Clinical Presentation and Evaluation of Glenohumeral Arthritis.
Last updated Thursday, January 27, 2005
History
The patient with significant glenohumeral arthritis usually presents
with pain and loss of function which are refractory to rest,
antiinflammatory medications and exercises. The history should include
a description of the onset of the problem, the mechanism of any
injuries, and the nature and progression of functional difficulties.
Systemic or polyarticular manifestations of sepsis, degenerative joint
disease, or rheumatoid arthritis may provide helpful clues. A past
history of steroid medication, fracture, or working at depths may
suggest the diagnosis of avascular necrosis. Past injury or surgery
suggest the possibility of secondary arthritis or capsulorrhaphy
arthropathy.Standardized assessment methods Recently, standardized methods have been developed by which patients
can assess their health status and shoulder function. Bostrom et al
(Bostrom, Harms-Ringdahl, Nordemar, 1991) found that standardized
assessments of shoulder function more reliable and reproducible than
conventional range of motion measurements. Matsen et al reported the
self assessment of 103 patients with primary glenohumeral degenerative
joint disease. (Matsen, Lippitt, Sidles, et al., 1994; Matsen, Ziegler
and DeBartolo, 1995) Over half reported that their SF 36 pain and
physical role function scores were more than one standard deviation
below those of age and sex-matched controls. These patients
consistently reported the inability to perform standard shoulder
functions, such as sleeping comfortably, lifting 8 pounds to shoulder
height, washing the back of the opposite shoulder, throwing overhand,
and tucking in a shirt behind. Smith et al used self assessment of
shoulder function and health status to compare patients with rheumatoid
arthritis and degenerative joint disease of the shoulder. (Matsen,
Smith, DeBartolo, et al., 1996)
Physical examination often reveals mild or moderate muscle wasting
about the shoulder, crepitus on joint motion, and limited range of
motion. The limitation of glenohumeral motion is most easily identified
if one of the examiner's hands is used to stabilize the scapula while
the flexion/extension and internal/external rotation of the humerus
relative to the scapula are documented with the other.Thorough evaluation is essential It is important to emphasize that shoulder arthritis may co-exist
with other medical conditions, many of which will substantially alter
the patient's disability and their potential to respond positively to
treatment. Thus a thorough evaluation of each individual is essential.
The SF 36
provides a standardized documentation of the patient's self-assessed
health status. The importance of factors such as the SF 36 scales of
emotional role function, mental health, and social function is well
demonstrated in the work of Summers et al (Summers, Haley, Reveille, et
al., 1988), who found that the objective severity of the disease showed
little relationship to patients' reports of pain, whereas psychological
variables were much more closely correlated with measures of pain and
functional impairment.
In the evaluation of glenohumeral arthritis, standardized radiographic
views are necessary to understand the disease process and its severity.Standard views Standard views include an anteroposterior view in the plane of the
scapula and a true axillary view (see figure 1). These views indicate
the thickness of the cartilage space between the humerus and glenoid,
the relative positions of the humeral head and glenoid, the presence of
osteophytes, the degree of osteopenia, and the extent of bony deformity
and erosion. Superior displacement of the humeral head relative to the
scapula suggests major cuff deficiency and argues against the use of a
glenoid prosthesis (see figure 2). If a humeral arthroplasty is being
considered, a templating AP view of the humerus in 35 degrees of
external rotation relative to the x-ray beam with a magnification
marker is obtained (see figure 3). This view places the humeral neck in
maximal profile, allowing comparison of the proximal humeral anatomy to
that of various humeral prostheses. If this view is taken with the arm
in 45 degrees of abduction, placing the middle of the humeral articular
surface in the middle of the glenoid fossa, it can reveal thinning of
the central aspect of the humeral articular cartilage typical of
degenerative joint disease (the "Friar Tuck" pattern), whereas
radiographs with the arm in other positions may suggest the presence of
a thicker layer of cartilage at the periphery of the head.
CT scans are obtained if there is question about the amount or
quality of bone available for reconstruction. Most often these
questions can be answered from plain radiographs alone. Friedman et al
(Friedman, Hawthorne and Genez, 1992) and Mullaji et al (Mullaji,
Beddow and Lamb, 1994) have used CT to characterize the changes in
version in a group of patients with degenerative and inflammatory
arthritis. The most important conclusion from these two studies is that
glenoid version varies through a range of 30 degrees in these
populations! Mallon et al (Mallon, Brown, Vogler, et al., 1992) have
also conducted detailed studies of the articular surface of the glenoid
and related this shape to the anatomy of the scapula.
