Chronic shoulder pain:Observations on the role of the potator cuff and the tendon of long head of biceps brachii
http://www.100md.com
《中华医药杂志》英文版
Department of Orthopaedic Surgery，Physical Medicine and Rehabilitation & Department of Radiodiagnosis*
Pt.B.D.Sharma Post Graduate Institute of Medical Sciences,Rohtak (Haryana)-124001，India,
Correspondence to Dr.Roop Singh，52/9J，Medical Enclave，Rohtak-(Haryana)124001，India
Tel: 91-1262-213171,Email:drroopsingh@rediffmail.com
[Abstract] Objective (1)To determine the role of rotator cuff and long head of biceps tendon (LHB) in chronic shoulder pain; (2)To evaluate commonly used treatment modalities in alleviating chronic shoulder pain. Methods In a prospective study，41 patients (48 shoulders) with chronic shoulder pain were evaluated using a standardized protocol of clinical，radiologic and sonographic examination.Conservative treatment in the form of nonsteroidal antiinflammatory drugs，physiotherapy and therapeutic ultrasonography was instituted，initially.Steroid injections were given and arthroscopy surgery was performed in refractory cases.At the one year，followup visit final Constant and Murley score was calculated for each patient. Results Bicipital tendinitis (25 shoulders)，impingement syndrome (5 shoulders)，calcific tendinitis (9 shoulders)，rotator cuff tendinosis (7 shoulders) and rotator cuff tears (11 shoulders) in isolation or in combination were the etiological factors.Most of these disorders were managed conservatively.Sonography was a highly accurate diagnostic supplement to the clinical and radiologic examination.Conclusions Our findings suggest，biceps tendon pathosis in addition to the rotator cuff disorders is the major etiological factor and be included in the overall evaluation of chronic shoulder pain.Majority of these disorders can be managed by a conservative approach.Few refractory cases may require open surgical or arthroscopic interventions.Sonography can be a highly accurate diagnostic tool in the evaluation of chronic shoulder pain，besides being a noninvasive，radiation free，dynamic and cheap investigation.
[Key words] rotator cuff; tendinitis; sonography; biceps brachii; shoulder; chronic pain
INTRODUCTION
Anterior shoulder pain is often diagnosed as impingement syndrome caused by pathologic changes of the rotator cuff，the subacromial space，calcium deposits，superior instability and biceps tendinitis[1].Even though most shoulder problem resolve in a few weeks to months long standing shoulder problem are common[2].Chronic shoulder pain leads to limitation of the activities of daily living and is a hindrance to a good quality of life.
Many clinicopathological entities lead to chronic painful shoulder.The pathophysiology of rotator cuffrelated shoulder dysfunction is generally divided into two broad categories: (1) primary rotator cuff disease either from impingement syndrome or intrinsic tendinosis; and (2) secondary rotator cuff disorders as a consequence of glenohumeral instability.(3) The contribution of the long head of biceps tendon (LHB) to pain and disability remains unclear and controversial.(4) Many studies in the literature have discussed primary versus secondary biceps tendinitis (BT) and different regimens with which to treat each of those entities[1,4~8].
The purpose of this study was: (1) to determine the role of rotator cuff and long head of biceps tendon(LHB) in chronic shoulder pain; (2) to evaluate commonly used treatment modalities in alleviating chronic shoulder pain.
MATERIALS AND METHODS
The study group comprised of consecutive patients with chronic shoulder pain who fulfilled the following criteria:Clinical suspicion of rotator cuff and biceps brachii lesion.
Shoulder pain originating from the shoulder joint / tendons，with duration of at least three months.
Exclusion criteria included prior impingement / rotator cuff surgery，previous shoulder fracture，existing glenohumeral instability，diffuse pain syndromes，disc，joint or nerve disease or glenohumeral arthritis.
Study Plan Consecutive patients were evaluated using standardized protocol of clinical，radiologic and sonographic (SG) examination.Patients were assessed initially by the author (R.Singh) for historical details and physical findings; and by a physiotherapist (Y.P.Mathur) for shoulder strength and other functional parameters.Historical variables as described by Hawkins and Dunlop[9] were recorded and detailed physical findings were assessed as described by Hawkins and Dunlop[9] and by Norregaard,et al.[10] Initial shoulder scores were recorded using the method of Constant and Murley[11] at the end of examination.
Plain anteroposterior radiographs were taken in all the shoulders to record any calcification，osteophytes and changes in the proximal humerus.
Sonography (SG) Shoulder sonography was performed by the radiologist (S.Magu) using high resolution 10 MHz linear array transducer ultrasonic machine.All shoulders were examined anteriorly，laterally and posterolaterally by both static and dynamic techniques.Subscapularis，biceps，supraspinatus and infraspinatus tendons were each examined longitudinally and transversely.Criteria for complete rotator cuff tear (RCT) were used as those previously reported[12~15].Subacromial impingement was tested by abduction in varying degrees of rotation and was recognised by the lack of movements or impaired movements of supraspinatus tendon.Biceps tendon was checked for maximum diameter of LHB，positioning in the bicipital groove (centric / eccentric)，and echogenicity of the edge (halo effect).Movements of the tendon were judged by dynamic evaluation，bulging and echogenicity of the tendon.Rotator cuff was also scanned for rotator cuff tendinitis and calcific tendinitis (CT).
