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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 12-15

Sonographic evaluation of painful shoulder and its comparison with clinical diagnosis

1 Department of Orthopaedics, Jawaharlal Nehru Medical College (DMIMS), Wardha, Maharashtra, India
2 Department of Radio-Diagnosis, Jawaharlal Nehru Medical College (DMIMS), Wardha, Maharashtra, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Suresh Vasant Phatak
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_52_18

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Objective: To study sonographic findings in cases of painful shoulder and to compare this with the clinical diagnosis made by physical examination.Materials and Methods: This is a prospective observational study of all patients visiting our hospital with painful shoulder. This study was conducted at AVBRH hospital, Sawangi, Wardha, from March 2016 to July 2018. Results: Sensitivity of physical examination with respect to ultrasonography was low with overall sensitivity, specificity, positive predictive vaue, and negative predictive value found were 65.38%, 77.78%, 89.47%, and 43.75%, respectively. Conclusion: Sonography of shoulder joint is more sensitive than clinical examination in cases of painful shoulder.

Keywords: Painful shoulder, physical examination, rotator cuff tear, tendinitis

How to cite this article:
Deshpande SV, Phatak SV, Marfani GB, Gupta NA, Daga SS, Samad SS. Sonographic evaluation of painful shoulder and its comparison with clinical diagnosis. J Datta Meghe Inst Med Sci Univ 2018;13:12-5

How to cite this URL:
Deshpande SV, Phatak SV, Marfani GB, Gupta NA, Daga SS, Samad SS. Sonographic evaluation of painful shoulder and its comparison with clinical diagnosis. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2020 Feb 17];13:12-5. Available from: http://www.journaldmims.com/text.asp?2018/13/1/12/240903

  Introduction Top

Shoulder pain is one of the most common complaints encountered in orthopedic practice and often responsible for considerable disability. There are various causes of a painful shoulder, but periarticular soft-tissue lesions involving various tendons and bursae are the most common. Even though a large amount of clinical tests used for the diagnosis of painful shoulder are considered accurate in determining the location of the periarticular lesions, these entities may be difficult to differentiate by physical examination.[1]

  Materials and Methods Top

This is a prospective hospital-based study conducted in the Department of Radiodiagnosis from July 2016 to July 2018. This study included 50 patients (36 males, 14 females) who were referred to the Department of Radiodiagnosis after clinical diagnosis made by physical examination in the orthopedic department. A thorough physical examination of cases was performed using various tests. The sonography examination was performed on Arietta 70S Aloka Hitachi machine having color Doppler, power Doppler, tissue harmonic imaging, and strain elastography using linear array transducer 12–18 MHz (multifrequency) for the evaluation of the above patients. Examination technique includes transverse and longitudinal planes from the biceps tendon groove, rotator cuff, and subacromial–subdeltoid bursa and transverse planes from the posterior glenohumeral recess and glenoid labrum were scanned.

  Results Top

The mean age of the patients was 51.5 years (ranges from 21 to 80 years). Maximum patients involved in the study were male 36 (72%). The most common age group of involvement was 31–40 years (30%) [Table 1]. The right shoulder was more commonly involved than the left shoulder (56%), and none of our cases had bilateral involvement [Table 2]. The most common clinical diagnosis was supraspinatus lesion (38) followed by subscapularis (13) and bicep tendon lesion (11) [Table 3]. On ultrasonography, the most common pathology detected in painful shoulders was supraspinatus partial tear followed by biceps tendon sheath effusion and subdeltoid–subacromial bursitis [Table 4]. Overall supraspinatus tendon was most commonly involved in our study. The sensitivity of physical examination with respect to ultrasonography (US) was low in the clinical diagnosis of all shoulder lesions [Table 5]. The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) found were 65.38%, 77.78%, 89.47%, and 43.75%, respectively. Percentage of change in the diagnosis after sonography was significant. A total number of cases included in the study were 50, but in clinical examination and sonography more than one lesion was found in many cases.
Table 1: Age and sex distribution of symptomatic shoulders (50)

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Table 2: Distribution of symptomatic shoulder according to side involved (50)

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Table 3: Lesions found on clinical examination

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Table 4: Sonographic findings in symptomatic shoulders

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Table 5: Comparison of clinical examination and ultrasonography examination

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  Discussion Top

The lesions of the rotator cuff are a common cause of shoulder pain and dysfunction. Cuff strain, impingement syndrome, rotator cuff tears make up a group of lesions that produce shoulder pain. It is clinically difficult to differentiate between these diagnoses and distinguish cuff problems from other conditions such as glenohumeral instability.[2] Many clinical tests are described in shoulder examination. Impingement tests include neer test, Hawkins–Kennedy test, empty can test, and rotator cuff tests are external rotation lag sign, drop arm test, supine impingement test, and belly-press test.[3] Many modalities are available for the diagnosis of articular and periarticular pathologies of shoulder joint such as plain radiography, ultrasonography, computed tomography (CT), CT arthrography, and magnetic resonance imaging (MR), and MR arthrography. Each of these has its own limitations and advantages over others. Ultrasound is a diagnostic tool for the evaluation of musculoskeletal disorders with excellent results. It is easily affordable, and universally available allows comparison with the opposite normal side uses no ionizing radiation and can be performed at bedside or in the operating room if the need arises with ease. Although physical examinations can detect good amount of individual lesions, still have a lower efficacy to differentiate between various causes of painful shoulder and to detect the pathology in the same. Our study has found lower sensitivity to detect various pathology of the shoulder on physical examination. It is difficult to distinguish between various rotator cuff diseases such as tendonitis, partial-thickness tear, or full-thickness tear by physical examination alone.[4]