Imaging of the rotator cuff by arthrography, MRI or ultrasound is
carried out if it will affect management of the patient. Usually the
status of the rotator cuff can be understood from evaluation of the
history, the physical examination, and the plain radiographs.
Green and Norris (Green and Norris, 1994a) and Slawson et al
(Slawson, Everson and Craig, 1995) have recently provided a review of
imaging techniques for glenohumeral arthritis and for glenohumeral
arthroplasty.
A number of different processes can destroy the glenohumeral joint surface.Establishing criteria Clinical evaluation, management and effectiveness measurement is
facilitated by establishing necessary and sufficient criteria which
enable us to standardize the assignment of each diagnosis. Six of the
more common types of glenohumeral joint destruction include: primary
degenerative joint disease, secondary degenerative joint disease,
rheumatoid arthritis, cuff tear arthropathy, capsulorrhaphy
arthropathy, and avascular necrosis.
In an extension of a recent study on self-assessment of patients
with glenohumeral osteoarthritis (Matsen, Ziegler and DeBartolo, 1995),
patients presenting with these conditions assessed their shoulder
function using the 12 questions of the Simple Shoulder Test.
(Matsen, Lippitt, Sidles, et al., 1994) These individuals with
glenohumeral arthritis had greatest difficulty with overhand throwing,
sleeping comfortably on the affected side, washing the back of the
opposite shoulder, and placing eight pounds on a shelf. Interestingly,
the degree of functional compromise at the time of presentation for
evaluation was comparable for the different diagnoses. Apparently, it
is this level of functional impairment, irrespective of the diagnosis,
that brings the patient in for evaluation.
These individuals also assessed their health status using the SF 36
(see footnote 1). The self-assessed overall health status of
individuals with glenohumeral arthritis is most compromised in the
domains of physical role function and overall comfort. For patients
with primary and secondary degenerative joint disease and cuff tear
arthropathy the other SF 36 parameters, such as vitality and overall
health, were relatively close to population-based age and sex matched
controls. The health status of patients with rheumatoid arthritis,
capsulorrhaphy arthropathy and avascular necrosis was poorer than
controls of the same age and sex. Footnotes Footnote 1: The SF 36 is a general health status self-assessment
used in many fields of medicine.(Radosevich, Wetzler and Wilson, 1994;
Ware, Snow, Kosinski, et al., 1993) It is very useful in orthopaedics
for documenting the general health deficits of patients before and
after reconstructive surgery. The overall comfort and physical role
function scales are most commonly affected by arthritic conditions of
the shoulder. Other SF 36 scores are useful in documenting the
patients' vitality, mental health, general health and social,
emotional, and physical function.
Primary DJD In degenerative joint disease (DJD), the glenoid cartilage and
subchondral bone are typically worn posteriorly, often leaving intact
articular cartilage anteriorly (see figure 4). The cartilage of the
humeral head is eroded in a "Friar Tuck" pattern of central baldness,
often surrounded by a rim of remaining cartilage and osteophytes.
Degenerative cysts may occur in the humeral head or glenoid.
Osteophytes typically surround the anterior, inferior and posterior
aspects of the humeral head and the inferior and posterior glenoid. As
a result the humeral and glenoid articular surfaces have a flattened
configuration which blocks rotation. Loose bodies are often found in
the axillary or subscapularis recesses. The triad of anterior capsular
contracture, posterior glenoid wear and posterior humeral subluxation
is common in primary degenerative joint disease. Rotator cuff defects
are uncommon in primary degenerative joint disease.Secondary DJD In contrast to primary degenerative joint disease, secondary
degenerative joint disease arises when previous injury, surgery or
other condition affects the joint surface precipitating its
degeneration. In chronic, unreduced dislocations, (Hawkins, Neer,
Pianta, et al., 1987; Pritchett and Clark, 1987; Rowe and Zarins, 1982)
the humeral head may be indented and worn. The cartilage of the joint
surfaces may be replaced with scar, or the subchondral bone may be so
weakened by bone atrophy that it will collapse after reduction, leading
to an incongruous joint surface. Samilson (Samilson and Prieto, 1983)
identified seventy-four shoulders with a history of single or multiple
dislocations that exhibited radiographic evidence of glenohumeral
arthritis. The dislocations had been anterior in sixty-two shoulders,
posterior in eleven, and one had multidirectional instability. The
number of dislocations was not related to the severity of the
arthrosis. Shoulders with posterior instability had a higher incidence
of moderate or severe arthritis, as did shoulders with previous surgery
in which internal fixation devices intruded on the joint surface.