Two cases (30 and 41) of severe chronic painful shoulders were subjected to magnetic resonance imaging (MRI).
Therapy Patients were prescribed nonsteroidal antiinflammatory medication in the initial phase to overcome shoulder pain.Physiotherapy programme consisting of shoulder exercises and schedule for doing them was taught and initially supervised by the physiotherapist and later on each patient was doing it at home himself.Minimum of ten therapeutic ultrasonography (TUSG) treatments were given to almost each patient (3 times per week) except for cases with calcific tendinitis who were given 24 treatments.The first 15 of 24 treatments were given daily (5 times per week) for 3 weeks，and the remaining 9 were given 3 times a week for 3 weeks.
Steroid injections were administered in selected patients who failed to respond to NSAID，exercise and TSUG after 6 weeks.
Arthroscopy was performed in refractory cases (not responding to conservative treatment for 3 months).
Followup Patients were followed up at monthly intervals for first 6 months and later on 6 monthly.At each visit，patients were questioned on for subjective improvement and were clinically evaluated.At the one year followup visit final Constant and Murley[11] score was calculated for each patient.
RESULTS
A total of 41 patients (48 shoulders) with chronic painful shoulder were enrolled in this study.Average patient age was 47.56±9.5 years (range 22 to 68 years); 13 patients were males and 28 were females.Clinical details of the patients are shown in Appendix I.Accuracy of clinical tests and diagnosis compared with sonographic findings and diagnosis is shown in Table 1.It was observed that sonography was more sensitive in diagnosis of rotator cuff tendinosis than clinical examination.Bicipital tendinitis either primary (16 shoulders) or associated with other shoulder lesions (9 shoulders) was present in 25 cases and was associated with 3 rotator cuff tear (27.2%).
Table 1 Comparison of Accuracy of Clinical Tests and Diagnosis Compared with Sonographic Findings and Diagnosis in Chronic Shoulder Pain
Three shoulders with impingement syndrome (Case No.9 and 15) were treated arthroscopically by debridement and acromioplasty.Arthroscopic acromioplasty along with mini arthrotomy tear repair was done in case No.30，34 and 38 of RCT who failed to respond to conservative treatment for 6 weeks.Case No.41 was also advised therapeutic arthroscopic repair but she refused.
The average followup was 14 years (range 1 year to 3.2 years).The mean Constant and Murley score at initial presentation was 7235±1203 and at one year，it was 8254±1147.In 90% of the patients，the score showed improvement and in 10%，it showed deterioration at one year of followup.
DISCUSSION
Pain is one of the most common presenting symptom in the practice of a hand and upper extremity surgeon.Shoulder pain is possibly third only to the common complaints of low back pain and carpal tunnel syndrome in the Western world[16].The accuracy with which a treating physician can determine the cause of chronic shoulder pain can have important implication for management[1~16].
For evaluation of a patient with longstanding shoulder pain in addition to the clinical examination，imaging techniques are indispensable.The present study utilized sonography in addition to clinical and plain radiography to diagnose the cause of chronic shoulder pain.On the basis of modern ultrasound criteria，a wide range of sensitivities (57% to 100%) and specificities (50% and 100%) have been reported for sonographic detection of rotator cuff tears[14,15,17~19].Sonography is as reliable as magnetic resonance imaging for analysing full thickness rotator cuff tears[20].In the 2 cases (Case No.30 and 41) of full thickness rotator cuff tears，both magnetic resonance imaging and sonography，picked rotator cuff tears.In 3 refractory cases (Case No.30，34 and 38) of sonography proven full thickness rotator cuff tears requiring therapeutic arthroscopy，full thickness rotator cuff tears were found during arthroscopy.Sonography had 100% sensitivity and specificity to pick rotator cuff tears in the present series also，although the number of cases is less to give comments.
The major finding of the present series is bicipital pathosis as a cause for chronic shoulder pain and in 52% of the shoulders biceps tendinitis either in isolation or in association with rotator cuff lesion was the cause of chronic shoulder pain.Seventy one percent of cases with biceps tendinitis were females.We agree with Pfahler,et al.[1] and Murthi,et al.[4] that biceps tendinitis is an important component of shoulder pain and dysfunction.Biceps tendon pathosis exists in many forms in shoulders with rotator cuff diseases[1,4].Murthi,et al.[4] reported in shoulder with partial thickness or full thickness tears，chronic changes in biceps tendon in 63% and 75% of specimens，respectively.Sonographic irritation of the biceps tendon was observed in 55% (hallo effect，bulging，ruptures) of shoulders with lesions of rotator cuff by Pfahler,et al.[1]
Teffey,et al.[3] reported 11% rupture of biceps tendon and six percent of dislocation in cases of rotator cuff tears.In the present study，biceps tendinitis was associated with nine cases of rotator cuff lesions (including tears，calcific tendinitis，rotator cuff tendinosis and cysticercosis).Possible explanation given is that intact rotator cuff transmits pressure only indirectly to the long head of biceps tendon.In cases of rotator cuff degeneration with tendon thinning or rotator cuff defects，pressure and friction will work directly on the biceps tendon and will cause degenerative changes[21,22].
