Search

Diagnosis of adhesive capsulitis is a clinical diagnosis based on history and physical examination. Afflicted patients exhibit active and passive loss of motion in all planes and a positive capsular stretch sign. The effect of adhesive capsulitis on acromioclavicular biomechanics leading to tenderness has not been documented in the literature. This study reports on the incidence of acromioclavicular tenderness in the presence of adhesive capsulitis. Furthermore, we note the natural history of such acromioclavicular joint pain in relation to that of adhesive capsulitis. Over a 2-year period (2005-2007), 84 patients undergoing initial evaluation for adhesive capsulitis were prospectively examined with the use of validated outcome measures and physical examination. Acromioclavicular joint tenderness results were compared and analyzed on initial evaluation and final follow-up of at least 1 year. Forty-eight patients (57%) with adhesive capsulitis had acromioclavicular joint pain on examination. At final follow-up, as range of motion improved, a significant increase in American Shoulder and Elbow Surgeons/Penn shoulder score and decrease in number of patients with acromioclavicular pain was noted with only 6 patients with residual pain (P<.05). In the presence of adhesive capsulitis, there is not only compensatory scapulothoracic motion but also acromioclavicular motion. This often results in transient symptoms at the acromioclavicular joint, which abate as the frozen shoulder resolves and glenohumeral motion improves. This is important to recognize to avoid unnecessary invasive treatment of the acromioclavicular joint when the patient presents with adhesive capsulitis., (Copyright 2011, SLACK Incorporated.)

The case of a male 76 year-old patient with a history of total hip replacement surgery is presented herein. The patient had tumors in the iliac fossa with swelling of the thigh and pain upon hip flexion and extension. The complementary ultrasound and computed tomography show a large lobed cystic tumor in the left iliac fossa, 7 cm in diameter, close to the prosthesis. The diagnosis was psoas bursitis secondary to the release of polyethylene particles that caused compression and thrombosis of the superficial femoral vein. Cyst formation caused by polyethylene disease after total hip arthroplasty is infrequent.

Purpose: The purpose of this study was to compare the percent relief from injection among subjects with arthroscopic findings of femoroacetabular impingement (FAI) and labral and chondral pathologies while controlling for coexisting extra-articular pathology., Methods: We retrospectively reviewed 72 consecutive subjects (54 female and 18 male subjects), aged 29.9 ± 10.4 years (range, 16 to 55 years), who underwent hip arthroscopy. Three separate analyses of covariance compared the percent relief after injection between groups based on surgically confirmed type of impingement (none, cam, pincer, or combined), labral pathology (none, mild, or torn), and chondral pathology (none, mild acetabular abnormality, acetabular delamination, or femoral lesion) while controlling for the presence of extra-articular pathology (iliotibial band, iliopsoas tendinopathy, or bursitis)., Results: The results of analysis 1 (F₃,₆₇ = 1.96, P = .128, partial η² = .081) and analysis 2 (F₂,₆₈ = 0.008, P = .992, partial η² = .000) indicated no significant main effect for FAI and labral pathology, respectively, on percent relief from injection. The results for analysis 3 indicated a significant main effect for chondral pathology of the hip on the percent relief from injection (F₃,₆₇ = 3.03, P < .05, partial η² = .128). Post hoc analysis showed that those with mild chondral pathology of the acetabulum and those with acetabular delamination had significantly greater percent relief compared with those without chondral pathology. Extra-articular pathology did not influence the percent relief from injection in any of the analyses., Conclusions: Subjects with chondral damage had greater relief from injection than those without, regardless of severity. The presence and severity of FAI and labral pathology did not influence the percent relief from injection. Concurrent extra-articular pathology did not alter the interpretation of the percent relief from injection. Therefore the interpretation and diagnostic value of an anesthetic injection in those with primary intra-articular pathology does not need to be altered by the presence of coexisting extra-articular hip pathology., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Children with juvenile idiopathic arthritis (JIA) may infrequently present with localized anterior knee pain or swelling, in addition to generalize knee pain induced by JIA. We report five cases of deep infrapatellar bursitis in children with JIA. The clinical features, radiological findings, management, and outcome of five children with JIA and deep infrapatellar bursitis are reviewed. Three boys and two girls with a mean age of 9.8 years (range 6-14 years) were reviewed. Four children had persistent oligoarticular JIA, and one child had extended oligoarticular JIA. The presentation of deep infrapatellar bursitis was variable. In only one patient was the bursal swelling painful. Knee magnetic resonance imaging (MRI) was performed in four patients and demonstrated coexistent knee joint synovitis in three. Treatment included targeted corticosteroid injections into the deep infrapatellar bursa in two cases with complete resolution. One case was treated with corticosteroid injection by an outside health care provider with poor clinical response. Two cases are being treated with non-steroidal anti-inflammatory drugs and methotrexate. Deep infrapatellar bursitis can occur as an isolated finding or concurrently with knee joint synovitis in patients with JIA. Awareness of this entity is important because direct injection of the bursa may be needed for treatment, as the bursa does not communicate with the knee joint. Furthermore, when bursitis is suspected in JIA, MRI can be helpful to confirm the diagnosis, detect concurrent knee joint synovitis, and exclude other pathologies.

