Wednesday, April 17, 2019
Shoulder pain
Please review this radiograph of a patients shoulder. This patient described a gradual onset of symptoms that has progressively worsened over the last 5-6 months. Strength is maintained however the patient reports shoulder stiffness throughout range of motion. Using ABCs and other things you have learned in imaging class comment on 1 thing that you see on the image. For near 40 students to all comment on one new thing you do not have to all comment on the pathology. You can comment on what may appear normal on the image also. Everyone make one observation - and try not to replicate someone else's comment. Please make your comment sometime over the weekend before Monday morning at 7:00 am.
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I can see capsular thickening near around the glenoid labrum and what appears to be deposits of some sort that have been laid down. This could explain the stiffness felt throughout all range of motion due to the thickening appearing to cover the entire joint surface. The image was done using an anterior-posterior view with the arm in neutral as noted by the approximation of the humeral head in the glenoid labrum.
ReplyDeleteIn the image above, there is apparent decreased glenohumeral joint space, which leads pain, stiffness, decreased range of motion, and osteoarthritis. Like mentioned previously, there are deposits that have laid down at the joint and may have or will eventually lead to bone spurs.
ReplyDeleteThe image above is an AP view of the L shoulder, with the humerus in mostly neutral position, but some slight internal rotation because the greater tubercle is more anterior and not completely lateral. Discussing the rest of the “ABCS,” alignment and bone density, there is significant arthritis and decay of the glenoid head at the glenohumeral joint, because there are not clearly defined edges, and there is significant loss of space. The bony deposits may lead to bone spurs, and eventually cartilage and soft tissue damage of the labrum, which would then need to be viewed with an MRI. This would essentially cause the decreased AROM and PROM, with pain likely. The image is overexposed, or not correctly positioned sine the joint spaces and edges are burnt out.
ReplyDeleteThis radiograph appears to be of an adult's shoulder secondary to the absence of several growth plates, one of which is the proximal humeral growth plate, which closes around 17 years of age.
ReplyDeleteGoing off of what my classmates have mentioned, the image was taken using an AP view of the L shoulder in neutral positioning. The patient appears to have normal bone density as noted with the outline of the humerus. Given the patient subjective feedback of L shoulder pain with chronic insidious onset over the course of 5-6 months, my impression of the radiograph is that of decreased joint space and possibly increased osteophyte formation. Although it is difficult to see from this view, it appears as though the L scapula is excessively upwardly rotated given that the view was taken in neutral positioning. Alternate imaging views would be useful in order to determine the extent of decreased joint space with physiological movements. Further imaging such as MRI would be useful in determining the extent of soft-tissue/labrum involvement contributing to the patient's main complaints of L shoulder pain.
ReplyDeleteI initially thought this was calcific tendonitis, but after reviewing what calcific tendonitis looks like it definitely is not. This pathology is much more widespread and dispersed within the joint capsule. We learned that bone is bright white and as these small dots are bright white that would indicate bone. It appears there are bony loose bodies within the joint capsule surrounding the GH head.
ReplyDeleteAs my esteemed colleagues have noted there is decreased joint space and osteophyte formation at the glenohumeral joint. I note the relatively normal separation between the acromion and the humeral head.
ReplyDeleteIn this you can see part of the left lung and the superior aspect of the heart. You can see the difference because the lung is filled with air so it has less radiodensity and appears black. The thicker heart is a lighter white because it has greater radiodensity, however it does not have as much radiodensity as the bright white bone.
ReplyDeleteThis is a X-ray pf the patients Left shoulder. Normal appearances include the clavicle and greater tuberosity. Healthy bone will have the grayish appearance while new bone will be bright white in coloration. Extra tid bit, x-rays are very easy to perform and cost effective making x-rays a first line for diagnosing fractures and narrowing of joint spaces.