Bony anatomy of bicipital groove and soft tissues have roles in causing chronic irritation of the synovial membrane and of the tendon，leading to chronic painful shoulder.The long head of biceps tendon running in its intertubercular groove is exposed to high strains of friction，especially in the case of deep and acute angled grooves[23,24].Flat groove，smaller medial groove angle，degenerative changes like osseous protrusions and spurs can lead to biceps tendon disease[25].In the case of a flat medial wall of the bicipital groove，an insufficient coracohumeral ligament or a simultaneous lesion of the rotator cuff will contribute to a spontaneous medial luxation of the tendon.
In the literature，different regimens have been described to treat primary versus secondary biceps tendinitis.Surgical procedures like biceps tenodesis，tenosynovectomy and acromioplasty have been described to treat biceps tendinitis in addition to the conservative measures[4,5,26~28].In the present series only in one case of rotator cuff tears (Case 38) arthroscopic acromioplasty and tenosynovectomy of biceps tendon was done along with mini open cuff repair.In three shoulder of impingement syndrome acromioplasty along with release of coracoacromial ligament was done.The rest of the shoulders responded well to conservative treatment.
We have no clear explanation for the finding that biceps tendinitis is more common in females.Plausible explanation can be that females are engaged in heavy manual work in this part of world leading to repetitive mechanical strains of the biceps tendon.Less muscular development and hormonal status may be another explanation[29].Further research in this area needs to be undertaken.
Significant rotator cuff lesions were the source of chronic pain in 27 shoulders in the present series.Tears of the rotator cuff tendon are a common cause of shoulder disability and in approximately 90% of patients with a rotator cuff tear recover without surgery[30].Out of 11 shoulders with rotator cuff tears，only two shoulders associated with other significant lesions were treated surgically in the present series.Nonsurgical treatments have led to improvements in the Constant score in the rest of shoulders except in two.We agree with the views of other authors[9,30] that conservative treatment can lead to improvement in significant number of shoulders with rotator cuff tears.Rotator cuff ‘tendinitis’ is a debilitating degenerative condition and one of the principal causes of chronic shoulder pain[31].Although often considered to resolve with time，the prognosis is poor in a significant number of patients[32].It was the cause of chronic shoulder pain in six shoulders which responded well to the conservative treatment.
Calcific tendinitis of the shoulder is characterized by a reactive calcification that affects the rotator cuff tendon[33,34].Most patients with calcific tendinitis develop a chronic syndrome that may cyclically precipitate subacute and acute symptoms[33,34].Many methods have been applied in the treatment of calcific tendinitis of the shoulder，including the use of non steroid antiinflammatory drugs (NSAIDs)，local injections with steroids，percutaneous needle aspiration，physical modalities with therapeutic ultrasound or shock wave diathermy and other conservative management methods such as therapeutic exercise[35,36].Therapeutic ultrasound along with exercises and NSAIDs gave excellent functional results in nine cases of calcific tendinitis in the present series.We agree with the observations in the literature[37] that therapeutic ultrasonography is an excellent method of treating calcific tendinitis.
Further studies need to be undertaken to find positive correlation between work culture and bicipital tendinitis.Research into the areas like anatomical，radiological and correlative pathological issues of chronic shoulder pain.
CONCLUSION
Our findings suggest that biceps pathosis in addition to the rotator cuff disorders is the major cause of chronic shoulder pain.Majority of these disorders can be managed by a conservative approach consisting of NSAIDs，therapeutic ultrasonography，physical therapy and exercises.Few refractory cases may require open surgical or arthroscopic interventions.Sonography can be a highly accurate diagnostic tool in the evaluation of chronic shoulder pain，besides being a non invasive，radiation free，dynamic and cheap investigation.
REFERENCES
1.Pfahler M，Branner S，Refior HJ.The role of the bicipital groove in tendopathy of the long biceps tendon.J Shoulder Elbow Surg,1999,8: 419-424.
2.MacFarlane GJ，Hunt IM，Silman AJ.Predictors of chronic shoulder pain: a population based prospective study.J Rheumatol,1998,25: 1612-1615.
3.Teefey SA，Middleten WD，Yamaguchi K.Shoulder sonography: State of the arts.Radiol Clin North Am,1999,37:767-785.
4.Murthi AM，Vosburgh CL，Neviaser TJ.The incidence of pathologic changes of long head of the biceps tendon.J Shoulder Elbow Surg,2000,9: 382-385.
5.Hitchcock HH，Bechtol CO.Painful shoulder: observation on the role of the tendon of the long head of the biceps brachii in its causation.J Bone Joint Surg Am,1948,30A:263-273.
6.DePalma AF，Callery GE.Bicipital tenosynovitis.Clin Orthop,1954,3: 69-85.
