Dot is a New Yorker whose passion is swimming.

She has a long history of shoulder pain that never got in the way over decades of swimming. In early September of 2013 she had a severe attack of right shoulder pain that went on for several months. Her diagnosis was shoulder impingement syndrome which lead to progressive fraying and tearing of the supraspinatus tendon. She attributed the pain to more frequent swimming sessions.

Her pain was so bad that it impacted her ability to carry items and lie on her right shoulder while sleeping. The pain even woke her up at night.

Learn more with this short video on shoulder impingement syndrome

Imaging

September, 2013- MRI right shoulder noted a severe supraspinatus tendinosis at the insertion on the humerus with a focal full thickness tear (yellow arrow).

September, 2013- A right shoulder ultrasound evaluation noted tendinosis and a partial to complete tear of the supraspinatus tendon (red arrow) and bony irregularity (blue arrow) indicating tissue overload and incomplete healing for many years.

Management

Early September, 2013- Several sessions of physical therapy severely exacerbated her pain so she had to stop.

September, 2013- Ultrasound-guided supraspinatus tendon insertion corticosteroid injection- slightly helpful but not with longstanding improvement.

Platelet-rich plasma therapy

Late September, 2013- Platelet-rich plasma procedure into the right supraspinatus insertion with 50% improvement after several weeks.

Early October, 2013- Platelet-rich plasma procedure into the right supraspinatus insertion with a total of 90% improvement after several weeks with an eventual return to swimming.

December, 2015- The patient remains pain-free. A follow-up ultrasound image of the supraspinatus tendon noted increased tendon thickness (red arrow) and decreased bony insertion irregularity (blue arrow) which is associated with the healing process.

A very grateful patient

Coronal T2 Shoulder MRI highlighting the important anatomy of the shoulder

Background

Shoulder impingement syndrome is the most common disorder of the shoulder.

Associated with subacromial bursitis, partial rotator cuff tears, rotator cuff tendinosis, and calcified tendonitis
Incidence of shoulder pathology ranges from 7 to 25 per 1000 visits to primary care physicians
Prevalence ranges from 7% to 27% in those less than 70 years of age and 13% to 26% in those older than 70 years of age
Repetitive or excessive contact or abrasion of the rotator cuff muscles and/or tendons due to compression between the humeral head and acromion, coracoacromial ligament and acromioclavicular joint

Risk Factors

Deconditioning
Neurological injuries
Sports involving throwing or overhead activities
Trauma
Poor ergonomics

Clinical Features

Shoulder pain causes pain along the scapula and trapezius muscle but not the neck and is worsened with forward flexion of the shoulder and the pain is often referred to the lateral shoulder and mid arm. Patients note difficultly removing their shirt or coat
Cervical pathology can radiate into the shoulder and shoulder pathology can radiate into the neck
Cervical pathology may lead to secondary shoulder disease such as frozen shoulder
Atrophy of the shoulder musculature can be associated with either C5 or C6 radiculopathy or chronic rotator cuff injury
Active shoulder range of motion limitations may be related to deltoid or rotator cuff weakness resulting from a cervical radiculopathy or disuse atrophy caused by pain.
Progresses from edema and hemorrhage to cuff fibrosis and thickening or a partial cuff tear and finally develop into full thickness tears, tendon ruptures and bony changes

Diagnosis

Differential diagnosis

Cervical disc herniation with radiculopathy
Cervical myelopathy
Cervical spondylosis
Frozen shoulder
Glenohumeral instability or osteoarthritis
Lung tumors
Nerve palsies
Shoulder impingement syndrome

Workup

X-rays of the shoulder should include anterior-posterior, lateral and axillary views
MRI is the study of choice for assessing for rotator cuff tears
MRI may detect rotator cuff tears in 34% of asymptomatic individuals and this frequency increases with age
CT is useful in diagnosing subtle dislocations, labral tears, full thickness rotator cuff tears, bony lesions, subtle dislocation
Musculoskeletal ultrasonography
Electrodiagnostic studies are usefully in differentiating shoulder pathology from radiculopathy and myopathy as well as determining the severity and chronicity of the neurological process

Treatment

Rest
Ice
Nonsteroidal anti-inflammatory medications such as naprosyn or ibuprofen for < 2 weeks
Acetaminophen
Progressive strengthening exercises of the rotator cuff muscles
Heat, cold, ultrasound, and transcutaneous electrical nerve stimulation have been used for symptomatic relief of pain and muscle spasms.
Anesthetic injection into the subacromial region can help with diagnosis and treatment
Intra-articular or subacromial corticosteroid and anesthetic injections have been shown to provide short-term relief
Intra-articular sodium hyaluronates into the glenohumeral joint or bursa have been well tolerated
Regenerative injections can be useful for tissue repair and long-term improvement
Intra-articular injections should be done under imaging guidance
Open acromioplasty and rotator cuff repair in 21 patients with electrodiagnostically documented cervical radiculopathy demonstrated decreased shoulder pain in 87% of patients and decreased neck pain in 66% of patients.

Prognosis

Progression of a partial rotator cuff tear to a full tear with loss of shoulder function
Mobility may be maintained even with evidence of a full rotator cuff tear

References

Hawkins RJ, Bilco T, Bonutti P. Cervical spine and shoulder pain. Clin Orthop Relat Res. 1990 Sep;(258):142-6.

Panagos A. Rehabilitation Medicine Quick Reference-Spine (ed. Buschbacher R.M.) New York: Demos Publishing; 2010. p. 200-201.

Platelet-Rich Plasma Therapy Propels Dot Back To The Pool