ReplyDeleteUpon view of the L shoulder AP view X-ray, there seems to be significant arthritis showing increased deterioration of the glenoid head at the GH joint leading to significant loss of space. What is also worth noting is the decreased joint space of the AC Joint leading to increase friction and discomfort of arm past 90 degrees of elevation.
ReplyDeleteLooking at the image, we can see different tissues of the body based on their density. We can see the air in the lungs (black), which is the least radiodense of all body structures; the gray of the water-based soft tissues surrounding the humerus, and the white of the bone, which is the most radiodense tissue of the body.
ReplyDeleteThe lung field looks normal with no s/s of hyperinflation (caused by COPD or Emphysema) of the lung with normal rib angles. There are also no s/s of TB which would show grey dots throughout the lung field. Instead there is a normal black space throughout the lung field.
ReplyDeletePublished by Addison Nichols, same as Bryan Romero.
DeleteThis is Bryan Romero. Since Arli pretty much posted the same thing as me before my browser refreshed when I posted earlier, I'll make another comment.
ReplyDeleteThe density of the humerus appears to have sufficient radiographic contrast between the bone and soft tissue, as well as sufficient contrast withing the bone itself--demonstrating a denser cortical shell (whiter) and a relatively less dense cancellous center (less white).
The humeral head and glenoid fossa are significantly deformed. They are not the smoothly liked up surfaces that we would expect to see in a radiograph of the shoulder. The white spots in this area represent bony or calcification deposits in the surrounding tissues. The joint space between the humeral head and glenoid fossa appears to be decreased from the normal 5mm width we would hope to see. Along with my classmates concerns already listed, I am concerned about this patient's stiffness through range of motion progressing to a frozen shoulder. I would emphasize to this patient to continue using the upper extremity for daily activities.
ReplyDeleteThe ribs are all properly spaced and no fractures appear to be present in the ribs.
- Sarah Loesing
John Zirkle
ReplyDeleteBased off of the clearly defined area showing both the AC/SC joint gap without being superimposed the shoulder is in an IR position that is also noted by the GH joint being able to see 3/4 of the total congruency with minimal portions being cover up by the humerus as well as the bicepital grove being more medial/ IR then centered.
Also noted is terrible grammar and a run on sentence that should have been removed/fixed but not possible. John Zirkle
DeleteAs noted above, there is a large amount of calcification and decreased joint space. It is difficult to tell but if there was a chronic rotator cuff pathology, the findings would include: irregularity of the greater tuberosity, narrowing between the acromion and humeral head, and erosion of the inferior aspect of the acromion secondary to superior migration of the humeral head. Depending on the severity and age of the patient, a total shoulder arthroplasty may be indicated.
ReplyDeleteTyler Nance
DeleteThis is Jessica Hobbs.
ReplyDeleteIt appears the the Left Pleural Cavity seems filled. ONE reason could be to an enlarged heart - which is difficult to depict in this particular image - but one should be able to see more of the lateral border of the chest cavity as this picture clearly shows little spacing. There could be other reason's to why the left pleural cavity is depicted to be smaller.
The structure of the 1st rib appears be abnormal. Possibly a previous fracture that has healed with malalignment? This would lead to several secondary symptoms including but not limited to cervical pain, TOS, shoulder dysfunctions, and limited cervical ROM.
ReplyDeleteJanelle Petrisor
Like others have mentioned the following image is a AP view of the left shoulder. This view allows a clinician to be able to accurately assess the glenohumeral joint space, which in healthy individuals averages 5mm. Distances greater than this can be suggestive of joint effusion or posterior humeral dislocation while distances <5mm indicate degenerative joint disease and rheumatoid arthritis.
ReplyDeleteRachel Miller
DeleteThis is an AP view as a few of my classmates has mentioned previously. The shoulder complex/scapula is horizontally abducted, demonstrating greater than 3 inch from mid-line. In normal shoulder radiography the scapula should be superimposed by the ribs but still well within the visible lung area, relatively 3 inches from mid-line.