7.Neer CS II.Impingement lesion.Clin Orthop,1983,173:70-77.
8.Neviaser RJ.Lesions of the biceps and tendinitis of the shoulder.Orthop Clin North Am,1980,11: 343-348.
9.Hawkins RH，Dunlop R.Nonoperative treatment of rotator cuff tears.Clin Orthop,1995，32:178-188.
10.Norregaard J，Krogsgaard MR，Lorenzen T，Jensen EM.Diagnosing patients with longstanding shoulder joint pain.Ann Rheum Dis,2002,61: 646-649.
11.Constant CR，Murley AH.Clinical method of functional assessment of shoulder,1987,214: 160-164.
12.Weiner SN，Seitz WH Jr.Sonography of the shoulder in patients with tear of rotator cuff: Accuracy and value for selecting surgical options.AJR,1993,160: 103-110.
13.Vick CW，Bell SD.Rotator cuff tears: Diagnosis with sonography.AJR,1990,154:121-123.
14.Hodler J，Fretz CJ，Terrier F，et al.Rotator cuff tears: correlation by sonographical and surgical findings.Radiology,1988,164: 791-794.
15.Van Holsbeeck M，Introcaso JH.Sonography of the shoulder.In: Van Holsbeeck M，Introcaso JH，editors.Musculoskeletal Ultrasonic St.Louis: Mosby,1991,265-284.
16.Boufford JA，Lee SM，Dhanju J.Ultrasonography of the shoulder.Semin Ultrasound CT MRI,2000,21(3): 164-191.
17.Teefey SA，Hasan SA，Middleton WD，Patel M，Wright RW，Yamaguchi K.Ultrasonography of the rotator cuff.J Bone Joint Surg,2000,82-A(U): 498-500.
18.Prickett WD，Teefey SA，Galatz LM，et al.Accuracy of ultrasonic imaging of the rotator cuff in shoulders that are painful postoperatively.J Bone Joint Surg,2003,85-A(6): 1084-1089.
19.Nelson MC，Leather GP，Nirschi RP，et al.Evaluation of the painful shoulder.A prospective comparison of magnetic resonance imaging，computerized tomography，arthrography，ultrasonography and operative findings.J Bone Joint Surg,1991,l 73-A (6): 707-716.
20.Swen WAA，Jacobs JWG，Algra DR，et al.Sonography and magnetic resonance imaging equivalent for the assessment of full thickness rotator cuff tears.Arth Rheum,1999,10: 2231-2238.
21.Ericksen SJ，Fitzgerald SW，Quinn SF，et al.Long bicipital tendon of the shoulder: normal anatomy and pathologic findings on MR imaging.Am J Radiol,1992,158: 1091-1096.
22.Refior MJ，Krodel A，Melzer C.Examination of the pathology of the rotator cuff.Arch Orthop Trauma Surg,1987,106: 301-304.
23.Bateman JE.The shoulder and neck.2nd ed.Philadelphia: WB Saunders Co.，1978，315-338.
24.Paavolainen P，Sliitis K，Aalto K.Surgical pathology in chronic shoulder pain.In: Bateman JE，Welsh RP，editors.Surgery of the shoulder.Philadelphia: Mosby,1984,313-318.
25.Cone RO，Danzig L.The bicipital groove: radiography，anatomic and pathologic study.Am J Radiol,1983,141:781-788.
26.Curtis AS，Snyder SJ.Evaluation and treatment of biceps tendon pathology.Orthop Clin North Am,1993,24(1): 33-43.
27.Neviaser TJ.The role of the biceps tendon in the impingement syndrome.Orthop Clin Northm Am,1987,18(3): 383-386.
28.Becker DA，Cofield RH.Tendosis of the long head of the bicep brachii for chronic bicipital tendinitis.J Bone Joint Surg,1989,71-A (3): 376-381.
29.Berbig R，Weishaupt D，Prim J，et al.Primary anterior shoulder dislocation and rotator cuff tears.J Shoulder Elbow Surg,1999,8: 220-225.
30.DePalma AF.Surgery of shoulder.Philadelphia: JB Lippincott Co.，1950.
31.Chard MD，Hazlemon BL.Shoulder disorders in the elderly (a hospital study).Ann Rheum Dis,1987,46: 486-487.
32.Chard MD，Satelle IM，Hazlemann BI.The long term outcome of rotator cuff tendinitisa review study.Br J Rheum,1988,27: 385-390.
33.Uhthoff WK.Calcifying tendinitis.Ann Chir Gynaecol,1996,85: 111-115.
34.Uhthoff HK，Sarkar K，Maynard JP.Calcifying tendinitis: a new concept of its pathogenesis.Clin Orthop,1976,118: 164-168.
35.Pan PJ，Chou CL，Chiou HJ,et al.Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: A functional and sonography study.Arch Phys Med Rehabil,2003,84: 988-993.
36.Ebenbichler GR，Erdogmus CB，Resch KL et al Ultrasound therapy for calcified tendinitis of the shoulder.N Engl J Med,1999,340: 1533-1538.
37.Gam AN，Johannsen F.Ultrasound therapy in musculoskeletal disorders: a meta anlysis.Pain,1995,63: 85-91.
