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The clinical efficacy and tolerability of sodium hyaluronate, a high-molecular-weight hyaluronic acid preparation, in the treatment of patients with periarthritis of the shoulder was investigated in a multicenter, cooperative study. Of 70 patients seen at 12 participating centers between April and September 1992, follow-up was possible in 62 (28 men and 34 women; mean age, 65.4 years). Patients received sodium hyaluronate 25 mg (1% solution in an ampule) once weekly for 5 weeks by injection into the glenoid cavity or the subacromial bursa. If periarthritis resolved during this period, treatment was stopped; if periarthritis had not fully resolved by the end of the 5 weeks, weekly or biweekly treatment was continued as appropriate. The mean treatment period was 8.16 +/- 0.88 weeks, and the mean total administered dose was 6.05 +/- 0.61 ampules. Rates of improvement over pretreatment values were 75.0% for pain at rest, 73.7% for pain on motion, and 78.8% for pain on pressure. Significant increases in joint angles (measured as components of joint range of motion after administration of sodium hyaluronate) were observed; activities of daily living also improved significantly (P < 0.05 to P < 0.001). No adverse reactions were observed. These results strongly suggest that sodium hyaluronate is an effective agent for the treatment of patients with periarthritis of the shoulder.
186 patients with periarthritis of the shoulder have been studied. The sex ratio was female:male, 1-52:1. The peak age of onset was 54-59 years in both sexes. Over 40% of the patients were referred to the clinic after 6 months had elapsed from the time of onset of the disease. The right shoulder was more frequently involved than the left, particularly in the men. One shoulder only was affected in 75% of patients. There was frequently a previous history of 'rheumatism' before the episode of periarthritis. In one-third of the women 'nonspecific rheumatism' had occurred. Cervicobrachial pain and a previous episode of shoulder pain had occurred more often in the women. There were a number of associated diseases, ischaemic heart disease, thyroid disease among women, diabetes among women, hemiplegia, pulmonary tuberculosis, chronic bronchitis, and epilepsy. Acute trauma was rarely a precipitating factor. Manual workers were more frequently seen than sedentary workers in the sample, and there were more in the sample than in the general population of Leeds. The general psychological background was no different from a control group. The Maudsley Personality Inventory gave no different results among patients with periarthritis of the shoulder than among a control group and among the general population. It is suggested that there is no evidence in this study for a 'periarthritic personality'. It is suggested that the cause of periarthritis of the shoulder is likely to be related to chronic trauma occurring in an age range when changes in connective tissue are occurring. Certain associated diseases may predispose the patient to this disorder.
The association between periarthritis of the shoulder and diabetes mellitus is well recognized. A study of 100 hospitalized patients with diabetes was performed, comparing them with 100 control subjects. The mean +/- SEM age of the subjects was 47 +/- 2 yr. Nineteen percent of the patients with diabetes had periarthritis. The afflicted subjects had a higher incidence of retinopathy (P less than 0.005) and albuminuria (P less than 0.005). The duration of shoulder pain correlated with the duration of the diabetes mellitus (P less than 0.001). However, the presence of other complications in subjects with periarthritis was not as well correlated with the duration of the diabetes mellitus. These data emphasize the common occurrence of periarthritis in subjects with diabetes mellitus and its extension to people of diverse backgrounds.
We describe a mother and 2 daughters with familial recurrent calcific periarthritis in a family with an inherited tendency to develop generalized osteoarthritis (OA). Low levels of serum alkaline phosphatase were found in 1 of the daughters while the mother developed erosive OA in later life. HLA typing was noncontributory. However, the 3 individuals with periarthritis possessed blood group A+, while the 6 unaffected family members were O+. The experience of this family adds weight to the case that recurrent calcific periarthritis may be due to an inherited abnormality of alkaline phosphatase production and suggest that this may also be responsible for the recently observed association of calcific periarthritis and erosive OA.
On retrospective reviews of radiographs, periarthritis calcarea was distinguished from os acetabula by interval radiographic progression and regression. Among 59 men and 51 women, there were 137 instances of para-acetabular calcifications and ossifications, which were morphologically classified as 58 discrete, 58 amorphous, and 21 segmented types. Correlations with other radiographic abnormalities, symptoms, signs, and laboratory abnormalities were sought, but not established. Out of 93 serially imaged opacities, 90 changed, including 37 of the 40 instances (92.5%) of the discrete type and 53 instances (100%) of the amorphous and segmented types--due to periarthritis calcarea. At least 43 of 90 densities were newly developed. Mean age at first detection was 47.7 years. Three of the discrete densities were unchanged and represented os acetabula. Thus, recognition of para-acetabular periarthritis calcarea is not only of academic importance; it can facilitate proper treatment as well.