Manipulation under anaesthesia (MUA) has been used to speed up recovery. However, the outcome of frozen shoulder after MUA in patients with diabetes has not been well documented in the past. A higher prevalence of frozen shoulder has been reported in diabetes mellitus (DM) patients. In this study, we revealed the short- and long-term outcomes for treatment of frozen shoulders by MUA and compared these results in patients with and without non-insulin dependent DM by adjusted Constant score. The scores showed no significant differences between the two groups at both early and late follow-ups. Our results revealed that MUA for frozen shoulders is a simple and noninvasive procedure to improve symptoms and shoulder function within a short period of time. Even though DM is a predisposing factor to frozen shoulder, non-insulin dependent DM alone does not influence both the short- and long-term outcomes of frozen shoulder.

Objective: Many approaches to treatment of frozen shoulder, or adhesive capsulitis, including use of steroid injections, provide only short-term relief. We present a method for pulsed mode radiofrequency (PRF) lesioning of the suprascapular nerve using ultrasound guidance in patients with severe pain from frozen shoulder., Design: Patients with frozen shoulder were treated by using real-time, high-resolution ultrasound guidance to facilitate PRF lesioning of the suprascapular nerve., Setting and Patients: Two patients with frozen shoulder of a tertiary hospital were reported., Measures: Pain intensity and shoulder movement before and after procedure were recorded. Results.  In the two cases presented, both patients experienced pain relief and increased shoulder flexibility for 5-6 months., Conclusion: Ultrasound can not only quickly and effectively identify the suprascapular notch and nerve, but also helps the operator manipulate and advance the needle to a more precise position., (Wiley Periodicals, Inc.)

DM is associated with various musculoskeletal manifestations. The strength of this relationship varies among the various musculoskeletal disorders; the associations are based mostly on epidemiologic data. For most of these conditions, definitive pathophysiologic correlates are lacking.Hand and shoulder disorders occur more frequently than other musculoskeletal manifestations of DM. Recognition of the association between DM and shoulder adhesive capsulitis, DD, and stenosing flexor tenosynovitis facilitates their correct diagnosis in the setting of DM and prompt initiation of appropriate treatment, which may include optimizing glycemic control. Conversely, awareness and identification of the characteristic musculoskeletal manifestations of DM may facilitate earlier diagnosis of DM and initiation of glucose-lowering therapy to retard the development of diabetic complications.Much less has been published about the musculoskeletal complications of DM than about its micro- and macrovascular complications. Prospective case-control cohort studies are needed to establish the true prevalence of musculoskeletal complications of DM and the metabolic syndrome, especially in this era of tighter glycemic control.The potential relationship between DM and the development of OA needs to be clarified in large, prospective, case-control cohort studies. The effect on musculoskeletal manifestations of various therapeutic regimens to manage DM should be studied prospectively. Treatment regimens for some musculoskeletal conditions associated with DM, such as DISH, should be studied in larger prospective, randomized,controlled clinical trials.At the molecular level, further studies are warranted to clarify the potential contribution of AGEs and adipokines to the development of OA and diabetic musculoskeletal syndromes, such as shoulder adhesive capsulitis, DD, stenosing flexor tenosynovitis, and LJM. Identification of such molecular targets for therapy would promote the development of additional treatments for these and other rheumatic diseases., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: Pain is one of the most commonly reported breast complaints. Referred pain from inflammation of the shoulder bursa is often overlooked as a cause of breast pain. The objective of this study is to evaluate the role of shoulder bursitis as a cause of breast/chest pain., Method: An IRB-approved retrospective review from July 2005 to September 2009 identified 461 patients presenting with breast/chest pain. Cases identified with a trigger point in the medial aspect of the ipsilateral scapula were treated with a bursitis injection at the point of maximum tenderness. The bursitis injection contains a mixture of local anesthetic and corticosteroid. Presenting complaint, clinical response and associated factors were recorded and treated with descriptive statistics., Results: Average age of the study group was 53.4 ± 12.7 years, and average BMI was 30.4 ± 7.4. One hundred and three patients were diagnosed with shoulder bursitis as the cause of breast pain and received the bursitis injection. Most cases (81/103 or 78.6%) presented with the breast/chest as the site of most significant discomfort, where 8.7% (9/103) had the most severe pain at the shoulder, 3.9% (4/103) at the axilla and 3.9% (4/103) at the medial scapular border. Of the treated patients, 83.5% (86/103) had complete relief of the pain, 12.6% (13/103) had improvement of symptoms with some degree of residual pain, and only 3.9%(4/103) did not respond at all to the treatment. The most commonly associated factor to the diagnosis of bursitis was the history of a previous mastectomy, present in 27.2% (28/103) of the cases., Conclusions: Shoulder bursitis represents a significant cause of breast/chest pain (22.3% or 103/461) and can be successfully treated with a local injection at site of maximum tenderness in the medial scapular border.

