percutaneous treatments of painful shoulder

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INTERVENTIONAL PROCEDURES IN MUSCULOSKELETAL RADIOLOGY I 0033-8389/98 $8.00 + .OO

PERCUTANEOUS TREATMENTS OF PAINFUL SHOULDER

Caroline Parlier-Cuau, MD, Pierre Champsaur, MD, Remi Nizard, MD, Marc Wybier, MD, Marie Christine Bacque, MD, and Jean-Denis Laredo, MD

Two different painful conditions of the shoulder may be treated with simple percutaneous procedures. In frozen shoulder syndrome (FSS), distention arthrography (DA) with intra-articular injection of steroids may provide pain relief and improvement in joint motion. In pain related to calcific deposits within the rotator cuff tendons, dramatic pain relief may be obtained by needle aspiration of the calcification followed by in situ injection of steroids.

DA IN FSS

Background

FSS is characterized by the spontaneous onset of pain in the shoulder with insidious progressive restriction of both active and passive motion in every direction, mainly external rotation and anterior elevation. Pain is often very severe and disturbs sleep. After several weeks or months, the painful phase gradually abates and is followed by a period of stiffness. This period of stiffness without improvement lasts between 4 and 12 m0nths.2~ Spontaneous gradual recovery of motion then follows over a period of several months. The total duration of FSS may be difficult to evaluate because the exact times of onset and resolu-

tion are frequently questionable; the initial pain may be confused with that of a shoulder tendinitis or trauma that, not infrequently, may precede FSS. Complete recovery from FSS is also difficult to define. Some patients who consider their range of motion still re- stricted are found to have no restriction on objective testing at long-term follow-up and, conversely, many other patients who regard their range of motion as normal are found to have significant restriction at clinical exami- nation.% 27,29,30

Technique

DA consists of the intra-articular injection of a contrast medium, steroids, lidocaine, and a large volume of fluid in order to obtain joint distention. The procedure is performed on an outpatient basis. The patient is placed in the supine position with the arm at the side and, as far as possible, the palm up to hold an external rotation of the shoulder, which facili- tates needle placement into the anterior aspect of the glenohumeral joint. The central x-ray is vertically oriented over the joint. The skin is prepared with an iodine solution and is anesthetized with 1% lidocaine. A 20-gauge 9-cm needle is vertically inserted under fluoroscopic control into the anterior aspect of the joint.

From the Departments of Bone and Joint Radiology (CP-C, MW, MCB, J-DL) and Orthopedic Surgery (RN), Lariboisiere Hospital, Paris; and the Department of Radiology, la Timone Hospital (PC), Marseille, France

RADIOLOGIC CLINICS OF NORTH AMERICA ~

VOLUME 36 - NUMBER 3 * MAY 1998 589

590 PARLIER-CUAU et a1

First, 2 to 3 mL of contrast material (meg- lumine loxaglate), are injected and immediately outline the glenohumeral space, con- firming the correct intra-articular needle position. The joint capacity, which is system- atically measured, is typically dramatically red~ced.~, 9-11, 22, 24, 27, 3u Most patients have no more than 2- to 3-mL joint space volume to- gether with loss of distensibility of the capsule. In most cases, the arthrogram is very suggestive of adhesive capsulitis (Fig. 1). There is a marked reduction in size of all joint recesses, especially the inferior (axillary) and internal (subcoracoid and subscapularis) recesses. The bicipital tendon sheath is incon- stantly opacified. In addition, the synovial pouch around the humeral head is tight-look- ing and has an irregular indented outlining. Early lymphatic filling is not uncommon; however, arthrography may be surprisingly normal in some patients with full clinical cri- teria of FSS.3, 3u A rotator cuff tear is present in

Second, 3 mL of 2% lidocaine and 1.5 mL (3.75 mg) of cortivazol or 2 mL (8 mg) of betamethasone are injected intra-articularly. Injection of fluids immediately causes a severe exacerbation of shoulder pain. Charac- teristically, releasing the finger from the plunger of the syringe leads to immediate return of fluid into the syringe and allows immediate decrease of shoulder pain.