PURPOSE: Evaluation of MRI in radiotherapy of humeroscapular periarthritis. PATIENTS AND METHODS: Seventy-seven patients with humeroscapular periarthritis prospectively underwent MRI before radiotherapy. RESULTS: Six months after radiotherapy, 34% of the patients had achieved complete pain relief, 35% major pain relief. Twenty percent had only slight improvement and 12% no improvement. Positive correlation of radiotherapy outcome and MRI findings could be shown for acute tendinitis, erosions, and complete and incomplete ruptures of the supraspinatus tendon. CONCLUSIONS: Radiotherapy is highly effective in the treatment of humeroscapular periarthritis. The indication can be improved using MRI.
Basic calcium phosphate (BCP) crystal deposition around the joints may sometimes lead to an acute inflammatory condition called calcific periarthritis. In this article, the authors describe a 62-year-old man with BCP crystal-induced periarthritis coexisting with an infection. Rheumatoid arthritis and crystal-induced synovitis complicated by infection has been described in the literature. To date, this is the first report of coexistent calcific periarthritis and an infection.
Three patients with limited cutaneous scleroderma (CREST syndrome) and acute calcific periarthritis are presented. "Chalky" bursal effusion in one patient demonstrated masses of calcium hydroxyapatite crystals. In contrast to idiopathic acute calcific periarthritis, resorption of periarticular calcifications after resolution of acute attacks occurs both less frequently and incompletely in scleroderma associated acute calcific periarthritis.
To clarify the scapulo-humeral rhythm in twenty-five patients with periarthritis scapulo-humeralis, the movements of the scapula and the humerus during arm elevation were measured and analysed using a fluoroscope and a computer, and the rhythm of five patient with rotator cuff tear was compared with that of seven normal subjects. The ratio of scapular movement to humeral one in the patients with severe shoulder contracture due to periarthritis scapulohumeralis was greater than that of patients with mild contracture and that of normal subjects. In the patients with rotator cuff tear, wider range of scapular rotation was observed in the early phase of the motion. During the early phase of arm elevation, the humeral head moved to the upper direction by means of gliding in the patients with severely contracted shoulder and rotator cuff tear, and in the patients with mildly contracted shoulder the humeral head moved to the upper direction by means of ball rolling. In the normal subjects no such upward movement of the humeral head was observed. We believe that the restriction of the glenohumeral joint motion and dysfunction of the rotator cuff, which were caused by periarthritis scapulohumeralis, may break down the scapulohumeral rhythm.
The condition of generalized periarthritis calcarea (hydroxyapatite deposition disease) is characterised by multiple periarticular calcification which can be localised around practically any joint and also in proximity to the spine. This calcification consists of hydroxyapatite crystals which are responsible for the episodes of acute, subacute or chronic periarticular or articular inflammation so typical of the condition. Because of this one can classify periarthritis calcarea along with gout and chondrocalcinosis in the group of crystal deposition diseases. The actual cause of the calcification remains unknown but it is probable that, along with hereditary factors, disturbances in metabolism play an important role. The diagnosis of generalised periarthritis is made from the characteristic X-ray picture in conjunction with the clinical findings and, on occasion, the demonstration of hydroxyapatite crystals in the affected tissues. In the differential diagnosis gout, chondrocalcinosis, various inflammatory rheumatic conditions and septic arthritis must be excluded and various calcification processes, particularly interstitial calcinosis and lipocal cinogranulomatosis, must also be considered. Since the etiology of the calcification remains unknown to specific treatment is available. Symptomatic treatment with colchicine is mostly inadequate which is why one often has recourse to the use of non-steroid anti-inflammatory drugs and corticosteroids.
Over the past few years periarthritis calcarea - also known as hydroxyapatite rheumatism - has attracted increasing interest. The periarticular calcification hitherto regarded as a secondary finding is today a well-defined disease entity occurring either in localized or generalized form, i.e. around one or more joints respectively. Although the origin of this calcification is now known, various hypothetical causes have been discussed in the literature. In the light of studies on familial clustering and the HL-A constellation, it is now evident that genetic factors have a definite role to play in the etiology of the disease. Even though no metabolic defect has been identified as yet, it is impossible to state with certainty that no metabolic cause is involved. As in gout, periarthritis calcarea is liable to cause attacks of acute pain that last for several days and then disappear. In consequence, the clinical picture is misleadingly similar to that of arthritis. The subsequent disappearance of the periarticular calcium deposits previously shown to be present can be considered a cardinal symptom of the disease. To detect this calcification it is necessary to use the electron microscope, since the crystals are too small to be seen with the light microscope. Periarthritis calcarea undoubtedly ranks as a crystallopathy. Since its origin is unknown, causal therapy such as exists for gout cannot be adopted. Treatment is restricted to purely symptomatic measures.