The aim of this report is to present the clinical result and efficacy of reverse lateral supramalleolar adipofascial flap and skin grafting for one stage soft tissue reconstruction of the foot and ankle joints. Reconstruction using a reverse lateral supramalleolar adipofascial flap and skin grafting was performed in eight cases between January 2005 and March 2009. All the subjects were male with a mean age of 53 years. The mean follow-up period was 20 months. The reasons for soft tissue defects were diabetic foot, infected bursitis, open injuries of the foot, and chronic osteomyelitis. The mean size of the flaps was 3.5 (3-4) × 4.5 (4-6) cm. The flaps were elevated in the form of an adipofascial flap and split-thickness skin grafting was performed over the flaps and adjoining raw areas. Flaps survived in all cases. The implantation of the split-thickness skin graft over the flap was also successful in all cases. Neither partial necrosis in the adipofascial flap nor venous congestion was observed. At the last follow-up, there were no limited motions in the ankle and the toe. No cases complained of inconveniences in ambulation or had difficulties in selecting footwear. In cases that require a flap for the exposed bone or tendon of the foot with a small-sized defect, reverse lateral supramalleolar adipofascial flap and skin grafting is considered a useful method as it lowers the morbidity rate of the donor site and reconstructs soft tissues.

Background: Greater trochanteric pain syndrome can be severely debilitating. Ideal imaging modalities are not established, treatments are not reliably evaluated, and the underlying pathology is not well understood., Questions/purposes: Using surgical and histopathology findings as a gold standard, we therefore determined the positive predictive value of preoperative ultrasound assessment for greater trochanteric pain syndrome recalcitrant to nonoperative management. In addition, we report the outcomes of gluteal tendon reconstructive surgery using validated clinical and functional outcome tools and evaluate the contribution of the tendon and bursa to greater trochanteric pain syndrome., Patients and Methods: We reviewed 24 patients who had combined gluteal tendon reconstruction and bursectomy. Preoperative ultrasound imaging was compared with surgical findings. In the absence of a greater trochanteric pain syndrome specific outcome tool, surgical outcomes for pain and function were assessed via a 100-mm visual analog scale, the modified Harris hip score, and the Oswestry Disability Index. Strength also was measured. The tendon and bursa tissue collected at surgery was histopathologically reviewed., Results: In our small study, ultrasound had a high positive predictive value for gluteal tendon tears (positive predictive value = 1.0). Patients reported high levels of pain relief and function after surgery; tendon and bursa showed pathologic changes., Conclusions: Ultrasound appears to be clinically useful in greater trochanteric pain syndrome; reconstructive surgery seems to relieve pain and the histopathologic findings show tendinopathy and bursa pathology coexist in greater trochanteric pain syndrome., Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Background and Purpose: No previous study has described the association between stroke and previous adhesive capsulitis (AC). This study aims to investigate the risk of stroke after AC with a population-based database., Method: Records for 10 935 with a principal diagnosis of AC and 32 805 randomly selected controls were collected between 2000 and 2003. The log-rank test was performed to analyze the differences in accumulated stroke-free survival rates between the 2 groups. Cox proportional hazard regressions were performed to calculate the longitudinal hazard of stroke., Results: During the follow-up period, 575 patients from the study group (5.3%) and 1201 from the comparison group (3.7%) had strokes. The crude hazard ratio for stroke for patients with AC was 1.46-times greater than for controls (95% CI, 1.32-1.62; P<0.001), and the adjusted hazard ratio was 1.22 (95% CI, 1.06-1.40; P=0.002)., Conclusions: Our study demonstrates increased prevalence and risk of stroke after AC. Further study is needed to confirm our findings and explore underlying mechanisms.

Shoulder pain is a common musculoskeletal complaint in the community, which can arise from diverse causes. Regardless of the cause, mild cases can often be effectively treated conservatively, with options including rest, physiotherapy, pain relief and glucocorticoid injections. If conservative strategies fail after a 3-6 month period then surgery might be considered. Generally, the proportion of patients with shoulder pain who require surgery is small. When surgery is considered, a clear diagnosis and structural information from imaging are required. The indications for surgery, and success rate, depend on the specific diagnosis as well as on the individual clinical presentation. Evidence from case series suggest that surgical interventions for shoulder pain are effective when used appropriately. This article outlines the surgical management of the most common painful conditions that affect the shoulder, including impingement, rotator cuff tear, frozen shoulder, osteoarthritis, rheumatoid arthritis and calcific tendonitis.

Polymyalgia rheumatica (PMR) and temporal arteritis (TA) are 2 common conditions in the elderly patient. Early diagnosis and rapid introduction of treatment with corticosteroids is critical, in order to avoid potentially serious complications. The diagnosis is largely clinical for PMR, whereas it is both clinical and histopathological for TA. Certain situations may require complementary investigations such as ultrasound or PET-CT. Bilateral subacromial/subdeltoid bursitis is extremely frequent in patients with PMR, but rarely present in healthy subjects. Intravenous bolus corticosteroids may be useful at presentation with TA, particularly when associated with visual symptoms. There may be a role for disease-modifying antirheumatic drugs (DMARD) such as methotrexate in reducing the requirement for corticosteroids. Finally, clinical and radiological follow-up is important in order to detect aortic aneurysms or large vessel involvement.

