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WASHINGTON, D.C.—A 70-year-old woman had been diagnosed with rotator cuff disease three years earlier and received an array of treatments.
What she hadn’t received was an X-ray. She’d had an MRI, and her doctor—not an orthopedist or a rheumatologist, but a primary care physician—had zeroed in on degenerative changes in her rotator cuff.
The problem, said Andrew Neviaser, MD, director of shoulder and upper extremity surgery at George Washington University, is that “everyone has degenerative changes in their rotator cuff when they’re 70 years old.”
The woman finally got an X-ray and was found to have “garden variety osteoarthritis”—something a total shoulder replacement would help, said Dr. Neviaser in the ACR Review Course at the 2016 ACR/ARHP Annual Meeting.
It was a cautionary tale that Dr. Neviaser used to drive home the importance of ordering X-rays when, as a rheumatologist, you are seeing a patient with shoulder pain and are trying to differentiate a rheumatic condition from an orthopedic one.
Be Systematic in Your Approach
Many clinical exam techniques exist for this, but the best accuracy rate is only in the 70% range.
“You really have to work this systemically, consider the age, consider the symptoms, consider where and how much pain a patient had when you’re testing them and get an internal control so you can reliably tease out things like rotator cuff, adhesive capsulitis and calcific tendonitis,” Dr. Neviaser said. “And then get an X-ray.”
Clinical exams tend to have poor specificity and sensitivity because “most of the pathology in the shoulder is going to be positive. When you take the arm and try to push it up over their head, arthritis will give you pain, adhesive capsulitis will give you pain, rotator cuff, labral problems, instability will all give you pain when you move the shoulder around.”
Several research groups have found that a telling measure could be the “critical shoulder angle,” which accounts for the inclination of the glenoid—the “socket” part of the shoulder joint—and the acromion, a bony extension of the shoulder blade. Bigger angles have been associated with rotator cuff disease and smaller ones with osteoarthritis.1,2
“It’s an interesting idea that we are investigating now and may be something that’s very useful for us as clinicians because this is a very inexpensive test,” Dr. Neviaser said.
Clinical exams tend to have poor specificity & sensitivity because ‘most of the pathology in the shoulder is going to be positive.’ —Dr. Neviaser
To Surgically Intervene or Not?
Whether to move to surgery remains a question in many patients. It’s generally been thought that those with symptomatic rotator cuffs tend to be at risk for an increasingly large tear over time and, therefore, should be candidates for surgery, but there have been conflicting studies on this, he said.
“One of the things that we are working on and we need to better understand is, who is going to progress, and we need to act on now, as opposed to later,” he said.
Treating patients even with full-thickness rotator cuff tears with physical therapy rather than surgery was validated in a study that found that only a quarter of the patients went on to surgery over two years.
Reasons for surgery should be pain, functional problems that don’t improve with physical therapy, possibly the risk of progression and the risk of developing fatty infiltrates into the rotator cuff muscle when the tear of the tendon from the rotator cuff muscle allows more space for lipocytes to get into the muscle, causing irreversible damage.
Adhesive capsulitis—also known as frozen shoulder, a term that Dr. Neviaser recommends against using because it doesn’t describe the disorder as well—is another problem that rheumatologists may have to recognize. It’s a painful loss of active and passive motion, caused by a thickening and tightening of the shoulder capsule, with stiff bands of tissue developing.
“It’s really that mechanical restriction of passive range of motion with external rotation at the side that gives the diagnosis away,” Dr. Neviaser said.
“There’s a natural course to this problem that we don’t seem to actually change too much. And if you manage to make the diagnosis in the early phase before they’ve lost a lot of motion and they just have diffuse pain, they will probably lose motion later,” he said. So if a patient worsens during physical therapy, they need to be reminded that it’s not the therapy that’s causing it; it’s just the natural course of the disease.
After physical therapy, he said, many patients are left with residual deficits, but usually not to the point that it affects their daily lives.
It’s reasonable to refer these patients to surgery if they have shown literally no improvement after four months. If they’ve shown modest improvement that’s still unsatisfactory for the patient, it’s reasonable to wait eight or even 12 months.
References
- Gerber C, Snedeker JG, Baumgartner D, et al. Supraspinatus tendon load during abduction is dependent on the size of the critical shoulder angle: A biomechanical analysis. J Orthop Res. 2014 Jul;32(7):952–957.
- Moor BK, Weiser K, Siankamenac K, et al. Relationship of individual scapular anatomy and degenerative rotator cuff tears. J Shoulder Elbow Surg. 2014 Apr;23(4):536–541.