Third, distention of the capsule is then performed using 30 to 40 mL of refrigerated sterile saline solution according to the Fareed and Gallivan technique.” The maximum volume injected depends on the distensibility of the joint capsule. Joint distention, the ”brisement procedure,”’ requires slow, graduate, inter-

27, 29 to 31.3YO2 of cases.

Figure 2. Shoulder arthrogram after injection of a large amount of fluid.

mittent injection of a larger and larger volume of refrigerated sterile saline solution. To avoid excessive leakage of fluid through the intra- articular needle while settling a new syringe of saline solution, a lockable three-way stop- cock is placed over the needle. It is wise to allow some of the fluid to return into the syringe after each injection by releasing the finger from the plunger. Actually, the aim of the procedure is to distend the joint with the largest volume of fluid (Fig. 2) without causing fluid extravasation. Fluid extravasation may occur at the subscapular recess or the bicipital tendon sheath, causing a sudden fall in the joint resistance to distention. Fur- ther injection is ineffective and the procedure should be stopped.

DA is immediately followed by active as- sisted range of motion (ROM) exercises under the supervision of a physical therapist. In the following days, the patient continues with regular home physical therapy exercises.

Authors’ Experience

The authors’ experience is a noncontrolled study including 30 glenohumeral joints in 29 patients with FSS (17 women and 12 men with an age range of 41 to 65 years and a mean age of 49 years) treated with DA. Pa- tients were assessed for pain (Huskinsson scale) and shoulder ROM in internal and external rotations, anterior and posterior eleva- tions, and abduction, first prior to DA and then 15 days and 45 days after treatment. At the 15-day follow-up, 80% of patients considered they had a very good (53%) or good (27%) result. At the 45-day follow-up, 90% of

Figure 1. Arthrogram in a frozen shoulder syndrome. Inferior and internal joint recesses are poorly filled.

PERCUTANEOUS TREATMENTS OF PAINFUL SHOULDER 591

patients considered they had a very good (80%) or good (10%) result; none of the patients considered that they had no benefit at all at the 45-day follow-up.

Discussion

A wide variety of treatments have been investigated in FSS. Physiotherapy is widely recommended in most of the published reports, including home exercises consisting of pendulum exercises and resisted exercises performed several times daily. Oral4 and lo- ca16 steroids are also frequently prescribed. Manipulations of the shoulder performed under general anesthesia31 or under interscalenic brachial plexus block anesthesiaz6 have also been proposed. More recently, arthroscopic releasez6 or surgical excision7, z4 of the coracohumeral ligament have been reported to be highly effective in patients who did not im- prove under conservative therapy. The coracohumeral ligament normally restrains external rotation of the shoulder with the arm at the side, and its contracture due to the chronic fibrotic thickening present in FSS7, z4

acts as a check-rein against external rotation resulting in loss of both active and passive m~vement .~

The therapeutic value of DA has been studied by many au th~rs~-~l , 15, 16, =, z8, 31 since An- dren and Lunberg' first reported that joint distention occurring during diagnostic arthrography could be effective for shoulder restriction. Most studies evaluating DA were noncontrolled series.'O, 11, u, 28, 31 Good results were obtained in 68% to 96% of cases.l0, Data provided by controlled studies9* l6 are more limited and their results are less demon- strative. Corbeil et a19 found no statistical difference in ROM at 3-month follow-up between patients having a nondistensive arthrography with intra-articular injection of steroids and those having additional intra- articular injection of 20 mL of lidocaine. In addition, Jacobs et all6 reported no statistical difference in ROM at 16-week follow-up between patients treated with intra-articular injection of steroids only and those treated with intra-articular steroids combined with distention. In the later group, however, distention consisted of intra-articular injection of only 6 mL of lidocaine plus 3 mL of air.16 Finally, additional controlled studies are necessary to determine the respective roles of intra-articular injection of steroids and of hy-

draulic distention in the improvement obtained by DA in FSS.