(Editor Jaque)(Roop Singh，Sarita Magu*，N)
Pt.B.D.Sharma Post Graduate Institute of Medical Sciences,Rohtak (Haryana)-124001，India,
Correspondence to Dr.Roop Singh，52/9J，Medical Enclave，Rohtak-(Haryana)124001，India
Tel: 91-1262-213171,Email:drroopsingh@rediffmail.com
[Abstract] Objective (1)To determine the role of rotator cuff and long head of biceps tendon (LHB) in chronic shoulder pain; (2)To evaluate commonly used treatment modalities in alleviating chronic shoulder pain. Methods In a prospective study，41 patients (48 shoulders) with chronic shoulder pain were evaluated using a standardized protocol of clinical，radiologic and sonographic examination.Conservative treatment in the form of nonsteroidal antiinflammatory drugs，physiotherapy and therapeutic ultrasonography was instituted，initially.Steroid injections were given and arthroscopy surgery was performed in refractory cases.At the one year，followup visit final Constant and Murley score was calculated for each patient. Results Bicipital tendinitis (25 shoulders)，impingement syndrome (5 shoulders)，calcific tendinitis (9 shoulders)，rotator cuff tendinosis (7 shoulders) and rotator cuff tears (11 shoulders) in isolation or in combination were the etiological factors.Most of these disorders were managed conservatively.Sonography was a highly accurate diagnostic supplement to the clinical and radiologic examination.Conclusions Our findings suggest，biceps tendon pathosis in addition to the rotator cuff disorders is the major etiological factor and be included in the overall evaluation of chronic shoulder pain.Majority of these disorders can be managed by a conservative approach.Few refractory cases may require open surgical or arthroscopic interventions.Sonography can be a highly accurate diagnostic tool in the evaluation of chronic shoulder pain，besides being a noninvasive，radiation free，dynamic and cheap investigation.
[Key words] rotator cuff; tendinitis; sonography; biceps brachii; shoulder; chronic pain
INTRODUCTION
Anterior shoulder pain is often diagnosed as impingement syndrome caused by pathologic changes of the rotator cuff，the subacromial space，calcium deposits，superior instability and biceps tendinitis[1].Even though most shoulder problem resolve in a few weeks to months long standing shoulder problem are common[2].Chronic shoulder pain leads to limitation of the activities of daily living and is a hindrance to a good quality of life.
Many clinicopathological entities lead to chronic painful shoulder.The pathophysiology of rotator cuffrelated shoulder dysfunction is generally divided into two broad categories: (1) primary rotator cuff disease either from impingement syndrome or intrinsic tendinosis; and (2) secondary rotator cuff disorders as a consequence of glenohumeral instability.(3) The contribution of the long head of biceps tendon (LHB) to pain and disability remains unclear and controversial.(4) Many studies in the literature have discussed primary versus secondary biceps tendinitis (BT) and different regimens with which to treat each of those entities[1,4~8].
The purpose of this study was: (1) to determine the role of rotator cuff and long head of biceps tendon(LHB) in chronic shoulder pain; (2) to evaluate commonly used treatment modalities in alleviating chronic shoulder pain.
MATERIALS AND METHODS
The study group comprised of consecutive patients with chronic shoulder pain who fulfilled the following criteria:Clinical suspicion of rotator cuff and biceps brachii lesion.
Shoulder pain originating from the shoulder joint / tendons，with duration of at least three months.
Exclusion criteria included prior impingement / rotator cuff surgery，previous shoulder fracture，existing glenohumeral instability，diffuse pain syndromes，disc，joint or nerve disease or glenohumeral arthritis.
Study Plan Consecutive patients were evaluated using standardized protocol of clinical，radiologic and sonographic (SG) examination.Patients were assessed initially by the author (R.Singh) for historical details and physical findings; and by a physiotherapist (Y.P.Mathur) for shoulder strength and other functional parameters.Historical variables as described by Hawkins and Dunlop[9] were recorded and detailed physical findings were assessed as described by Hawkins and Dunlop[9] and by Norregaard,et al.[10] Initial shoulder scores were recorded using the method of Constant and Murley[11] at the end of examination.
Plain anteroposterior radiographs were taken in all the shoulders to record any calcification，osteophytes and changes in the proximal humerus.
Sonography (SG) Shoulder sonography was performed by the radiologist (S.Magu) using high resolution 10 MHz linear array transducer ultrasonic machine.All shoulders were examined anteriorly，laterally and posterolaterally by both static and dynamic techniques.Subscapularis，biceps，supraspinatus and infraspinatus tendons were each examined longitudinally and transversely.Criteria for complete rotator cuff tear (RCT) were used as those previously reported[12~15].Subacromial impingement was tested by abduction in varying degrees of rotation and was recognised by the lack of movements or impaired movements of supraspinatus tendon.Biceps tendon was checked for maximum diameter of LHB，positioning in the bicipital groove (centric / eccentric)，and echogenicity of the edge (halo effect).Movements of the tendon were judged by dynamic evaluation，bulging and echogenicity of the tendon.Rotator cuff was also scanned for rotator cuff tendinitis and calcific tendinitis (CT).