ReplyDeleteThis reminds me of a case I saw once as a PTA where the patient ended up having synovial chondromatosis. SC presents most often in 1 articulation, it is 3x more frequent in men than in women, and the clinical age of presentation is between 30-50 y.o. These patients most commonly present with progressive articular pain, loss of movement, and swelling. Patients will complain of stiffness, aching, crepitus, or instability.The left shoulder xray reveals multiple intrarticular calcifications. However, further imaging would be benefical in diagnosing this specific patient with various views via xray or different type so of imaging such as an ultrasonography, arthroscopy, MRI, or CT scan. Differential diagnosis at this point could be DJD, osteochondritis dissecans, RA, etc.
ReplyDeleteJessica Zongker, SPT
Andrea Blits:
ReplyDeleteMy initial observation is that the joint itself appears more opaque than the surrounding bone, as we know, this may be due to arthritic changes, or decreased bone density. There are some faint lines throughout but this does not lead me to think fracture at this time. Bright spots are noted as well which are attributed to both positioning of equipment and potentially the patient. For a clearer picture of what may be going on, if I were a radiologist, I personally would like to see additional views as well as review patient demographics, including age, gender, and occupation as this may funnel our differential diagnosis.
Sahar Eshghi:
ReplyDeleteAlthough there has been mention of the presence of OA, I haven't seen anyone comment on the specific stage of OA. I would qualify this as stage IV, or severe OA. At this point, the cartilage is essentially completely obliterated, leading to an inflammatory response from the joint. The bone spurs that developed in the earlier stages have now multiplied, likely causing extreme pain and severely limiting the patient's ROM. In the radiograph you can see that there is bone-on-bone contact/decreased joint space, numerous osteophyte formations, and subchondral sclerosis present, all consistent with the diagnosis of severe, stage IV OA.
Molly Porter:
ReplyDeleteIn this anterior/posterior radiographic view of the shoulder you can see that the distal clavicle has moderate to severe degeneration that is seen with the decreased radiodensity of the bone. Bone is the most radiodense tissue in the body and appears white in radiographs. You can see that the distal clavicle is much darker than its proximal part and that the decreased density is starting to progress towards the proximal clavicle. This degeneration can lead to pain in the shoulder, probably most notable in the AC joint as the degeneration can affect the mechanics of the AC joint throughout shoulder movement.
As previously mentioned, this is an AP view of the shoulder. The initial finding that I noticed was the decreased joint space and the ossifications of the glenohumeral joint which could be the cause of the decreased ROM that the patient is experiencing. A normal finding of this radiograph is an intact humeral shaft with no displays of a fracture.
ReplyDeleteMelanie
As many of my classmates have mentioned, this view demonstrates degeneration and osteophyte formation at the glenohumeral joint. Going off of Molly's comment about the decreased radiodensity of the distal clavicle and its susceptibility to injury, I think it is important to note the average angle that the clavicle should project when viewing an AP radiograph. In reference to the sternoclavicular joint, the clavicle should be angled cephalic ally at a 15-30 degree angle. This radiograph appears to have an appropriately angled clavicle demonstrating no signs of displacement at this time.
ReplyDeleteIvy Ables
wow, nice article. keep helping and know more here, orthopedic doctor in NYC
ReplyDeleteBrandon Hughes
ReplyDeleteIn this AP view of the GH joint, something that stands out to me as pathological is the relationship of the acromion and clavicle at the acromioclavicular joint. There is little to no space within the joint which would lead to further degeneration, dysfunction, and pain. However, although it is almost cut off in the image, one can see the sternoclavicular joint having good space with no current signs of pathology reaching the proximal third of the clavicle at this point.
