Ultrasound assessment of new onset bilateral painful shoulder in patients with polymyalgia rheumatica and rheumatoid arthritis

Abstract

The aim of our study was to investigate by ultrasound (US) the anatomical structures affected during a new episode of bilateral painful shoulder in patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA) and to compare the findings between these two conditions. PMR and RA patients complaining of new onset bilateral painful shoulder were included. Subjects without any known rheumatic condition with a new onset unilateral painful shoulder were assessed as a control group. US evaluation includes the depiction subacromial-subdeltoid (SAD) bursitis, long head biceps (LHB) tenosynovitis and/or gleno-humeral (GH) synovitis. Thirty patients with PMR, 30 with RA, and 60 controls were included for a total of 60 shoulders per group. Unilateral SAD bursitis and LHB tenosynovitis were significantly more frequent in patients with PMR when compared to those with RA (p < 0.0001 and p < 0.01, respectively) and controls (p < 0.001 and p < 0.01, respectively). Unilateral GH synovitis was more common in RA than in PMR and controls (p < 0.05 and p < 0.01, respectively). Bilateral SAD bursitis was significantly more frequent in patients with PMR than in those with RA (p < 0.01) as was bilateral LHB tenosynovitis (p < 0.01). No significant differences were found in bilateral GH synovitis. US-detected periarticular inflammatory involvement more frequently in PMR both unilaterally and bilaterally and intra-articular inflammatory involvement was commonly in RA but only unilaterally.

Imaging in polymyalgia rheumatica

“…In contrast, no significant difference was detected in the distribution of biceps tenosynovitis among the study groups. Another study that looked at shoulder US findings in patients with PMR and RA confirmed that SAD bursitis was more specific to PMR (36). In this study, bilateral SAD bursitis was revealed in 37% of PMR patients, but only in 3% of patients with RA, while bilateral biceps tenosynovitis was present in 30% of PMR patients versus none of the RA controls.…”

“…Importantly, US in PMR has excellent reliability, with very high intra-observer (0.96) and inter-observer (0.99) intraclass correlation coefficients (11). The most frequent US abnormalities are usually detected at shoulder level and are represented by SAD bursitis and long head of biceps tendon tenosynovitis (12). According to a recent review, SAD bursitis is found in about 70-100% of patients with PMR, while the prevalence of long head of biceps tendon tenosynovitis hovers around 45-100% (13).…”

Musculoskeletal ultrasound in the evaluation of Polymyalgia Rheumatica

“…The most frequent US abnormalities were detected at shoulder level and were represented by SAD bursitis and LTB tenosynovitis that have been reported in percentages ranging from 6.2%-100% (fig 1) [12][13]. However, the prevalence of SAD bursitis resulted higher compared to LBT tenosynovitis in the majority of the studies, suggesting this lesion as the inflammatory hallmark in PMR [13,[18][19][20]22,25,26].…”

“…As shown in table I, most of them were cross-sectional studies, were performed in Southern European countries (above all Italy) and described the main inflammatory US lesions at disease onset or during relapse. Except for the study of Zaccaria et al, they were conducted in small groups of PMR patients [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. In terms of clinical assessment, when patients were investigated for the presence of symptoms, shoulder pain was the most frequent complain.…”

“…An extensive polyarticular US examination was performed in two studies which were focused on the comparison between PMR and Rheumatoid arthritis (RA) [21][22]. Concerning the scoring system used for grading the severity of inflammatory lesions, in the majority of studies exclusively a binary assessment was applied [12,13,19,[22][23][24]; in a few of them a semiquantitative 0 to 3 score was used [18,25,26], and finally, in two cases both scoring methods were applied [21][22][23][24][25][26][27].…”