Two cases (30 and 41) of severe chronic painful shoulders were subjected to magnetic resonance imaging (MRI).
Therapy Patients were prescribed nonsteroidal antiinflammatory medication in the initial phase to overcome shoulder pain.Physiotherapy programme consisting of shoulder exercises and schedule for doing them was taught and initially supervised by the physiotherapist and later on each patient was doing it at home himself.Minimum of ten therapeutic ultrasonography (TUSG) treatments were given to almost each patient (3 times per week) except for cases with calcific tendinitis who were given 24 treatments.The first 15 of 24 treatments were given daily (5 times per week) for 3 weeks，and the remaining 9 were given 3 times a week for 3 weeks.
Steroid injections were administered in selected patients who failed to respond to NSAID，exercise and TSUG after 6 weeks.
Arthroscopy was performed in refractory cases (not responding to conservative treatment for 3 months).
Followup Patients were followed up at monthly intervals for first 6 months and later on 6 monthly.At each visit，patients were questioned on for subjective improvement and were clinically evaluated.At the one year followup visit final Constant and Murley[11] score was calculated for each patient.
RESULTS
A total of 41 patients (48 shoulders) with chronic painful shoulder were enrolled in this study.Average patient age was 47.56±9.5 years (range 22 to 68 years); 13 patients were males and 28 were females.Clinical details of the patients are shown in Appendix I.Accuracy of clinical tests and diagnosis compared with sonographic findings and diagnosis is shown in Table 1.It was observed that sonography was more sensitive in diagnosis of rotator cuff tendinosis than clinical examination.Bicipital tendinitis either primary (16 shoulders) or associated with other shoulder lesions (9 shoulders) was present in 25 cases and was associated with 3 rotator cuff tear (27.2%).
Table 1 Comparison of Accuracy of Clinical Tests and Diagnosis Compared with Sonographic Findings and Diagnosis in Chronic Shoulder Pain
Three shoulders with impingement syndrome (Case No.9 and 15) were treated arthroscopically by debridement and acromioplasty.Arthroscopic acromioplasty along with mini arthrotomy tear repair was done in case No.30，34 and 38 of RCT who failed to respond to conservative treatment for 6 weeks.Case No.41 was also advised therapeutic arthroscopic repair but she refused.
The average followup was 14 years (range 1 year to 3.2 years).The mean Constant and Murley score at initial presentation was 7235±1203 and at one year，it was 8254±1147.In 90% of the patients，the score showed improvement and in 10%，it showed deterioration at one year of followup.
DISCUSSION
Pain is one of the most common presenting symptom in the practice of a hand and upper extremity surgeon.Shoulder pain is possibly third only to the common complaints of low back pain and carpal tunnel syndrome in the Western world[16].The accuracy with which a treating physician can determine the cause of chronic shoulder pain can have important implication for management[1~16].
For evaluation of a patient with longstanding shoulder pain in addition to the clinical examination，imaging techniques are indispensable.The present study utilized sonography in addition to clinical and plain radiography to diagnose the cause of chronic shoulder pain.On the basis of modern ultrasound criteria，a wide range of sensitivities (57% to 100%) and specificities (50% and 100%) have been reported for sonographic detection of rotator cuff tears[14,15,17~19].Sonography is as reliable as magnetic resonance imaging for analysing full thickness rotator cuff tears[20].In the 2 cases (Case No.30 and 41) of full thickness rotator cuff tears，both magnetic resonance imaging and sonography，picked rotator cuff tears.In 3 refractory cases (Case No.30，34 and 38) of sonography proven full thickness rotator cuff tears requiring therapeutic arthroscopy，full thickness rotator cuff tears were found during arthroscopy.Sonography had 100% sensitivity and specificity to pick rotator cuff tears in the present series also，although the number of cases is less to give comments.
The major finding of the present series is bicipital pathosis as a cause for chronic shoulder pain and in 52% of the shoulders biceps tendinitis either in isolation or in association with rotator cuff lesion was the cause of chronic shoulder pain.Seventy one percent of cases with biceps tendinitis were females.We agree with Pfahler,et al.[1] and Murthi,et al.[4] that biceps tendinitis is an important component of shoulder pain and dysfunction.Biceps tendon pathosis exists in many forms in shoulders with rotator cuff diseases[1,4].Murthi,et al.[4] reported in shoulder with partial thickness or full thickness tears，chronic changes in biceps tendon in 63% and 75% of specimens，respectively.Sonographic irritation of the biceps tendon was observed in 55% (hallo effect，bulging，ruptures) of shoulders with lesions of rotator cuff by Pfahler,et al.[1]
Teffey,et al.[3] reported 11% rupture of biceps tendon and six percent of dislocation in cases of rotator cuff tears.In the present study，biceps tendinitis was associated with nine cases of rotator cuff lesions (including tears，calcific tendinitis，rotator cuff tendinosis and cysticercosis).Possible explanation given is that intact rotator cuff transmits pressure only indirectly to the long head of biceps tendon.In cases of rotator cuff degeneration with tendon thinning or rotator cuff defects，pressure and friction will work directly on the biceps tendon and will cause degenerative changes[21,22].