Spectrum of the ultrasonographic findings in the current study

In our study, supraspinatus tendon pathologies include partial tear [Figure 1], complete tear [Figure 2], tendinitis [Figure 3], and calcific tendinitis [Figure 4]. In the case of subscapularis tendon, partial tear and calcific tendinitis were seen. Biceps tendinitis, biceps sheath effusion [Figure 5], subdeltoid–subacromial bursitis [Figure 6], and impingement were other pathologies which were observed.
Figure 1: Partial tear of supraspinatus tendon at insertion site

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Figure 2: Full-thickness tear of supraspinatus tendon. Loss of tendon fibers filled with fluid. Elastography showing soft colors (red and green)

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Figure 3: Thickened heterogeneous supraspinatous tendon showing soft colors on strain elastography suggestive of tendinosis

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Figure 4: Calcific tendinitis of supraspinatus tendon at insertion site

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Figure 5: Large amount of fluid is seen in bicipital groove around long head of biceps tendon. Suggestive of effusion in the tendon sheath

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Figure 6: Fluid in subdeltoid–subacromial bursa suggestive of bursitis

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Supraspinatus tendon pathology was the most common finding in our study. The studies done by Naredo et al., 2002[1] and Patidar et al. in 2012[4] also showed similar findings. Subscapularis involvement was more common as compared to infraspinatus in our study, which was similar to the study by Patidar et al.[4] which was not in accordance with studies done by Naredo et al., 2002.[1] Partial-thickness tears were more common than full-thickness tears in the present study. Articular surface partial-thickness tear was the most common type of partial-thickness tear in our study in accordance with Patidar et al.[4] Most commonly observed pathology of the biceps tendon in association with rotation cuff tear was tendon sheath effusion. These findings are in accordance with Naredo et al. and Patidar et al.[1],[4] Subdeltoid–subacromial bursal fluid was found in 15 (30%) painful shoulder in our study. Calcific tendinitis is seen in the present study in five cases (four in the supraspinatus and one in subscapularis tendon). Impingement is seen in 11 cases while Patidar reported it as a rare isolated finding.[4] In our study, supraspinatus tendon pathology was most common, and sensitivity, specificity, PPV, and NPV observed was 75%, 50%, 91.30%, and 22.22%, respectively [Table 6]. In Patidar et al. study, it was 85%, 57%, 57%, and 50%.[4] In a study by Naredo et al., observed values were 72%, 38%, 61%, and 50%, respectively.[1] Limitations of US include lack of visualization of the posterior aspect of supraspinatus and infraspinatus tendons, limited view of the glenohumeral joint and glenoid labrum, and lack of desirable patient position during sonographic examination due to restricted painful movements of the shoulder joint.
Table 6: Analysis of clinical diagnosis considering ultrasonography as optimal modality

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Elastography is based on the principle of tissue deformability when the pressure is applied. Tissue or lesion can behave in different ways, depending on its molecular makeup, when external pressure is applied to it. Soft tissues will deform more, and hard tissues will deform less. This information is shown on the monitor as a spectrum of colors as follows: blue representing hard areas, red representing soft areas, and green representing firm areas with intermediate consistency/stiffness. The tissue contrast seen on sonoelastography is due to differential tissue stiffness.[5] Elastic properties of normal tendons are altered under pathological conditions, and a distinct intratendinous softening can be detected. It is possible that more lesions can be found by adding sonoelastography to the conventional US and that this could result in earlier and more accurate diagnoses of tendinopathy.[6]

  Conclusion Top

Sonography of shoulder is more sensitive than clinical examination for the diagnostic evaluation of painful shoulder. Noninvasiveness, easy availability, an excellent demonstration of structures, and cost-effectiveness make its investigation of choice.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Naredo E, Aguado P, De Miguel E, Uson J, Mayordomo L, Gijon-Baños J. Painful shoulder: Comparison of physical examination and ultrasonographic findings. Ann Rheum Dis 2002;61:132-6.  Back to cited text no. 1
Madurwar AU, Sravan Kumar K, Ramya, Bhavani A. Clinico-radiological correlation of shoulder joint pain. IJSR 2017;6:1117-22.  Back to cited text no. 2
Moen MH, de Vos RJ, Ellenbecker TS, Weir A. Clinical tests in shoulder examination: How to perform them. Br J Sports Med 2010;44:370-5.  Back to cited text no. 3
Patidar M, Patil A, Verma V, Kaushal L. Evaluation of painful shoulder with high frequency sonography and their comparison with the clinical diagnosis made by physical examination. NJR 2012;2:43-50.  Back to cited text no. 4
Lalitha P, Reddy MC, Reddy KJ. Musculoskeletal applications of elastography: A pictorial essay of our initial experience. Korean J Radiol 2011;12:365-75.  Back to cited text no. 5
Klauser AS, Faschingbauer R, Jaschke WR. Is sonoelastography of value in assessing tendons? Semin Musculoskelet Radiol 2010;14:323-33.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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