Hypothesis: Oral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder., Materials and Methods: In a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used., Results: In the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P < .0001), SST (P=.035), VAS (P < .0001), and range of motion (P < .05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P < .0001), SST (P < .0001), the VAS (P < .0001), and range of motion (P < .05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P < .05). Differences in the VAS for pain and function were not significant (P > .05)., Discussion: The use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids., (Copyright 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Patients with adhesive capsulitis were clinically evaluated to establish whether pain elicited by pressure on the coracoid area may be considered a pathognomonic sign of this condition. The study group included 85 patients with primary adhesive capsulitis, 465 with rotator cuff tear, 48 with calcifying tendonitis, 16 with glenohumeral arthritis, 66 with acromioclavicular arthropathy and 150 asymptomatic subjects. The test was considered positive when pain on the coracoid region was more severe than 3 points (VAS scale) with respect to the acromioclavicular joint and the anterolateral subacromial area. The test was positive in 96.4% of patients with adhesive capsulitis and in 11.1%, 14.5%, 6.2% and 10.6% of patients with the other four conditions, respectively. A positive result was obtained in 3/150 normal subjects (2%). With respect to the other four diseases, the test had a sensitivity of 0.96 and a specificity ranging from 0.87 to 0.89. With respect to controls, the sensitivity and specificity were 0.99 and 0.98, respectively. The coracoid pain test could be considered as a pathognomonic sign in physical examination of patients with stiff and painful shoulder.

Objectives: The aim of the study was to compare the effects of two different exercise programs on pain, range of motion (ROM), and functional results in frozen shoulder., Methods: Twenty-two female and 7 male patients [mean age 52.1 years (range 38-65 years)] were randomly allocated into two groups: 14 in the first group and 15 in the second group. The patients were treated for 6 weeks (30 sessions) at hospital under the supervision of physical therapist. Both groups were treated with transcutaneous electrical nerve stimulation, cold pack, and nonsteroidal antiinflammatory drugs; and were given glenohumeral ROM exercises. The scapulothoracic exercises were performed only by the second group. Functional results were assessed using the modified Constant score, pain was assessed using visual analog scale (VAS), and ROM was measured with a goniometer. Assessments were performed before treatment and repeated at 6 and 12 weeks of treatment., Results: In both groups, the Constant score and ROM were increased, and VAS was decreased at the end of 6 and 12 weeks. The modified Constant score was not significantly different between the groups before and after treatment. VAS score was better in the second group at 6 weeks (p<0.01). Improvement in ROM was significantly better in the second group at 12 weeks (p=0.005)., Conclusion: In addition to glenohumeral ROM exercises, scapulothoracic exercises contribute to decreasing pain and increasing ROM in patients with frozen shoulder.

A 57-year-old female patient with a history of tophaceous gout based on chronic renal insufficiency caused by systemic lupus erythematosus nephritis developed bursitis of the right lateral malleolus. This was taken for gout and was treated with colchicine and an increased dose of her maintenance therapy of oral glucocorticoids. Since this had no effect, a local diagnostic puncture was performed. Aspiration yielded pus from which Staphylococcus aureus was cultured; upon polarisation microscopy many uric acid crystals were seen. The diagnosis was gout and coincident bacterial infection. Therapy consisted of incision of the bursa and antibiotic therapy. Local recovery was uneventful. In patients suspected of an acute gout attack who have an increased risk of bacterial infection, e.g. elderly and patients with severe comorbidity or immunodeficiency, a local diagnostic aspiration is the only adequate investigation. Only if (coincident) bacterial infection has been ruled out, patients with contraindications for non-steroidal anti-inflammatory drug therapy and colchicine may safely be treated for a gout attack with oral glucocorticoids.

Objective: The aim of this study was to evaluate the effects of corticosteroid injections on hemiplegic shoulder pain and range of motion., Design: Fifty-two stroke patients with shoulder pain were evaluated. Thirty-eight patients who fulfilled the criteria were assigned randomly into either injection or control groups. Transcutaneous electrical nerve stimulation and therapeutic exercise program were applied to both groups for 15 sessions. The patients in the injection group were administered either intra-articular or subacromial injections of corticosteroid and local anesthetic according to their pathology. The evaluations were performed before treatment and at the first and fourth weeks of treatment. Primary follow-up parameters were passive shoulder range of motion and verbal analog scale for shoulder pain; secondary follow-up parameters were modified Barthel index, Brunnstrom upper-extremity score, and modified Ashworth scale., Results: In both groups, shoulder range of motion and shoulder pain scores showed significant improvement. When the two groups were compared, the improvement was more significant in the injection group. Barthel scores improved in both groups, and no difference was found between the groups. Brunnstrom upper-extremity and modified Ashworth scores revealed nonsignificant changes in both groups., Conclusions: Adding corticosteroid injection to conventional treatment in hemiplegic shoulder pain improved shoulder range of motion and decreased pain scores before treatment to the first and fourth weeks of treatment. Injection in hemiplegic shoulder pain is recommended in appropriate patients.

This article presents a simple technique for fascia lata lengthening that is less aggressive, can be performed under local anaesthetic with little morbidity and disability, and has excellent results. Eleven patients (13 hips) were enrolled in this study. Mean age was 54.6 years, there was one man and ten women. Outcomes were assessed by using a visual analog pain scale, Harris hip score and Lickert scale (satisfaction). There was a mean follow-up time of 43 months (range 15-84). All patients were scored by the Harris hip scale with a mean improvement from 61 (range 48-77) to 91 (range 76-95) after surgery. The mean visual analogue scale (VAS) score improved from 83 (range 60-99) to 13 (range 0-70). We had 12 of 13 patients reporting a good result. Mean surgical time was 15 min, and only one seroma was reported as a complication. No inpatient management was needed. In conclusion, distal "Z" lengthening of the fascia lata appears to be a good alternative for treatment of this condition.