Bony anatomy of bicipital groove and soft tissues have roles in causing chronic irritation of the synovial membrane and of the tendon，leading to chronic painful shoulder.The long head of biceps tendon running in its intertubercular groove is exposed to high strains of friction，especially in the case of deep and acute angled grooves[23,24].Flat groove，smaller medial groove angle，degenerative changes like osseous protrusions and spurs can lead to biceps tendon disease[25].In the case of a flat medial wall of the bicipital groove，an insufficient coracohumeral ligament or a simultaneous lesion of the rotator cuff will contribute to a spontaneous medial luxation of the tendon.
In the literature，different regimens have been described to treat primary versus secondary biceps tendinitis.Surgical procedures like biceps tenodesis，tenosynovectomy and acromioplasty have been described to treat biceps tendinitis in addition to the conservative measures[4,5,26~28].In the present series only in one case of rotator cuff tears (Case 38) arthroscopic acromioplasty and tenosynovectomy of biceps tendon was done along with mini open cuff repair.In three shoulder of impingement syndrome acromioplasty along with release of coracoacromial ligament was done.The rest of the shoulders responded well to conservative treatment.
We have no clear explanation for the finding that biceps tendinitis is more common in females.Plausible explanation can be that females are engaged in heavy manual work in this part of world leading to repetitive mechanical strains of the biceps tendon.Less muscular development and hormonal status may be another explanation[29].Further research in this area needs to be undertaken.
Significant rotator cuff lesions were the source of chronic pain in 27 shoulders in the present series.Tears of the rotator cuff tendon are a common cause of shoulder disability and in approximately 90% of patients with a rotator cuff tear recover without surgery[30].Out of 11 shoulders with rotator cuff tears，only two shoulders associated with other significant lesions were treated surgically in the present series.Nonsurgical treatments have led to improvements in the Constant score in the rest of shoulders except in two.We agree with the views of other authors[9,30] that conservative treatment can lead to improvement in significant number of shoulders with rotator cuff tears.Rotator cuff ‘tendinitis’ is a debilitating degenerative condition and one of the principal causes of chronic shoulder pain[31].Although often considered to resolve with time，the prognosis is poor in a significant number of patients[32].It was the cause of chronic shoulder pain in six shoulders which responded well to the conservative treatment.
Calcific tendinitis of the shoulder is characterized by a reactive calcification that affects the rotator cuff tendon[33,34].Most patients with calcific tendinitis develop a chronic syndrome that may cyclically precipitate subacute and acute symptoms[33,34].Many methods have been applied in the treatment of calcific tendinitis of the shoulder，including the use of non steroid antiinflammatory drugs (NSAIDs)，local injections with steroids，percutaneous needle aspiration，physical modalities with therapeutic ultrasound or shock wave diathermy and other conservative management methods such as therapeutic exercise[35,36].Therapeutic ultrasound along with exercises and NSAIDs gave excellent functional results in nine cases of calcific tendinitis in the present series.We agree with the observations in the literature[37] that therapeutic ultrasonography is an excellent method of treating calcific tendinitis.
Further studies need to be undertaken to find positive correlation between work culture and bicipital tendinitis.Research into the areas like anatomical，radiological and correlative pathological issues of chronic shoulder pain.
CONCLUSION
Our findings suggest that biceps pathosis in addition to the rotator cuff disorders is the major cause of chronic shoulder pain.Majority of these disorders can be managed by a conservative approach consisting of NSAIDs，therapeutic ultrasonography，physical therapy and exercises.Few refractory cases may require open surgical or arthroscopic interventions.Sonography can be a highly accurate diagnostic tool in the evaluation of chronic shoulder pain，besides being a non invasive，radiation free，dynamic and cheap investigation.
REFERENCES
1.Pfahler M，Branner S，Refior HJ.The role of the bicipital groove in tendopathy of the long biceps tendon.J Shoulder Elbow Surg,1999,8: 419-424.
2.MacFarlane GJ，Hunt IM，Silman AJ.Predictors of chronic shoulder pain: a population based prospective study.J Rheumatol,1998,25: 1612-1615.
3.Teefey SA，Middleten WD，Yamaguchi K.Shoulder sonography: State of the arts.Radiol Clin North Am,1999,37:767-785.
4.Murthi AM，Vosburgh CL，Neviaser TJ.The incidence of pathologic changes of long head of the biceps tendon.J Shoulder Elbow Surg,2000,9: 382-385.
5.Hitchcock HH，Bechtol CO.Painful shoulder: observation on the role of the tendon of the long head of the biceps brachii in its causation.J Bone Joint Surg Am,1948,30A:263-273.
6.DePalma AF，Callery GE.Bicipital tenosynovitis.Clin Orthop,1954,3: 69-85.
7.Neer CS II.Impingement lesion.Clin Orthop,1983,173:70-77.
8.Neviaser RJ.Lesions of the biceps and tendinitis of the shoulder.Orthop Clin North Am,1980,11: 343-348.