Hawkins and his co-workers (Hawkins, Neer, Pianta, et al., 1987) have
suggested hemiarthroplasty if the dislocation is greater than six
months old or if the humeral head defect involves more than 45% of the
articular surface. If the glenoid is destroyed, a total shoulder
arthroplasty may be indicated.
Tanner and Cofield reviewed twenty-eight shoulders with chronic
fracture problems requiring prosthetic arthroplasty. (Tanner and
Cofield, 1983) Sixteen had malunions with a joint incongruity, eight
had post-traumatic osteonecrosis, and four had nonunion of a surgical
neck fracture with a small, osteopenic head fragment.
Shoulders with secondary degenerative joint disease often present
complex pathology and difficult surgical management. (Huten and Duparc,
1986; Neer and Kirby, 1982) Difficulties may be related to a number of
factors: muscle contracture, scarring, malunion requiring osteotomy,
nonunion, or bone loss, especially humeral shortening. Dines et al
(Dines, Warren, Altchek, et al., 1993) recently reported their results
with shoulder arthroplasty in twenty patients with posttraumatic
changes. They emphasize the difficulty of these cases and the
advisability of avoiding tuberosity osteotomy. Other series of
arthroplasty for late sequellae of trauma include that of Norris et al
(Norris, Green, McGuigan, 1995), Habermeyer and Schweiberer (Habermeyer
and Schweiberer, 1992), and Frich et al (Frich, Sojbjerg and Sneppen,
1991).
Rheumatoid arthritis is a systemic disease with highly variable
clinical manifestations. It may be isolated to the glenohumeral joint
or may affect most of the tissues in the body.Effects of arthritis In rheumatoid and many other types of inflammatory arthritis, the
cartilage is characteristically destroyed evenly across all joint
surfaces. The glenoid is eroded medially (see figure 5) rather than
posteriorly as in degenerative joint disease (see figure 6). The
condition is often bilaterally symmetrical. The arthritic process
erodes not only the cartilage, but also the subchondral bone and
renders it osteopenic. The glenohumeral, acromioclavicular,
sternoclavicular, elbow, wrist and hand articulations may all be
affected, greatly amplifying the resulting functional losses. Soft
tissues, including the rotator cuff, may likewise be swollen,
contracted, weakened or torn.
In a clinical and arthrographic study of 200 painful shoulders in
patients with rheumatoid arthritis, Ennevarra found only 26 per cent of
patients had full-thickness rotator cuff defects. (Ennevaara, 1967) In
two series of patients with rheumatoid arthritis that required total
shoulder arthroplasty, the rotator cuff had full-thickness tearing in
29 of 69 shoulders (42%) and in 18 of 66 shoulders (27%). (Cofield,
1983b; Neer and Kirby, 1982)
Even the skin may be fragile and subject to compromise in wound
healing. The fragility of the patient with rheumatoid arthritis is
frequently compounded by long term use of steroids and other
antimetabolic medication. Because the condition itself involves the
immune system, because the patient is often on immunosuppressive
medication and because the clinical manifestations of rheumatoid
arthritis are similar to those of infectious arthritis, the physician
must be aware of the possible coexistence of joint infection.
Petersson (Petersson, 1986a) pointed to the prevalence and
progression of rheumatoid involvement of the shoulder. Winalski and
Shapiro(Winalski and Shapiro, 1991) and Mulliaji et al (Mullaji, Beddow
and Lamb, 1994) used computerized tomography to characterize the
rheumatoid involvement of the sternoclavicular and glenohumeral joints.
Alasaarela and Alasaarela (Alasaarela and Alasaarela, 1994) have used
ultrasonography to define the soft tissue changes associated with
rheumatoid arthritis of the shoulder. Other conditions Other conditions may produce shoulder findings quite similar to
those of rheumatoid arthritis. Included in the list are localized
processes, such as pigmented villonodular synovitis (Dorwart, Genant,
Johnston, et al., 1984a; Dorwart, Genant, Johnston, et al., 1984b)
synovial chondrometaplasia (Hjelkrem and Stanish, 1988) and pseudogout.