Purpose: The purpose of this study was to determine the incidence of clinically significant postoperative stiffness following arthroscopic rotator cuff repair. This study also sought to determine the clinical and surgical factors that were associated with higher rates of postoperative stiffness. Finally, we analyzed the result of arthroscopic lysis of adhesions and capsular release for treatment of patients who developed refractory postoperative stiffness 4 to 19 months (median, 8 months) following arthroscopic rotator cuff repair., Methods: A retrospective review of a consecutive series of arthroscopic rotator cuff repairs was conducted. During a 3-year time period, the senior author (S.S.B.) performed 489 arthroscopic rotator cuff repairs. The operative indications, technique of the rotator cuff repair, and the rehabilitation protocol were essentially unchanged during this time period. Demographic data, comorbid medical conditions, rotator cuff tear description, technique of repair, and concomitant surgical procedures were evaluated for their effect on stiffness. All office evaluations were reviewed to determine the pre- and postoperative motion, pain scores, functional strength, and patient satisfaction. Patients who were dissatisfied because of the development of postoperative stiffness underwent secondary arthroscopic lysis of adhesions. The final result of the secondary lysis of adhesions and capsular release were analyzed., Results: In total, 24 patients (4.9%) were dissatisfied with the result of their procedure because of the development of postoperative stiffness, which was more likely (P < .05) to develop in patients with Workers' Compensation insurance (8.6%), patients younger than 50 years of age (8.6%), those with a coexisting diagnosis of calcific tendonitis (16.7%) or adhesive capsulitis (15.0%) requiring additional postoperative therapy, partial articular-sided tendon avulsion (PASTA) type rotator cuff tear (13.5%), or concomitant labral repair (11.0%). Patients with concomitant coracoplasty (2.3%) or tears larger in size and/or involving more tendons were less likely (P < .05) to develop postoperative stiffness. Among 90 patients positive for selected risk factors (adhesive capsulitis, excision of calcific deposits, single-tendon repair, PASTA repair, or any labral repair without a concomitant coracoplasty), 12 (13.3%) developed postoperative stiffness (P < .001). This overall clinical risk factor combined with Workers' Compensation insurance identified 16 of the 24 cases resulting in a sensitivity of 66.7% and a specificity of 64.5%. All 24 patients who experienced postoperative stiffness elected to undergo arthroscopic lysis of adhesions and capsular release, which was performed from 4 to 19 months (median, 8 months) after the rotator cuff repair. During second-look arthroscopy, 23 patients (95.8%) were noted to have complete healing of the original pathology. Following capsular release, all 24 patients were satisfied with the overall result of their treatment., Conclusions: In a series of 489 consecutive arthroscopic rotator cuff repairs, we found that 24 patients (4.9%) developed postoperative stiffness. Risk factors for postoperative stiffness were calcific tendinitis, adhesive capsulitis, single-tendon cuff repair, PASTA repair, being under 50 years of age, and having Workers' Compensation insurance. Twenty-three of 24 patients (95.8%) showed complete healing of the rotator cuff. Arthroscopic release resulted in normal motion in all cases., Level of Evidence: Level IV, therapeutic case series.

Patients with prepatellar septic bursitis are typically successfully managed nonoperatively with rest, compression, immobilization, aspiration, and antibiotics. Rarely, surgical excision of the bursa may be required for recalcitrant cases. Prepatellar bursectomy, however, has been associated with considerable risk of surgical-site morbidity. Although skin necrosis is frequently cited as a complication of open bursectomy, there is limited information in the medical literature on the etiology and management of this rare but serious complication.

Background and Purpose: The purpose of this study was to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis., Participants: Data were examined from 2,370 patients (mean age=55.3 years, SD=12.4; 65% female, 35% male) classified into ICD-9 code 726.0 who had completed an episode of outpatient physical therapy., Methods: Principal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50% or greater change in Physical Component Summary-12 (PCS-12), physical function (PF), bodily pain (BP), and hybrid function (HF) scores., Results: None of the patients achieved a 50% or greater improvement in PCS-12 scores. Improvement in BP scores was more likely in patients who received joint mobility interventions (odds ratio=1.35, 95% confidence interval=1.10-1.65). Improvement in HF scores was more likely in patients who received exercise interventions (odds ratio=1.50, 95% confidence interval=1.03-2.17). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19% to 32%., Limitations: The authors relied on clinician-identified ICD-9 coding for the diagnosis. Impairment measures were not available to support the diagnosis, and some interventions were excluded because of infrequent use by participating therapists., Discussion and Conclusion: These results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

Soft tissue infections are common and potentially fatal conditions. Infections are a major cause of morbidity and mortality in patients who have rheumatic disease. Patients who have rheumatic diseases may be at increased risk for soft tissue infections because of various factors, including inherent immunologic defects, genetics, and use of immunomodulatory therapy, including biologic agents. Timely diagnosis and management with the institution of antibiotics with or without surgical intervention is imperative for effective resolution of infection. This article provides a review of recent literature on the presentation and clinical course of infectious tenosynovitis, septic bursitis, pyomyositis, and necrotizing fasciitis, especially in relation to patients who have rheumatic disease.