9.Hawkins RH，Dunlop R.Nonoperative treatment of rotator cuff tears.Clin Orthop,1995，32:178-188.
10.Norregaard J，Krogsgaard MR，Lorenzen T，Jensen EM.Diagnosing patients with longstanding shoulder joint pain.Ann Rheum Dis,2002,61: 646-649.
11.Constant CR，Murley AH.Clinical method of functional assessment of shoulder,1987,214: 160-164.
12.Weiner SN，Seitz WH Jr.Sonography of the shoulder in patients with tear of rotator cuff: Accuracy and value for selecting surgical options.AJR,1993,160: 103-110.
13.Vick CW，Bell SD.Rotator cuff tears: Diagnosis with sonography.AJR,1990,154:121-123.
14.Hodler J，Fretz CJ，Terrier F，et al.Rotator cuff tears: correlation by sonographical and surgical findings.Radiology,1988,164: 791-794.
15.Van Holsbeeck M，Introcaso JH.Sonography of the shoulder.In: Van Holsbeeck M，Introcaso JH，editors.Musculoskeletal Ultrasonic St.Louis: Mosby,1991,265-284.
16.Boufford JA，Lee SM，Dhanju J.Ultrasonography of the shoulder.Semin Ultrasound CT MRI,2000,21(3): 164-191.
17.Teefey SA，Hasan SA，Middleton WD，Patel M，Wright RW，Yamaguchi K.Ultrasonography of the rotator cuff.J Bone Joint Surg,2000,82-A(U): 498-500.
18.Prickett WD，Teefey SA，Galatz LM，et al.Accuracy of ultrasonic imaging of the rotator cuff in shoulders that are painful postoperatively.J Bone Joint Surg,2003,85-A(6): 1084-1089.
19.Nelson MC，Leather GP，Nirschi RP，et al.Evaluation of the painful shoulder.A prospective comparison of magnetic resonance imaging，computerized tomography，arthrography，ultrasonography and operative findings.J Bone Joint Surg,1991,l 73-A (6): 707-716.
20.Swen WAA，Jacobs JWG，Algra DR，et al.Sonography and magnetic resonance imaging equivalent for the assessment of full thickness rotator cuff tears.Arth Rheum,1999,10: 2231-2238.
21.Ericksen SJ，Fitzgerald SW，Quinn SF，et al.Long bicipital tendon of the shoulder: normal anatomy and pathologic findings on MR imaging.Am J Radiol,1992,158: 1091-1096.
22.Refior MJ，Krodel A，Melzer C.Examination of the pathology of the rotator cuff.Arch Orthop Trauma Surg,1987,106: 301-304.
23.Bateman JE.The shoulder and neck.2nd ed.Philadelphia: WB Saunders Co.，1978，315-338.
24.Paavolainen P，Sliitis K，Aalto K.Surgical pathology in chronic shoulder pain.In: Bateman JE，Welsh RP，editors.Surgery of the shoulder.Philadelphia: Mosby,1984,313-318.
25.Cone RO，Danzig L.The bicipital groove: radiography，anatomic and pathologic study.Am J Radiol,1983,141:781-788.
26.Curtis AS，Snyder SJ.Evaluation and treatment of biceps tendon pathology.Orthop Clin North Am,1993,24(1): 33-43.
27.Neviaser TJ.The role of the biceps tendon in the impingement syndrome.Orthop Clin Northm Am,1987,18(3): 383-386.
28.Becker DA，Cofield RH.Tendosis of the long head of the bicep brachii for chronic bicipital tendinitis.J Bone Joint Surg,1989,71-A (3): 376-381.
29.Berbig R，Weishaupt D，Prim J，et al.Primary anterior shoulder dislocation and rotator cuff tears.J Shoulder Elbow Surg,1999,8: 220-225.
30.DePalma AF.Surgery of shoulder.Philadelphia: JB Lippincott Co.，1950.
31.Chard MD，Hazlemon BL.Shoulder disorders in the elderly (a hospital study).Ann Rheum Dis,1987,46: 486-487.
32.Chard MD，Satelle IM，Hazlemann BI.The long term outcome of rotator cuff tendinitisa review study.Br J Rheum,1988,27: 385-390.
33.Uhthoff WK.Calcifying tendinitis.Ann Chir Gynaecol,1996,85: 111-115.
34.Uhthoff HK，Sarkar K，Maynard JP.Calcifying tendinitis: a new concept of its pathogenesis.Clin Orthop,1976,118: 164-168.
35.Pan PJ，Chou CL，Chiou HJ,et al.Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: A functional and sonography study.Arch Phys Med Rehabil,2003,84: 988-993.
36.Ebenbichler GR，Erdogmus CB，Resch KL et al Ultrasound therapy for calcified tendinitis of the shoulder.N Engl J Med,1999,340: 1533-1538.
37.Gam AN，Johannsen F.Ultrasound therapy in musculoskeletal disorders: a meta anlysis.Pain,1995,63: 85-91.
(Editor Jaque)(Roop Singh，Sarita Magu*，N)