Considering the technique of DA, Rizk et alZ8 found in an open trial including 16 patients that good results were achieved only when capsular rupture was obtained during the procedure; our own results do not confirm this statement because in most of our patients capsular rupture did not occur during joint

As mentioned previously, physiotherapy is widely recommended as an early therapy ei- ther alone or in association with other treatments including DA. To our knowledge, however, the advantage of physiotherapy in association with DA over DA alone was not studied. In contrast, DA was found to be effective in patients unsuccessfully treated by previous physiotherapy in many reports,'O, 11,31 suggesting that DA has an advantage over physiotherapy alone in FSS. In our insti- tution, patients recently treated with DA had no physical therapist assistance and were asked to perform regular home physical therapy exercises by themselves in the days following the procedure. Finally, assessment of treatment results in FSS is challenging because FSS is a self-limiting condition with spontaneous recovery after several months or years. Bulgen et a16 reported that various treatment regimens, including intra-articular injection of steroids, ice therapy, and mobili- zations, have little long-term advantage over no treatment in FSS. The aim of a procedure such as DA in FSS, however, is not to modify the whole course of the disease but simply to shorten the most disabling phase of the condition.

filling.

ASPIRATION OF TENDINOUS CALClFlC DEPOSITS

Background

Calcific tendinitis results from the deposition of calcium hydroxyapatite crystals in or around tendons mostly in periarticular locations. The shoulder is the most frequent location of calcific tendinitis. Calcific tendinitis may be encountered in a wide range of anatomic locations, however, such as the hip, wrist, foot, and cervical spine. Some patients have a single joint involved, whereas many others have bilateral involvement of the shoulders or involvement of multiple differ-


ent joints (calcium hydroxyapatite deposition disease).

Apatite deposits may also be responsible for acute or chronic pain. Chronic pain may be related to the inflammation process caused by the presence of the cal~ification.~ The aim of needle aspiration in calcific deposits (NACD) is to remove a significant part of the calcification in order to decrease the patient's pain. Partial removal of the calcification by needle aspiration is usually followed by a spontaneous resorption of the remaining calcium.s This is probably facilitated by the opening of the calcium-containing cavity at the time of needle a sp i r a t i~n . '~* '~ ,~~ NACD is mostly indicated in calcific tendinitis of the shoulder; however, it may be occasionally performed in other anatomic locations. Most authors perform NACD under fluoroscopic guidance.8, 18, 23, 25 Farin et al,12-14 however, recently reported a technique of NACD under ultrasonographic guidance.

Indications

The procedure has three goals: (1) evacua- tion of a maximum of calcium, (2) fragmenta- tion of the residual calcific deposits in order to facilitate resorption during the following weeks, and (3) reduction of the inflammation due to the presence and migration of residual calcific deposits by in situ injection of cortico- steroids.

The most important clinical selection crite- ria for NACD is exacerbation of pain at night.32, 33 Conversely, absence of pain at night, pain caused by a specific kind of motion within a given arc, and limitation of a specific motion suggest that pain is related to an impingement syndrome rather than the calcific deposit. Prior studies have shown that in most cases no rotator cuff tear is associated with calcified tendiniti~.'~, 19, 23 Prior to NACD, a careful radiologic evaluation is necessary. The structure of the calcific deposits and their relation to the rotator cuff tendons and subacromial bursa must be determined.5, 33 Other features to evaluate are number, size, density, contours, and homogeneity of the calcific deposits and their tendency to evacuate into the subacromial bursa.*s, 23 The absence of changes on successive radiographs suggests an indica- tion for needle aspiration. Conversely, recent modifications in the radiographic appearance of the calcification, especially in patients with recent exacerbation of pain, should lead to

"wait and see" for spontaneous resorption of the calcific deposit. The calcification should be larger than 5 mm in diameter. The compo- sition of the deposit determines the success or failure of the aspiration. Faint milky calcifications with fuzzy contours are usually liq- uid and easily aspirated, whereas very dense calcifications with clearly defined margins are often very hard and cannot be aspirated. Ir- regular striated calcifications are usually located within tendon fibers (Fig. 3). They usually correspond to degenerative tendinitis and cannot be aspirated.