Rikki Choate
ReplyDeleteIn this radiograph, it is obvious that severe OA is present within the (L) shoulder joint. While analyzing the AP view of the shoulder, you might notice the presence of osteophytes within the joint capsule along with decrease joint surface between the humerus and the acromion process. An osteophyte formation on the AC joint can cause a tear of the RTC musculature which already seemed to be impinged on due to the bony build up in the radiograph. A RTC, especially the supraspinatus due to it's location, would present with decrease strength in external rotation and the beginning movement of abduction. The patient would also test positive for a drop arm test or empty can test which all would be indicative of a supraspinatus tear.
Chris Peters
ReplyDeleteThis AP view of the L shoulder reveals multiple calcificated loose bodies within the articular space of the GH joint. This person presented like adhesive capsulitis but I could not find an image that substantiated my initial diagnosis. I am leaning towards synovial chondromatosis of the shoulder as my colleague Jessica Z. mentioned. This rare pathology is more common in knees and hips but can occur in the shoulder. An MRI of the shoulder could better rule in/out this pathology. This individual would not be appropriate for PT and would require Arthroscopic or open surgery to remove the loose bodies in the joint as well as possible SAD and RTC repair that could have resulted from the loose bodies.
As many have stated signs of possible OA are present, indicated by decreased joint space and glenoid and humerus shape. It’s is very possible that a different underlying diagnosis is the cause. Increased calcification is present at the inferior glenoid, these may be loose bodies or reformation of bone. Clavicle and Corocoid Process appear normal. The acromion appears smaller but this may be due to positioning during X-ray. Ultimately, it appears a total shoulder is in this persons future.
ReplyDeleteKyle Waits.
This is an Anterior-Posterior view of the Left shoulder. This shoulder has significant arthritis present which is shown by the roughened edges and decreased joint space. These areas should typically present as very smooth surfaces with clearly defined edges and 5mm of space, on average. There are bone deposits present as well. We can see this in the areas with increased calcium build up. These deposits could cause a tear of the rotator cuff which are currently being impinged upon by the decreased joint space and superior migration of the humeral head. This could lead to decreased motion and increased pain with movement. The distal end of the clavicle also seems to have decreased bone density due to the darker and less clear visualization, which seems to be migrating towards the proximal clavicle. The distal clavicle degeneration could be causing AC joint pain which will also alter shoulder mechanics and increase pain. We can also see the ribs, which appear to be positioned normally, and the L lung, which is the darkened area just medial to the shoulder complex.
ReplyDeleteJess Turley
Thomas Baalmann
ReplyDeleteIt is important to look at the entire image to screen for other pathology. This pt does not appear to have any pneumothorax, lung nodules, or lung masses. There is slight blurring at the costophrenic angle but I think that is just due to poor image quality (this is not a dedicated lung view). Its import to look for these things in addition to subjective information gathered from the patient. (coughing, chest pain, tightness etc.)
Leslie Rausch
ReplyDeleteAP view of the L shoulder in neutral alignment shows good bone density seen throughout the shaft of the humerus. No cracks or breaks see in the clavicle. There seems to be no problem at the AC joint that may be limiting his ROM and increase in pain. Further imaging should be completed to get a different view of the glenohumeral joint.
Kelby Green:
ReplyDeleteThe distance between the humerus and clavicle is diminished, in which further imaging should be performed to determine the integrity of RTC. The supraspinatus mm also shows decreased opacity, possibly indicating a chronic supraspinatus tear. To elaborate further on the positioning of the pt during the x-ray, he/she was likely placed either in a lying down or standing position. Next, the x-ray technique took special care for the CR to be perpendicular to 1 inch below the coracoid process.
Great posts everyone. A lot of good content and information that you all noticed. Jessica hit the nail on the head. This is an image of someone who had synovial chondromatosis. Her description is probably better than what I could have provided you. I have seen this several times in the shoulder and several times in the knee. Causes symptoms exactly like the description. A lot of you saw a lot of other potential things such as GH OA, maybe AC OA, lungs, heart - many, many things. Nice job!
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