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Ecografia modo B e doppler no estudo do ombro : relação com dor e implicações no diagnóstico e prognóstico
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Shoulder pain is a common problem in clinical practice, with data in the literature showing an increased prevalence and stronger consequences with age, reaching an annual cumulative incidence of 2.4% in the age group from 45 to 64 years, with a higher incidence in women. The shoulder is one of the most frequent sites of musculoskeletal pain.
There are multiple causes, but rotator cuff and subacromial pathologies are predominant. Pathologies of the glenohumeral and acromioclavicular joints, as well as referred pain, especially of cervical origin, are also pointed out as frequent etiologies. The rotator cuff is an usual site for degenerative tendinopathy, a common cause for shoulder pain which most often affects the supraspinatus; it may progress to partial or full-thickness tendon tear. Subacromial conflict has been recognized since Neer as a cause for tendinopathy and rotator cuff tear.
Calcifying tendinitis has generally a more favorable course, being able to resolve completely and spontaneously, and predominates at a younger age. It involves the deposition of calcium hydroxyapatite crystals, more frequently in the supraspinatus and infraspinatus, but the etiopathogenesis is controversial; it seems to occur as a primary tendinopathy reactive to ischemia or mechanical factors in a viable tendon, in a cycle including fibrocartilaginous metaplasia of tenocytes, crystal deposition and resorption, and tendon repair. But not all calcifications are symptomatic. Calcifications with a diameter greater than 1.5 cm, with an ill-defined contour, and associated with Doppler signal and subacromial effusion have been described as related to symptoms, but only in a few studies.
This research project was aimed to validate clinical tests in the determination of the level of pain and disability and to search for ultrasound characteristics in rotator cuff calcifications, or another marker or set of ultrasound markers, which allow for the prediction of symptoms and, in addition, to determine the prognosis. The dimension of calcifications was particularly focused. The project included a case-control observational study to identify characteristics associated with shoulder pain, and a longitudinal observational study to look for prognostic factors. Relevant aspects on the physical examination of patients with shoulder pain were also investigated, by an observational cross-sectional study.
A total of 140 patients and 62 controls were enrolled (median age 56 years, 155 women), and inflammatory pathology was excluded. The evaluation comprised a DASH questionnaire (Disabilities of the Arm, Shoulder and Hand outcome measure), a physical examination and an ultrasound exam with recording of the size, morphology and location of calcifications, Doppler signal, changes in echotexture, rotator cuff tears and joint or subacromial effusion. P-values < 0,05 were considered significant. On the clinical evaluation of the patients, a linear regression model with six independent variables (age, gender, complaints on dominant side, palm-up test, range of motion in active flexion and external rotation) was found capable of predicting 44% of the variability of the DASH score (R = 0.665; p < 0.001).
A calcification size ≥ 6 mm was associated with shoulder pain (p = 0.02), but only in younger subjects (< 56 years). In older subjects (≥ 56 years), a distance to the tendon insertion ≥ 6 mm was also associated with pain (p = 0.009). Pain was also associated with a positive Doppler signal (p = 0.003), the number of calcifications (p = 0.02), alterations in the tendon echotexture (p < 0.001), bone irregularity or thickening at the insertion of the supraspinatus and subscapularis tendons (p < 0.05) and rotator cuff tears (p = 0.001). Subacromial effusion was only found in symptomatic subjects (p = 0.002). Follow-up of patients suggested a better prognosis when a tendinous Doppler signal or when poorly defined or sparsely distributed calcifications were present. Clinical improvement was associated with a reduction in the Doppler signal and subacromial effusion, when present on first exam, suggesting a role in the pathophysiological mechanism of pain.
An algorithm was proposed, based on a set of specific ultrasonographic criteria, which makes it possible to classify the sample of this study for rotator cuff pathology likely to cause pain, with a sensitivity of 69% and a specificity of 92%.
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Dor no ombro Ecografia Doppler Coifa dos rotadores Tendinopatia Calcificações Shoulder pain Ultrasonography Rotator cuff Tendinopathy Calcifications