Technique

The technique that is described here is performed under fluoroscopic guidance and con- cerns the shoulder, which is the most frequent site of tendinous calcific deposits.

A direct anteroposterior approach under fluoroscopic guidance is used. The patient is placed in the supine position on the radiographic table. The radiograph beam is cen- tered vertically to the shoulder or slightly tilted if this allows better separation of the calcium deposit from the adjacent bone on the image intensifier screen (Fig. 5A). Arm position is chosen according to the location of

Figure 3. Shoulder calcific deposits with a striated appearance. These calcifications are usually located within tendon fibers and cannot be significantly evacuated by needle aspiration.


Figure 4. Fluoroscopic procedure to check that needle tip is within the calcific deposits. A, When the radiograph beam is directed along the needle axis, the needle appears as a dot in the center of the calcification. B and C, The radiograph beam is then successively tilted in maximal cephalad and caudad directions. If correctly placed, the needle tip remains within the calcification. (From Normandin C, Seban E, Laredo JD, et al: Aspiration of tendinous calcific deposits. In Bard M, Laredo JD (eds): lnterventional Radiology in Bone and Joint. New York, Springer-Verlag, 1988, p 285; with permis- sion.)

the calcification within the rotator cuff. Asep- tic conditions are mandatory. The skin and superficial planes are anesthetized with 1% lidocaine. A 19-gauge needle is vertically ad- vanced under fluoroscopic guidance to the center of the calcification following a direction parallel to the radiograph beam. During the entire approach the needle appears on the image intensifier screen as a single point in the center of the calcification (Figs. 4A and 5B). At any time during the procedure, the radiograph beam can be successively tilted cranially (Figs. 4B and 5 0 ) and caudally (Figs. 4C and 5C) to confirm on the screen that the needle is within the calcification. A firm sensation is obtained when the calcification is reached as well as exacerbation of pain. Cal- cium aspiration is then performed using a syringe containing first lidocaine and then

sterile water or saline solution (1 to 2 mL), doing a succession of propulsions and suc- tions with the syringe plunger. Aspirated calcium appears in the syringe as a white cloudy return. This procedure is repeated until maximal aspiration of calcium has been obtained (Fig. 6). In large and lobulated calcific deposits, insertion of two parallel needles may be helpful. The amount of calcium aspirated at the end of the procedure is variable and al- ways incomplete (10% to 80%) (see Fig. 6) . In some cases, the calcification has a hard consistency and no calcium can be aspirated. Grinding of the calcific deposit with the needle, however, may in itself accelerate the process of spontaneous resorption8, 23 and is as important as aspiration. Once the maximum of calcium has been aspirated, 2 to 3 mL of prednisolone acetate (50 to 75 mg) are


Figure 5. Anteroposterior radiographs of the shoulder. A, Su- praspinatus calcific deposits prior to the procedure. 6, Direct anteroposterior view. The needle appears as a dot in the center of the calcification. C and 0, The radiograph beam is then successively tilted in maximal caudad and cephalad directions. The needle tip must project within the calcification on both views.

Figure 6. Supraspinatus calcific deposits before (A) and after (6) needle aspiration. The calcification is fragmented and faint on the postprocedural view (6).

injected in Radiographs are performed at the end of the procedure to document evac- uation of the deposits (Fig. 6B). In the great majority of cases, the procedure is well-tolerated and painless.

Keeping the shoulder at rest for 5 or 6 days is recommended. In the following hours or days, one third of patients have a painful reaction rarely lasting more than 2 to 4 days. This is managed with intermittent application of ice and prescription of antalgics and non- steroidal anti-inflammatory agents.21 This painful crisis is usually accompanied by an almost complete resorption of the remaining calcification.