(Hughes, Biundo, Scheib, et al., 1990) The shoulder may be a site of
manifestation of systemic disorders such hemophilia and
hemachromatosis, (Epps, 1983; Rand and Sim, 1981) primary
hyperparathyroidism, (Nussbaum and Doppman, 1982) acromegaly,
(Podgorski, Robinson, Weissberger, et al., 1988) amyloid arthropathy,
(Curran, Ellman and Brown, 1983) gout, (Ellman and Curran, 1988)
chondrocalcinosis, (Cosendai, Gerster, Vischer, et al., 1976)
ankylosing spondylitis, (Fournie, Railhac, Monod, 1987; Marks, Barnett
and Calin, 1983) psoriasis,(Fournie, Railhac and Monod, 1987) and Lyme
arthritis. (Curran, Ellman and Brown, 1983) Recently, Sethi et al
(Sethi, Naunton-Morgan, Brown, et al., 1990) have reported a "dialysis
arthropathy" which affects multiple joints, including the shoulder, in
individuals on long term dialysis.
Because of the fragility of the skin and other soft tissues, the
osteopenia, and the severe bony erosion common with this condition, the
patient with substantial involvement from rheumatoid or similar types
of arthritis needs to be treated with extreme gentleness, thoroughness
and care. These admonitions are referred to as "rheumatoid rules."
In a recent review, Sneppen et al (Sneppen, Fruensgaard, Johannsen,
et al., 1996) pointed to the challenges of arthroplasty in rheumatoid
disease. In their series of Neer arthroplasties, at 92 month followup,
55% showed proximal migration of the humerus relative to the glenoid,
40% showed progressive loosening of the glenoid component, 5 of 12
press fit humeral components showed progressively loosening (but none
in 50 cemented humeral components). In spite of these problems, 89% of
the patients demonstrated good pain relief. Boyd et al (Boyd, Aliabadi,
Thornhill, 1991) found that of 111 Neer total shoulders with an average
followup of 55 months, progressive proximal migration occurred in 22%
of patients (29 shoulders).
Individuals with rheumatoid arthritis characteristically have
substantially lower self-assessed vitality and overall physical
function than the other causes of glenohumeral arthritis. The
compromised general health and strength of individuals with rheumatoid
arthritis must be considered in their management as has been emphasized
by a recent comparison study of RA and DJD conducted by Smith et al.
(Matsen, Smith, DeBartolo, et al., 1996) About cuff tear arthropathy Cuff tear arthropathy occurs when a chronic, massive rotator cuff
defect subjects the uncovered humeral articular cartilage to abrasion
by the undersurface of the coracoacromial arch (see figure 7). The
humeral head becomes femoralized and the coracoacromial arch acetabularized
(see figure 8). The erosion of the humeral articular cartilage begins
superiorly rather than centrally as is the case in degenerative joint
disease and capsulorrhaphy arthropathy.
In 1981, McCarty and co-workers described a shoulder condition: the
"Milwaukee shoulder." This included significant rotator cuff disease
and shoulder arthritis in older patients, often women. (Garancis,
Cheung, Halverson, et al., 1981; Halverson, Cheung, McCarty, et al.,
1981; McCarty, Halverson, Carrera, et al., 1981) The synovial fluid
contained aggregates of hydroxyapatite crystals, active collagenase,
and neutral protease. At that time, these authors hypothesized that the
crystals within the synovial fluid were phagocytized by the
macrophage-like synovial cells, and the cells in turn released enzymes,
resulting in damage of the joint and joint-related structures. The
inciting process could not be identified.
In 1983, the hypothesis was further refined. The crystals were
identified as basic calcium phosphate (BCP). (McCarty, 1983) It was
thought these crystals would form in the synovial fluid by unknown
mechanisms. They would then be phagocytosed by the synovial lining
cells. These cells would then secrete the collagenase and neutral
protease. This would damage the tissues and, in addition, cause the
release of additional crystals. The importance of this concept may be a
more universal understanding of crystal-related arthropathies and a
better understanding of how multiple joint structures can be affected
by an underlying problem. (Halverson, Cheung, McCarty, 1982; Halverson,
Garancis, McCarty, 1984; Halverson, McCarty, Cheung, et al., 1984;
Klimaitis, Carroll and Owen, 1988)
Nguyen and Nguyen (Nguyen and Nguyen, 1990) and Campion (Campion,
McCrae, Alwan, et al., 1988) have described an "idiopathic destructive
arthritis" of the shoulder, which may be another form of the same
condition.