Osteochondroma is the most common benign bone tumor and present as multiple masses in the hereditary disorder of multiple hereditary exostosis. It is usually painless without specific symptoms. However, it rarely causes symptoms such as mass effects that produce several mechanical problems, and malignant transformation of the cartilaginous cap. The deformities and interference with major joint function are the most frequent musculoskeletal complaints dependent on the location of the mass. Large bursa formation with mechanical symptom has been very rarely reported in osteochondroma in which bursa is over the cap. Here, we first described a patient with multiple hereditary exostosis who had developed huge bursitis on chest wall around the osteochondroma arising from the anterior surface of the right scapula after dumbbell lifting exercise for 3 months, and suggest that cystic mass can develop in any site of osteochondroma and should be early differentiated from malignant transformation of osteochondroma.

Objective: This article presents a case report illustrating an improvement in the curvature of idiopathic scoliosis as a secondary benefit from treatment of adhesive capsulitis with an active therapeutic movement (ATM) device., Clinical Features: The patient was a 55-year-old school teacher who was referred to physical therapy for adhesive capsulitis. It was determined that part of the patient's limited shoulder range of motion was due to her significant kyphoscoliosis posture, which resulted in decreased mobility of her thoracic spine., Intervention and Outcome: The patient was treated with an ATM device as a means to help mobilize her thoracic spine. The patient completed several weeks of therapy, which consisted of using the ATM exclusively. The patient gained near-normal range of motion in both arms and had improvement in her kyphoscoliosis posture., Conclusion: A nonsurgical treatment was a useful intervention for some of the physical and psychosocial aspects that this patient with kyphoscoliosis encountered.

Unlabelled: For patients with refractory retrocalcaneal bursitis (Haglund's syndrome), the most effective surgical approach has not been defined. We asked whether patients undergoing the tendon-splitting approach and the lateral approach would have comparably effective relief of pain for both types of calcaneal ostectomies. We retrospectively reviewed 30 patients (31 feet) who underwent the tendon-splitting approach and compared their results with 32 previous patients (35 feet) who had a lateral incision. Minimum followup was 12 months (mean, 16 months; range, 12-23 months) for the tendon-splitting group and 15 months (mean, 51 months; range, 15-109 months) for the lateral group. The mean American Orthopaedic Foot and Ankle Society score improved from 43 points preoperatively to 81 points (range, 8-100 points) postoperatively in the tendon-splitting group and from 54 points to 86 points (range, 55-100 points) in the lateral group. The mean physical component score of the Short Form-36, version 2, at followup was 52 (range, 22-61) in the tendon-splitting group and 49 (range, 34-63) in the lateral group. The median return to normal function was 4.1 months (range, 3-13 months) in the tendon-splitting group and 6.4 months (range, 4-20 months) in the lateral group. Both approaches to calcaneal ostectomy provided symptomatic pain relief. However, patients in the tendon-splitting group returned to normal function quicker than patients in the lateral group., Level of Evidence: Level III, retrospective comparative study.

Objective: To estimate the contribution of selected non-articular conditions (NACs) to pain severity and functional limitation in community-dwelling older adults with knee pain., Design: Population-based, cross-sectional study of 745 adults aged 50 years and over with knee pain. Self-complete questionnaires, clinical history and physical examination were used to identify the presence of selected NACs that could cause pain around the knee. Regression analyses were used to compare levels of knee pain severity (0-20) and functional limitation (0-68) (Western Ontario and McMaster Universities osteoarthritis index physical function subscale [WOMAC-PF]), between those with one or more NACs and those with none (NACs-absent)., Results: Two hundred and seventy-three (36.6%) participants had at least one NAC: widespread pain, n=159; low back pain with index leg referral, n=102; full-leg pain, n=88; hip arthritis, n=65; prepatellar, infrapatellar or pes anserine bursitis, n=35. The NACs group had significantly higher levels of pain severity and functional limitation than the NACs-absent group: 8.2(+/-4.6) vs 5.4(+/-3.8) and 27.9(+/-15.8) vs 16.8(+/-13.2), respectively. The groups did not differ with respect to severity of radiographic osteoarthritis (ROA). Having one or more NACs accounted for a significant proportion of the variance in WOMAC scores, above that which could be explained by age, gender, body mass index and severity of ROA., Conclusion: NACs appear to be common in older adults with knee pain. They make a significant contribution to knee pain severity and functional limitation and are likely to represent additional, rather than alternative, causes of knee pain/functional limitation to osteoarthritis (OA). These factors should be taken into account in epidemiological studies of knee pain and OA.

Study Design: Prospective cross-sectional study., Objectives: To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology., Background: LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem., Methods and Measures: Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance imaging (MRI) studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined., Results: Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large., Conclusions: The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MRI as a diagnostic reference standard. This factor, together with the imprecise point estimates of the likelihood ratios, means that no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology.

Bicipitoradial bursitis is a rare condition: we found 36 cases reported in the literature, none in children. The main manifestation is a painful tumefaction. We report a case observed in an adolescent whose magnetic resonance imaging findings were compatible with a malignant tumor. Surgical biopsy enabled the correct diagnosis of inflammatory synovium without signs of malignancy compatible with bicipitoradial bursitis. Complete cure was achieved without resection.

