoulder and Hand Questionnaire.

RESULTS

Out of the 179 enrolled patients, only 122 completed the follow up: group A (n= 34), group B (n= 46) and group C (n= 42). Compared to intra-articular distension preceded by physical therapy, IAD followed by physical therapy did not improve significantly the outcome in terms of pain relief (p= 0.123) but it enhanced the upper extremity function (p= 0.002). Upper extremity pain and function were found to improve with time regardless of the protocol (p< 0.001).

CONCLUSIONS

IAD followed by physical therapy is more beneficial than IAD preceded by physical therapy in terms of upper extremity function. IAD, whether or not preceded by physical therapy, does not significantly improve pain compared to physical therapy alone. Time is a crucial factor to take into consideration while treating adhesive capsulitis of the shoulder.

Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.

Iliopsoas bursitis: The role of diagnostic imaging in detection, differential diagnosis and treatment

Iliopsoas bursitis is characterized by distension of the iliopsoas muscle bursa due to synovial fluid and/or hypertrophic synovium. Hip disease is usually associated with it, however, isolated bursitis is also present. Clinically Diagnosing iliopsoas bursitis can be difficult, and imaging is usually required to differentiate iliopsoas bursitis from other inguinal masses such as lymphadenopathy, hernias, and tumors. We present the case of a 45-year-old athletic patient who underwent diagnostic examination for recurrent right hip pain and a recent development (last 3 months) of a bulky right inguinal mass.

Evaluation of the Olecranon Bursa: An Anatomical Structure in the Normal Horse

This study aimed to determine whether a true synovial structure exists over the olecranon tuberosity, which could be attributed to a noninflamed olecranon bursa. Contrast radiography, gross anatomical dissection, and histopathology were used to evaluate the olecranon bursa in horses with no previous elbow pathology. The radiographic study revealed that the contrast was positioned subcutaneously, superficial to the long head of the triceps and its insertion on the olecranon tuberosity and did not extend cranial to the triceps tendon. The contrast region was consistent in shape, size, and location. Gross anatomical dissection of the area revealed a potential bursal space overlying the tendons of the lateral and medial heads of the triceps brachii and the tensor fascia antebrachii in the normal horse. Histopathology confirmed a bursal lining, which was of mesenchymal origin and suggestive of a single-cell membrane, lined by fibroblast-like synoviocytes.

The Pterygoid Hamulus Syndrome - An Important Differential in Orofacial Pain

The purpose of this review was to document cases of pterygoid hamulus (PH) syndrome and to describe the various etiology, differential diagnosis, and management strategies so far reported in literature. Here, we also present two case reports of PH syndrome. A comprehensive search in PubMed/Medline database was done using MeSH terms such as "Pterygoid Hamulus," "Pterygoid Hamulus Syndrome," and "Hamular Bursitis" using various Boolean operators such as "AND" and "OR". Till date, 31 cases of this entity including the present cases have been found. Conservative management was followed in the earlier reported cases; however, most cases were treated by surgical resection.

Shoulder ultrasound and serum lactate dehydrogenase predict inadequate response to glucocorticoid treatment in patients with polymyalgia rheumatica

We aimed to identify predictors of inadequate response to glucocorticoid (GC) treatment in patients with polymyalgia rheumatica (PMR). We retrospectively studied 32 patients as a derivation cohort and 24 patients as a validation cohort. The patients were divided into two groups according to the response to GC treatment: GC-responders and GC-inadequate responders (GC-IRs). We compared laboratory data and bilateral shoulder ultrasound findings between the groups. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff value of candidate predictors of treatment response; the predictors were examined using multivariate logistic analysis. Gray-scale ultrasound findings of long head of the biceps (LHB) tenosynovitis and subacromial/subdeltoid (SAD) bursitis were scored semiquantitatively (0-3). A total gray-scale score (TGSS) was calculated as the sum of the gray-scale scores. In the derivation cohort, serum lactate dehydrogenase (LDH) levels and TGSS were significantly higher in GC-IRs than in GC-responders. On ROC analysis, the cutoff values of serum LDH levels ≥ 175 IU/ml and TGSS ≥ 5 were found to be the candidate predictors. Multivariate logistic analysis revealed an independent association of both the predictors with inadequate response to GC treatment. In the validation cohort, patients with one or both predictors exhibited a higher incidence of inadequate response to GC treatment. These findings indicate that the severities of LHB tenosynovitis and SAD bursitis evaluated using ultrasound and serum LDH levels are independent predictors of inadequate response to GC treatment in patients with PMR. Treatment adjustment based on prediction model may allow precise treatment of patients with PMR.