In 1983, Neer and co-workers published an article on cuff tear
arthropathy describing pathological changes in 26 patients. (Neer,
Craig and Fukuda, 1983) These changes included massive rotator cuff
tearing, glenohumeral instability, loss of articular cartilage of the
glenohumeral joint, humeral head collapse, and related bone loss. This
entity was distinctly different from osteoarthritis, which he had
defined earlier. Neer felt that mechanical factors associated with
extensive rotator cuff tearing played a prominent role in the creation
of this problem and that secondary nutritional changes may augment the
pathological changes that occur.
The relationship between &"Milwaukee shoulder" syndrome, crystal
deposition arthritis and cuff tear arthropathy is unclear. They may be
the same process or different process with similar end stages. For the
surgeon, however, the challenge is an eroded joint lacking normal bone
stock and lacking reconstructable rotator cuff tissue. In this
condition the glenohumeral joint is deprived of several of its major
stabilizing factors:
- The normal cuff muscle force vector compressing the humeral head into the glenoid (see figure 9).
- The superior lip of the glenoid concavity, which is typically worn away by chronic superior subluxation (see figure 10).
- The cuff tendon interposed between the humeral head and the coracoacromial arch (see figure 11).
As a result of these deficits, the superior instability is of
sufficient severity that it cannot be reversed in a dependable way at
the time of reconstructive surgery.
Arntz et al (Arntz, Jackins and Matsen, 1993) reported their results
from 21 shoulders with cuff tear arthropathy. These shoulders were not
candidates for glenoid replacement because of the massive deficiency in
the cuff and the fixed upward displacement of the humeral head. Thus
they were treated with a special hemiarthroplasty, allowing the
prosthesis to articulate with the coracoacromial arch. The
prerequisites for successful hemiarthroplasty were an intact deltoid
and a functionally intact coracoacromial arch to provide superior
secondary stability for the prosthesis. One important aspect of the
operative technique was the selection of a sufficiently small
prosthesis so that excessive tightness of the posterior aspect of the
capsule could be avoided. Eighteen shoulders in sixteen patients were
available for follow-up, which ranged from twenty-five to 122 months.
Pain decreased from marked or disabling in fourteen shoulders
preoperatively to none or slight in ten and to pain only after unusual
activity in four. Active forward elevation improved from an average of
66 degrees preoperatively to an average of 109 degrees postoperatively.
One patient, who had an excellent result, fell and sustained an
acromial fracture, so the functional result changed to poor. Three
patients had persistent, substantial pain in the shoulder that led to a
revision. Neither infection nor prosthetic loosening developed in any
shoulder.
Capsulorrhaphy arthropathy is recognized as a special subset of
secondary degenerative joint disease in which deterioration of the
joint surface related to a previous repair for recurrent dislocations.Common cause of arthritis This is one of the commonest causes of severe arthritis in the
individual under fifty-five years of age. Capsulorrhaphy arthropathy
may be caused by overtightening the anterior capsule, for example in a
Putti Platt repair, limiting external rotation and causing obligate
posterior translation forcing the humeral head out of its normal
concentric relationship with the glenoid fossa (see figures 12 and 13).
The posterior glenoid is typically eroded from this chronic posterior
humeral subluxation; occasionally major posterior bone deficiencies
result (see figure 13). The converse situation may arise when obligate
anterior translation results from excessive posterior capsular
tightening. Lusardi et al (Lusardi, Wirth, Wrutz, et al., 1993)
reported a retrospective study of 20 shoulders in 19 patients who had
been managed for severe loss of external rotation of the glenohumeral
joint after a previous anterior capsulorrhaphy for recurrent
instability. All patients had noted a restricted range of motion, and
17 shoulders had been painful. In 7 shoulders, the humeral head had
been subluxated or dislocated posteriorly, and 16 shoulders had been
affected by mild to severe glenohumeral osteoarthrosis. All 20
shoulders were treated with a reoperation, which consisted of a release
of the anterior soft tissue. In addition, eight shoulders had a total
arthroplasty and one had a hemiarthroplasty. At an average duration of
followup of 48 months, all shoulders had an improvement in the ratings
for pain and range of motion. The average increase in external rotation
was 45 degrees.