Background: Idiopathic frozen shoulder is a self-limiting regional skeletal problem of unknown etiology. Clinically, patients first experience a phase of pain, progressing to a freezing stage when glenohumeral motion is lost, followed by a thawing phase when pain gradually subsides and most of the lost motion returns., Objectives: To identify possible specific and non-specific risk factors for idiopathic frozen shoulder., Methods: We compared the medical histories, drug treatment, previous hospital as well as health management organization blood tests of 126 new consecutive frozen shoulder patients from a shoulder clinic to those of an age-matched control group of 98 consecutive patients from an orthopedic foot and ankle clinic and to the regional population disease prevalence registry. Frozen shoulder was classified as idiopathic only if there was no history of trauma and no evidence of a rotator cuff tear., Results: Among the frozen shoulder patients 29.4% had diabetes and 13.5% had thyroid disorders. The risk ratio for diabetes in the frozen shoulder group was 5.9 for males (95% confidence interval 4.1-8.4, P< 0.001) and 5.0 for females (95% CI 3.3-7.5, P< 0.001). The risk ratio for thyroid disorders among females with frozen shoulder was 7.3 (95% CI 4.8-11.1, P= 0.001). No significant difference was found in the prevalence of thyroid disorders between frozen shoulder and the control group, but there was a significantly higher prevalence of diabetes in males and a trend for higher prevalence in females in the frozen shoulder group., Conclusions: Physicians should be aware that diabetes is a specific risk factor for idiopathic frozen shoulder in both males and females and thyroid disorders are a non-specific risk factor in females only.

Background: Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated., Methods: In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial., Results: The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion., Conclusion: This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone., Trial Registration: The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.

Objective: The fibular collateral ligament (FCL)-biceps femoris (BF) bursa is not a commonly known location for calcific bursitis. A case of FCL-BF calcific bursitis is presented., Clinical Features: An 18-year-old man had a blunt trauma on the lateral side of his right knee approximately 1 year before his examination. The pain and physical distortion developed in the trauma region over time. Physical examination revealed a 30 degrees flexion contracture and slight valgus deformity in the right knee. There was 30 degrees of external rotation in the leg and a 15 degrees equinus deformity in the ankle. The patient had toe-toe gait. There was a tender swelling 3 x 4 cm in size on the posterolateral aspect of the right knee., Intervention and Outcome: Plain radiography and computed tomography revealed a calcific mass, approximately 1.5 x 4 cm in size, between soft tissues adjacent to the posterolateral side of the right lateral femoral condyle. There were articular cartilage thinning and joint space narrowing at the lateral site of the knee joint, and magnetic resonance imaging showed bone marrow edema at the lateral condyles of the tibia and femur. The enlarged calcified bursa was excised. A segment of the contracted iliotibial tract was excised, and a fractional lengthening was performed on the BF tendon., Conclusion: This case report revealed that calcific bursitis can occur in the FCL-BF bursa, which may lead to complications when neglected.

Background: A nonsurgical intervention, interventional microadhesiolysis, was developed to release adhesions in joints and soft tissues. This paper introduces the procedure and evaluates the efficacy of the intervention for adhesive capsulitis of the shoulder., Methods: Ten patients (five men and five women) with primary adhesive capsulitis of the shoulder were treated at a chronic pain management center in Korea. Three specially made needles are used in interventional microadhesiolysis: the Round, Flexed Round, and Ahn's needles. A Round Needle is inserted on the skin over middle of supraspinatus and advanced under the acromion and acromioclavicular joint (subacromial release). A Flexed Round Needle is inserted two-fingers caudal to the inferior border of the scapular spine and advanced over the capsule sliding on the surface of infraspinatus muscle-tendon fascia. The capsule is released while an assistant simultaneously passively abducts the shoulder to full abduction (posteroinferior capsule release). An Ahn's Needle is inserted on the skin over the lesser tubercle and advanced under the coracoid process sliding on the surface of the subscapularis muscle (subcoracoid release)., Results: After the patients underwent interventional microadhesiolysis, the self-rated pain score or severity declined significantly (p < .01), the shoulder range of motion increased significantly (p < .01), and joint effusion in the affected shoulder decreased or disappeared in nine of ten patients on magnetic resonance imaging compared to their initial status., Conclusion: Our findings suggest that interventional microadhesiolysis is effective for managing adhesive capsulitis of the shoulder.

We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertrochanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoperative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present.

We report on a 54-year-old woman with rheumatoid arthritis who had severe femoral nerve palsy affected by a distended synovium in the hip joint. Surgical exploration demonstrated a perforation of the iliopectineal bursa connecting with the hip joint. The patient fully recovered from femoral nerve palsy after surgery. It was considered that synovitis of the hip joint had developed following huge iliopectineal bursitis.

Background: Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders.The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period., Methods/design: This paper presents the design for a randomized controlled trial to be conducted between September 2007 - September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm. After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire., Discussion: Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study., Trial Registration: This randomized clinical trial is registered at current controlled trials ISRCTN75722066.

A case of coexistent acute gout and septic olecranon bursitis is presented. Our hypothesis is that asymptomatic monosodium urate crystals, possibly present in the bursa could secondarily been triggered by the infection.

