The aim of this book was to stress the meaning of the ultrasound examination without which we cannot imagine the differential diagnostics in the area of the shoulder joint nowadays. Mainly in rheumatologic practice we meet patients at who we can simultaneously find a few basic pathological states in the area of the shoulder girdle – i.e. arthritis of the glenohumeral and acromioclavicular articulation, bursitis, tenovaginitis of the long head of the biceps, often in various combinations. The development points out that the entrance ultrasound examination in these cases will have a clear priority before any other examination. An clinical picture in the area of the shoulder is sometimes deceptive, and the ultrasound brings trustworthy findings having a basic meaning for an adequate therapy. We cannot consider in any case the anamnesis and clinical examination together with the X-ray of the shoulder joint for adequate ones for the diagnostics of the pathological state in the area of the shoulder joint. If we evaluated 4 years of our work with the ultrasound device and its contribution for our patients, we could introduce these outcomes:
A usage of the ultrasound, which must become a procedure
immediately accessible in the outpatient department, is except the basic
anamnesis and physical examination an entrance examination at pains of the
shoulder girdle. (If for example we do not have in mind traumas with a suspicion
of osseous pathology with the entrance X-ray examination).
Examining methods as MRI and arthroscopy are indicated
after this examination, or the ultrasound at least more specifies on which
structures these methods have to be aimed at. Our conclusion is that most
frequent affected structure in the area of the shoulder girdle is the tendon of
the long head of the biceps.
From other structures we began to be more interested in the
acromioclavicular articulation whose role for the origin of problems is, in our
A finding out of a present occurrence of several
pathological states at the same patient was quite surprising.
A high effectiveness of a local steroid was found out also
at the diagnoses as traumas of the shoulder girdle where the steroids are not
used for the time being. We have of course in mind the traumas with a great
inflammatory reaction, and a secondary presence of a liquid – in bursae,
joints with a synovial epithelium, and a tendon of the long head of the biceps.
But a success of this therapy came if the steroids were applied targetably under
the ultrasound, and the pathological liquid was aspirated before the
peritendinous injection. At this progress the applications of steroids neither
parcial ruptures of the tendons were not contraindications for us.
Not to be full only of optimism for a possible reader, we
have to admit that some problems, which in our opinion deserve another
attention, occurred. Exudative tenovaginitis of the long head of the biceps in
the acute stage with a presence of highly inflammatory (little viscid) liquid
reacted on the therapy with steroids perfectly. Unfortunately tenovaginitis of
the long head of the biceps with a presence of viscid substances of a type of
ganglion were resistant to this therapy. There were reoccurrences very often. We
think that a solution for this state is an operation, synovectomy of the sheath of the tendon of the long head of the biceps. Results which would confirm the
effectiveness of tenosynovectomy, but we do not have them at our disposal so
The findings of the free liquid are clear in the ultrasound
device. Sensitiveness and specifity at these finding in the case of the bursa,
joint, tendon of the long head of the biceps is high, minimally the same as at
MRI. But we meet also findings of an effusion of soft tissues which are not so
expressive that we do not risk to publish them in this book. The ultrasound
possibly seems to be more sensitive than MRI. It concerns mainly the possibility
of dry synovitis of the glenohumeral and acromioclavicular articulation, and
sometimes also tenovaginitis of the long head of the biceps.
We do not know sufficiently clinically efficient doses of
local steroids yet. It is necessary to evaluate the present rather smaller
doses. When we used the targetable applications under the ultrasound, we think
that the undesirable effects of steroids so far applied without looking are
decreasing. Therefore we consider carefully if it is more suitable to apply at
the inflammation of synovial structures bigger doses of steroids than it was in
the habit, i.e. about 40 – 50 mg of Depo Medrol of one application.