Capsulorrhaphy arthropathy may also be related to intraarticular
positioning of metallic internal fixation devices (screws or staples)
or bone graft used in repairs of recurrent instability. (Zuckerman and
Matsen, 1984)
Bigliani et al (Bigliani, Weinstein, Glasgow, et al., 1995) and
Hawkins (Hawkins and Angelo, 1990) reported their results from
reconstruction of shoulders damaged by capsulorrhaphy arthropathy.
Nontraumatic avascular necrosis of the humeral head may be idiopathic
or associated with the systemic use of steroids, dysbaric conditions,
transplantation, or systemic illnesses with vasculitis.Other implicated conditions Other implicated conditions include alcoholism, sickle cell disease,
hyperuricemia, Gaucher's disease, pancreatitis, familial
hyperlipidemia, renal or other organ transplantation, and lymphoma.
(Bradford, Szalapski, Sutherland, et al., 1984; Cruess, 1976; Cruess,
1985; Rossleigh, Smith, Straus, et al., 1986)
The pathology may first be detected by magnetic resonance imaging
before collapse is seen radiographically. Later osteoporosis and/or
osteosclerosis may be seen on plain radiographs. Next there is evidence
of a fracture through the abnormal subchondral bone superior-centrally.
Later, collapse of the subchondral bone occurs, often with a separated
osteocartilaginous flap. In end-stage avascular necrosis, the irregular
humeral head destroys glenoid articular cartilage resulting in
secondary degenerative joint disease. (Cruess, 1976; Rutherford and
Cofield, 1987) Types Neurotrophic arthropathy arises in association with syringomyelia,
diabetes, or other causes of joint denervation. The joint and
subchondral bone are destroyed because of the loss of the trophic and
protective effects of its nerve supply. It has been suggested that the
injection of corticosteroids may contribute to the development of this
condition. (Parikh, Houpt, Jacobs, et al., 1993) The Charcot joint
presents with functional limitation and pain (in spite of the
denervation). Cervical spine trauma may have occurred in the past,
(Rhoades, Neff, Rengachary, et al., 1983) or unrecognized syringomyelia
may exist.(Mau and Nebinger, 1986; Tully and Latteri, 1978) There is
usually significant bone destruction and with osseous debris about the
joint area. This condition may resemble infectious arthritis.
(Louthrenoo, Ostrov, Park, et al., 1990)
Radiation therapy, especially for the treatment of breast cancer,
may cause a number of shoulder problems: brachial plexopathies,
osteonecrosis, malignant bone tumors, and fibrous replacement of many
tissues. Glenohumeral cartilage and subchondral bone are on occasion
affected by these changes and may require treatment by prosthetic
arthroplasty or other alternative methods.
Septic arthritis of the shoulder is uncommon, but when it occurs, it
is often in a person debilitated from a generalized disease (Baker,
Oddis, Medsger, 1987; Burdge, Reid, Reeve, et al., 1988), in a person
on immunosupressive medications, or in a person who has an underlying
shoulder disease process such as rotator cuff tearing (Armbuster,
Slivka, Resnick, et al., 1977) or rheumatoid arthritis. (Kraft, Panush
and Longley, 1985) In this latter setting, there appears to be an
exacerbation of the underlying shoulder disease, and in the absence of
fever or an elevated white blood count, diagnosis will depend on a high
level of suspicion, jointaspiration, and bacteriological testing.
Leslie et al (Leslie, Harris and Driscoll, 1989) reviewed 18 cases of
shoulder sepsis, of which 11 had Staph aureus. Some were initially
confused with non-septic arthritis and treated with anti-inflammatory
agents. The results of treatment were poor, but somewhat better with
arthrotomy than repeated aspiration.
Neoplasia present insidiously; it is often characterized by non
mechanical pain. The tumor may incite a synovial response, mimicking an
arthritic condition. (Benjamin, Hirschowitz, Arden, et al., 1982;
Medsger, Dixon, Garwood, 1982) The pain may be more intense than the
usual arthritic pain and decidedly unresponsive to rest. Diagnosis will
depend on accessing the patient's general health, high quality plain
x-rays, and additional imaging modes including tomography, computerized
tomographic scanning, bone scanning, or magnetic resonance imaging.
Identification of the primary lesion in metastatic disease is
desirable, but sometimes biopsy of the shoulder lesion is the most
direct route to diagnosis.
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