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A 66-year-old male presents with a three-month history of increasing right shoulder pain. He denies any trauma or prior shoulder problems, and has good rotator cuff strength. His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. A current MRI image of his shoulder is shown in Figure A. What is the most likely diagnosis?
Chronic rotator cuff tendinopathy
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The atraumatic lesion shown in Figure A is most consistent with osteonecrosis (also known as avascular necrosis, or AVN). Initial MRI findings of AVN include decreased signal intensity in the subchondral region on both T1- and T2-weighted images, suggesting edema in early disease. In the shoulder, this is most commonly associated with the chronic use of corticosteroids, such as prednisone.
Sarris et al provide a review of osteonecrosis of the shoulder. They state that treatment is most effectively guided by staging of the disease, and that stage I and II disease can be treated conservatively. Surgical intervention is advocated when the patient is persistently symptomatic, and signs of articular collapse are evident. The surgical options include arthroscopic débridement, core decompression, vascularized bone grafting, and shoulder arthroplasty.
1-Gaucher disease is usually associated with large boney infarcts on MRI and severe pain. It is also a less common cause of AVN than chronic corticosteroid use.
2-Osteoarthritis is not frequently associated with subchondral collapse and fragmentation, especially in the absence of prior symptoms.
3-Chronic rotator cuff tendinopathy does not typically present with the changes noted on the MRI in Figure A.
5-Calcific tendinitis usually presents with severe acute pain, and a hypointense area within the soft tissues around the shoulder representing the calcific deposit. An example of calcific tendinitis is shown in Illustration A.
Sarris I, Weiser R, Sotereanos DG
Orthop. Clin. North Am.. 2004 Jul;35(3):397-404, xi. PMID: 15271548 (Link to Abstract)
Sarris, CORR 2004
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A 37-year-old severe asthmatic has been taking daily corticosteroids for twenty years and now reports 4 months of worsening left shoulder pain. He is unable to complete a full day of work due to the pain. A radiograph is provided in Figure A. Which of the following describes the pathogenesis behind this disease process?
Cell-mediated immune response inciting synovial hypertrophy and mononuclear destruction of cartilage
Humoral immune response following a systemic infection in an HLA-B27 positive individual
Hyperuricemia induced crystalline deposition within the synovial fluid
Cellular death of the subchondral bone following an interruption in the vascular supply
Bacterial seeding of the joint inducing polymorphonuclear cell destruction of the cartilage
The radiograph demonstrates AVN of the humeral head and early collapse of the articular surface. Patients with radiographic evidence of proximal humerus AVN should also have hip radiographs performed as part of their evaluation.
Cruess reviews 95 patients with steroid-induced AVN of the humeral head reporting success with both conservative and arthroplasty treatment.
L'insalata et al reviews 65 shoulders with AVN of the humeral head reporting mixed results with 35 shoulders requiring arthroplasty after failure of conservative therapies. Surgical drilling and decompression did not alter the progression of disease.
Answers 1, 2, 3, and 5 describe rheumatoid arthritis, Reiter's Syndrome, gout, and septic arthritis respectively.
J Bone Joint Surg Br. 1976 Aug;58(3):313-7. PMID: 956247 (Link to Abstract)
Cruess, BJJ 1976
L'Insalata JC, Pagnani MJ, Warren RF, Dines DM
J Shoulder Elbow Surg. 1996 Sep-Oct;5(5):355-61. PMID: 8933457 (Link to Abstract)
L'Insalata, JSES 1996
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