We report a case of an EBV-associated high grade B-cell lymphoproliferative disorder occurring in the synovial membrane of an elderly patient with gout arthropathy. The EBV-infected B-cells displayed a pattern of viral gene expression (EBNA2+/LMP1+) typically seen during primary EBV-infection and in lymphoproliferations occurring in immunosuppressed individuals. This case conforms to senile EBV-associated lymphoproliferative disorders previously reported only in Japanese patients. We suggest that an impaired EBV-specific T-cell immunity, local or systemic, may play a role in the development of this disorder and that chronic diseases such as gout may be contributing factors., (2007 John Wiley & Sons, Ltd.)

Objectives: To describe the prevalence of greater trochanteric pain syndrome (GTPS); to determine whether GTPS is associated with iliotibial band (ITB) tenderness, knee osteoarthritis (OA), body mass index (BMI), or low back pain (LBP); and to assess whether GTPS is associated with reduced hip internal rotation, physical activity, and mobility., Design: Cross-sectional, population-based study., Setting: Multicenter observational study., Participants: Community-dwelling adults (N=3026) ages 50 to 79 years., Interventions: Not applicable., Main Outcome Measures: Greater trochanteric tenderness to palpation in subjects with complaints of hip pain and no signs of hip OA or generalized myofascial tenderness., Results: The prevalence of unilateral and bilateral GTPS was 15.0% and 8.5% in women and 6.6% and 1.9% men. Odds ratio (OR) for women was 3.37 (95% confidence interval [CI], 2.67-4.25), but age and race were not significantly associated with GTPS. In a multivariate model, adjusting for age, sex, ITB tenderness, ipsilateral and contralateral knee OA, BMI, and LBP, ITB tenderness (OR=1.72; 95% CI, 1.34-2.19), knee OA ipsilaterally (OR=3.47; 95% CI, 2.72-4.42) and contralaterally (OR=1.74; 95% CI, 1.32-2.28), and LBP (OR=2.79; 95% CI, 2.22-3.50) were positively related to GTPS. In this complete model, BMI was not associated with GTPS (OR=1.10; 95% CI, 0.80-1.52 when comparing >or=30 with <25kg/m(2)). Hip internal rotation range of motion did not differ based on GTPS status. After multivariate adjustment, GTPS did not alter physical activity score, but bilateal GTPS was significantly associated with a higher 20-meter walk time and chair stand time., Conclusions: The higher prevalence of GTPS in women and in adults with ITB pain or knee OA indicates that altered lower-limb biomechanics may be related to GTPS. Slower functional performance in those with GTPS suggests that the study of targeted rehabilitation may be useful. A longitudinal study will be necessary to identify causal factors and outcomes of interventions.

Manipulation under anesthesia (MUA) has been used to speed up the recovery of frozen shoulder, which is said to be a self-limiting process. We would like to elucidate the short- and long-term results of the treatment of frozen shoulders by manipulation under anesthesia and compare the results of idiopathic, post-trauma and post-surgery frozen shoulders. We applied an adjusted Constant score (Constant score after excluding the 25 points allocated for the assessment of muscle strength) to assess all patients. In our series, 47 cases with 51 frozen shoulders were collected and evaluated retrospectively. The adjusted Constant score at pre-manipulation was on average 22.8+/-4.9 (10-31) points. The score from the 3-week follow-up was 52.6+/-9.2 (31-67) points on average. The score from the averaged 82-month follow-up was on average 70.1+/-6.2 (54-75) points, with 23 shoulders scored for a maximum point number of 75. The score at the early and late follow-ups was significantly lower for the post-surgery group (63.2+/-6.7) when compared to the other two groups (P<0.001). Our results revealed that manipulation under anaesthesia is a very simple and noninvasive procedure for shortening the course of an apparently self-limiting disease and can improve shoulder function and symptoms within a short period of time. However, we found less improvement in post-surgery frozen shoulders, especially in residual pain and limited range of motion (ROM), which may be influenced by the initial injury or initial surgery. Although less improvement in pain and ROM was noted, manipulation is still a good and simple way to treat post-surgery frozen shoulders.

We report a 67-year-old woman with systemic lupus erythematosus and systemic disseminated tuberculosis affecting the femoral trochanteric bursae, a site rarely affected by tuberculosis. For quantification of the inflammation with gallium-67 scintigraphy, we calculated the radioisotope count ratio in the most inflamed areas, the right lateral thorax and bursa of the right greater trochanter. Systemic scanning with this modality allowed evaluation of the extent of lesions and simple quantitative determination of the severity of inflammation, yielding information useful for the follow-up of the patient during the course of tuberculosis treatment.

Myofascial pain refers to a specific form of soft-tissue rheumatism that results from irritable foci (trigger points) within skeletal muscles and their ligamentous junctions. It must be distinguished from bursitis, tendonitis, hypermobility syndromes, fibromyalgia and fasciitis. On the other hand it often exists as part of a clinical complex that includes these other soft-tissue conditions, i.e., it is not a diagnosis of exclusion. The clinical science of trigger points can be traced to the pioneering work of Kellgren in the 1930s, with his mapping of myotomal referral patterns of pain resulting from the injection of hypertonic saline into muscle and ligaments. Most muscles have characteristic myotomal patterns of referred pain; this feature forms the basis of the clinical recognition of myofascial trigger points in the form of a tender locus within a taut band of muscle which restricts the full range of motion and refers pain centrifugally when stimulated. Although myofascial pain syndromes have been described in the medical literature for about the last 100 years, it is only recently that scientific studies have revealed objective abnormalities.