44-year-old male that sustained a contusion to his left shoulder while falling at his home. Following the fall he suffered severe pain. An ultrasound to the shoulder was interpreted as showing some changes in the ACJ and peritendinitis of the biceps brachi. The orthopedic surgeon that examined the patient about 2 weeks post injury had the impression of tendinopathy and requested an MRI that had indicated changes in signals in the ACJ and superior impingement of the supraspinatus and peritendinitis of the biceps. On the basis of these findings an arthroscopy was suggested.
1) Do you confirm the diagnosis?
2) What therapy do you suggest? Specifically, do you deem the proposed surgery necessary? Any alternative treatments?
44 years old , male
Diagnosis: Post-trauma tendinopathy of left shoulder
October 2008 - contusion trauma to left shoulder following an accidental fall down the stairs of his home, with consequent intense loco-regional pain that did not allow the patient to sleep for the entire night that followed. Therefore on the day after the patient spoke to his primary care doctor who prescribed a 40-day rest period and who recommended an in-depth diagnostic analysis.
10/2008 - muscoltendineous ecography of the left shoulder, whose medical report is provided: “tumefaction of the acromion-clavicle joint with respect to the contralateral with initial signs of impingement on the tendon of the supraspinate. No solutions of continuity of the rotator cuff and subscapular. Peritendinitis of the long head of the biceps brachii with liquid distention of the sheath.
10/2008 - orthopaedic visit with Dr. X who, based on the medical report of the ecography and on the clinical assessment, confirmed the diagnosis of “supraspinal tendinopathy and long head of the biceps brachii of the left shoulder.” The specialist then requested a right and left shoulder MRI.
10/2008 - Left shoulder MRI, whose medical report is provided: “Regular continuity and signal of the tendons of the rotator cuff. Presence of altered signal of the acromion-clavicle joint, which presents irregularity in relation to second-degree injury results. Conditions of superior impingement of the critical area of the supraspinate are noted. Peritendinitis of the long head of the biceps brachii. No alterations on supraspinatus tendon and subscapular”.
The patient went again with this medical report for a check-up with Dr. X, who confirmed the previous diagnosis and recommended arthroscopic shoulder surgery.
As of today the pain in the left shoulder is so intense as to prevent several movements from being executed and considerably restricts use of the entire left limb.
The clinical picture at the present time as I understand from the medical information forwarded is: “ intense pain and significant range of motion restriction with difficulty to use the left upper extremity “.
I have reviewed the images of the MRI:
§ There is no significant tear of the rotator cuff tendons.
§ There is an area of osteoarthritic changes of the Acromio Clavicular Joint and mild bulging that is impressing very mildly on the supraspinatus, however no significant changes in the tendon itself are evident.
§ There are no pathologic changes of bone or cartilage of the shoulder.
After reviewing the images and reading the anamnestic clinical story my professional opinion is as follows:
§ There is mild impingement of the supraspinatus tendon with no tear.
§ No other traumatic changes are noted.
§ According to the persistent sever pain and motion restriction there might be also an acute tenosynovitis and the beginning of a clinical picture of “ frozen shoulder/adhesive capsulitis “.
- I would try a course of medical treatment prior to arhroscopic surgery.
- Combined non-steroidal anti-inflammatory medications as etoricoxib 90 mg once daily or etodalac 400 mg XL, twice daily for 10-14 days. Combined with an intra-articular injection of steroids, (Diprospan 2 Ml or Like).
- Analgesic medication as needed.
- If there is improvement after the first course, this may be repeated after 3-4 weeks for 3 consecutive treatment courses.
- Gentle physiotherapy to maintain and preserve motion (very gentle without trying to work through or against the pain).
- A sling for rest of the shoulder for a few days may be of benefit.
The following steps may negate the need for surgery; the prognosis is good for 80% of the patients. If in 3-4 months there is no improvement a rethinking should be made.