Results

According to several studies, good and excellent results are achieved in 619'0~~ to 74%14 of cases. Comfort and Arafiles8 in 1978 first described this technique and reported nine cases followed for an average of 9 years. Good to excellent results were obtained by needle aspiration and follow-up plain radiographs showed no residual deposits. In 1989, Normandin et a123 reported 69 cases of calcific tendinitis treated by needle aspiration. The clinical results were good in 60.9% of cases at 11 to 45 months (mean 24) of follow-up. In this study, aspiration of large amounts of calcium and secondary resorption of residual deposits on plain radiographs in the following weeks were significantly associated with good results. By contrast, in the case of the hard, stone-like consistency of the calcification or in the case of calcification encrusted within the tendon fibers, no significant calcium was usually aspirated and the result of the procedure was poor. In 1994, Pfister and Gerber25 reported on 212 patients with calcific tendinitis of the shoulder treated with needle aspiration. At 5 years of follow-up, 60% of the patients were free of pain, 34% had a marked pain relief, and 6% were unchanged. These results, however, were not compared with the spontaneous outcome of shoulder calcific tendinitis, which is often favorable. In 1996, Farin et all4 reported 61 patients with rotator cuff calcifications treated by needle aspiration and lavage under fluoroscopic guidance. Clinical results were good in 74% of cases and moderate or poor in 26%. Clini- cal results were compared with the changes in the calcification appearance on plain radiographs taken at l-year follow-up. In cases

with a good clinical result, the calcification was decreased in size in 86% of cases, whereas no change was seen in 14%. In cases with a moderate or poor result, the calcification was decreased in size in 37% of cases, whereas no change was seen in 63% of cases.14

Discussion

Surgical excision of calcifications of the rotator cuff gives prompt, complete, and perma- nent relief of symptoms in a high percentage of cases." At present, surgical excision of calcifications is mostly performed through arthroscopy2 There are many objections to the use of surgery as the primary procedure in rotator cuff calcifications, however, mainly owing to the prolonged period of disability and potential complications of surgery, especially the risk of secondary reflex sympathetic dystrophy. Therefore, we feel that NACD should be first attempted in all cases prior to surgery because it is a minimally invasive technique providing good results in at least two thirds of cases.8, 14, w, 25 In our experience, there are no technical failures resulting from difficulty in locating the calcification with the needle under fluoroscopic guidance. As in arthroscopic treatment of calcific tendinitis; it seems not to be essential with NACD to remove the deposit completely. To our knowledge, there is no established relationship between the clinical result and the amount of calcium aspirated. Good results are often obtained when the radiologic appearance of the calcification is not markedly changed at the end of the procedure. This can be explained by the opening of the calcium-containing cavity and creation of a communication between the cavity and surrounding vascularized tis- sues. This may cause local inflammation and hyperemia, which in turn accelerates the process of resorption.

CONCLUSION

In noncontrolled studies DA, which in- cludes intra-articular injection of steroids and hydraulic distention, provides good and excellent results in 90% of the cases with rapid improvement in pain and joint stiffness. The respective roles of intra-articular injection of steroids and hydraulic distention in the achievement of the good results, however, re- main to be evaluated in controlled studies.



In the case of calcific tendinitis, NACD is a well-tolerated conservative procedure that should be attempted after failure of medical treatment in chronically painful shoulders associated with rotator cuff deposits. Excellent and good results vary from 61% to 74% of patients. In these patients, dramatic and dura- ble improvement is obtained without surgery.

References

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2. Ark JW, Flock TJ, Flatov EL, Bigliani LU Arthro- scopic treatment of calcific tendinitis of the shoulder. Arthroscopy 2:183, 1992

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needle aspiration and lavage. Skeletal Radiol E551, 1996

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2 rue Ambroise Par6 75010 Paris, France

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percutaneous treatments of painful shoulder

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