The aim of this study was the instrumental evaluation of ultrasound therapy in patients with periarthritis of the shoulder, with regard to studies that show doubts about the real effectiveness of the antiinflammatory action of ultrasound. Two groups of subjects were studied, periarthritis versus normal patients. Clinical evaluation and instrumental measures (telethermography) were performed before and after ultrasound therapy. These data were statistically analyzed and constant variations were found, according to clinical evaluation of the patients. Therefore results of this study demonstrated a real influence of ultrasound therapy on periarthritis of the shoulder.
We wish to present an account of a child who developed acute calcification in his thenar eminence to highlight the difficulty in differentiation between calcific periarthritis, acute infection, on clinical grounds. Calcific periarthritis is due to hydroxyapatite crystal deposits in bursae, tendons and ligaments (Bonavita 1980) with characteristic radiographic appearances of opacities of variable density and shape around joints (Hitchcock 1959). The condition was first described in the shoulder, by Duplay in 1870 (Sandstrom 1938) and this remains the most commonly affected site. The hip, elbow, wrist, knee and ankle may also be involved but involvement of the hand is uncommon. Involvement in this site was first described in 1924 by Cohen (Carroll 1955). The previously reported age span ranged from thirteen years upwards, with an average of forty-five years, both sexes being equally affected (Currey 1970, Hitchcock 1959, Bonavita 1980).
Forty-one patients with periarthritis of the shoulder were entered into a double-blind, parallel comparison of naproxen and indomethacin. Both drugs were given twice daily, naproxen 250 mg in the morning and 500 mg at night and indomethacin 50 mg b.d. Twenty patients received naproxen and 21 received indomethacin. Patients were treated for four weeks. Both drugs significantly reduced pain and patients subjective impression of shoulder restriction, but had little significant effect on objective measurements of mobility. Fourteen patients from the naproxen group and 16 patients from the indomethacin group reported side-effects, the most common being nausea and headache. Three patients stopped naproxen and five patients stopped indomethacin because of side-effects. In conclusion, both drugs were equally effective in treating the pain of periarthritis of the shoulder but did little to change the partial loss of movement associated with the disorder.
Over a period of 31 years the patient described had recurrent attacks of acute calcific periarthritis at multiple sites. In the latter years of her follow-up she has developed an erosive polyarticular osteoarthritis at sites previously affected by calcific periarthritis and we speculate that there may be a pathogenetic link between these two conditions in some patients.
A group of 113 women and 73 men with periarthritis of the shoulder have been studied in detail. Electromyography showed 4 patients with neuralgic amyotrophy who had been referred for the shoulder study but were excluded on this basis. Nerve conduction studies showed little difference between the periarthritic group and a control group, apart from some reduction in amplitude and potential, and in women a suggestion of an increased latency. Duration of the action potential was equal. 6 patients had an undoubtedly long latency compatible with median nerve compression. Degenerative changes were found in the glenohumeral joints in 6-9%. Degenerative changes were found at the acromioclavicular joints in 31% of the men and 44% of the women. Calcification was found around 11 of the shoulder joints. There was frequently a previous history of 'rheumatism' before the episode of periarthritis. In one-third of the women 'nonspecific rheumatism' had occurred. Cervicobrachial pain and a previous episode of shoulder pain had occurred more often in the women. Arthrography was performed in 7 patients and there was a reduction in volume of material that could be injected in only one patient. There was obliteration of the axillary fold in that patient, and a torn capsule in a patient who had previously been manipulated. Lateral cervical spine x-rays were compared with films from an epidemiological survey. The disc space/vertebral body height ratio was taken, overcoming the magnification effects shown by technical alterations in the method of taking films. Good intra- and interobserver correlation was found for this ratio, but not for the width of the canal. There was no difference in the disc/body ratio between the periarthritic and control group in the upper cervical region. In the C5/6 and C6/7 intervertebral discs there was evidence of more disc degeneration in the periarthritic group. The differences from the control group were not great because of the high incidence of disc space narrowing and osteophytosis after the age of 45 years in the general population.