Ultras ono graphic Evaluation of Rotator Cuff Tendons in Patients with Rheumatoid Arthritis

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1 Med. J. Cairo Univ., Vol. 83, No. 1, June: , Ultras ono graphic Evaluation of Rotator Cuff Tendons in Patients with Rheumatoid Arthritis HALA I. ELGENDY, M.D.*; HATEM M. ELAZIZI, M.D.** and RASMIA M. ELGOHARY, M.Sc.* The Departments of Internal Medicine* and Radiodiagnosis**, Faculty of Medicine, Cairo University Abstract Introduction: To evaluate involvement of rotator cuff tendons in patients with rheumatoid arthritis (RA) and compare the ultrasound finding with clinical examination and disease activity. Material and Methods: Full history, thorough clinical examination and ultrasound assessment of rotator cuff and biceps tendons at the level shoulders were done for thirty patients with RA and 2 healthy controls matched by age, sex and body mass index (BMI). This study was performed on patients attended the rheumatology and immunology outpatient clinic, Internal Medicine Department of Kasr Al-Ainy Hospital, Cairo University, during ( ). Results: In our study, the biceps and rotator cuff tendons (except for teres minor which was not included in our study) showed evidence of tendon inflammation and damage in 15 (5) and 8 (26.7) of our patients, respectively. Conclusion: The results of current study recommended that long head of biceps and supraspinatus tendons should be included in follow-up of RA patients using the ultrasound. Key Words: Rheumatoid arthritis (RA) Rotator cuff Tenosynovitis Tendinopathy Ultrasound (US) Power Doppler Ultrasonography (PD U). Introduction THE tendon pathology is a well recognized consequence of rheumatoid arthritis (RA), but underestimated aspect of the disease, which may lead to irreversible functional impairment and consequent disability; there is a high possibility of rotator cuff lesion in the shoulder area secondary to synovitis, bursitis or tendonitis [1]. Ultrasonography (US) can be quick, inexpensive and useful tool in evaluating patients with early rheumatoid arthritis. US can detect pre-erosive synovitis. They can also identify early bone damage Correspondence to: Dr. Hala I. Elgendy, The Department of Internal Medicine, Faculty of Medicine, Cairo University before it becomes apparent on radiography [2]. Furthermore, ultrasonography (US) allows for a sensitive detection and characterization of periarticular soft-tissue involvement including tendon inflammation and damage [1]. The aim of our study was to evaluate involvement of shoulder tendons in rheumatoid arthritis patients, describing the most frequently affected tendons and to determine the factors that are potentially associated with more frequent tendon involvement. Material and Methods A total of thirty patients with RA, diagnosed according to the American College of Rheumatology (ACR) 1987 criteria for the diagnosis and classfication of RA [3], and 2 healthy controls matched by age, sex and body mass index (BMI) were enrolled in this study, a consent was obtained from each participant. We exclude patients with diabetes mellitus, history of trauma, surgical or arthroscopic joint intervention and recent joint injection therapy within the past six months. Detailed history of all the patients was obtained, including the sex, age, duration of the disease, occupation, medication profile and functional assessment using modified HAQ. A complete physical examination was carried out including the following tests for determining the location of the tendon lesions; Jobe s test for supraspinatus, infraspinatus test, Gerber s lift off test for subscapularis, and Yegarson s test for the long head of the biceps brachi. These tests are positive when patients experience pain or weakness during the maneuvers [4]. The disease activity was assessed by calculating the Disease Activity Score with a 28 joint count and ESR (DAS 28-ESR) for each patient. 395

2 396 Ultrasonographic Evaluation of Rotator Cuff Tendons Gray-scale (GS) ultrasound and power Doppler ultrasound (PDU), using a high frequency broadband linear array transducer, were performed using a General Electric (GE) LOGIQ P5 machine. Both shoulder joints were examined for the presence of effusion and/or synovitis that was assessed according to Naredo et al., [5] criteria. The following tendons were examined bilaterally; rotator cuff (supraspinatus, infraspinatus & subscapularis tendons) and long head of biceps tendons. The tendons were examined regarding findings indicative of tendon damage (internal tendon echotexture derangement, focal or diffuse swelling and partial or complete tendon tear) and findings indicative of tendon inflammation (synovial effusion and/or proliferation within the tendon sheath, peritendinous power Doppler signal and intra tendinous power Doppler signal). Control: The 2 healthy individuals were subjected to full history and physical examination as well as ultrasound assessment in the same anatomical sites. Statistical analysis: Statistical package for social sciences (SPSS) version 19. was used for data analysis. The relation between the US detected tendon abnormalities and the disease activity assessed by both DAS 28- ESR & total US synovitis score (using the GS and PDU) were tested by univariate regression analysis. p-values <.5 were considered statistically significant. Results All control subjects had normal findings on clinical and US examination. The demographic, clinical, and laboratory data of the RA patients are shown in Table (1). Table (1): Patients demographic and clinical data. Characteristics N () Mean Median, IQR (25-57) Number of patients 3 Gender (F/M) 27/3 (9/1) Age (years) 44.8±14.4 BMI 29.7±5.6 Disease duration (years) 6.3± (1-11.2) Modified HAQ.7±.6.6 (.2-1) Rheumatoid factor + 2 (66.7) Anti-CCP + 22 (73.3) ESR 52.4±23.5 DAS 28: 5.3± 1.2 IQR : Interquartiles ranges. BMI : Body mass index. HAQ : Health associated questionnaire. Anti-CCP : Anti cyclic citrulinated peptide. ESR : Erythrocyte sedimentation rate. DAS 28 : Disease activity score-28. Tenosynovitis/tendonitis was found in at least one tendon in 12 (4) patients. Tendon damage was found in 8 (26.7) patients. The biceps was the most frequently involved tendon by tenosynovitis/tendinitis while the supraspinatus tendon was the most frequently involved by damage Fig. (1). Fig. (1): Supraspinatus Tear. Sonographic images, obtained in transverse (A) and longitudinal (B) scans, show supraspinatus tear related to the articular surface erosion (arrow). The distribution of US findings indicative of tendons inflammation and damage is reported in Figs. (2,3) Peritendon effusion Synovial hypertrophy Peritendon PD Intratendon PD Tenosynovitis/tendinitis Biceps Suprspinatus Infraspinatus Subscapularis Fig. (2): Distribution of US findings indicative of tendon inflammation at shoulder level. PD: Power doppler.

3 Hala I. Elgendy, et al Biceps Suprspinatus Infraspinatus Subscapularis Echotexture derangement Diffuse swelling Partial tear Focal swelling Calcification Complete tear Fig. (3): Distribution of US findings indicative of tendon damage at shoulder level. Fig. (4) showed clinical examination (CE) findings for the tendons of the studied patients with comparison to US. Overall, they had more positive findings on physical examination compared to US CE CE CE CE CE CE CE CE Negative Positive Negative Positive Negative Positive Negative Positive Supraspinatus Infraspinatus Subscapularis Biceps US positive US negative Fig. (4): Comparison between individual tendon test and US finding indicating tendon involvement. Table (2) shows the sensitivity and specificity of physical examination for the detection of tendon abnormalities using the US as gold standard. The relation between US findings of tendon involvement and disease activity as assessed by DAS 28-ESR and shoulder synovitis score is reported in Table (3). Table (2): Sensitivity and specificity of clinical examination for detection tendon abnormalities in RA patients using the US as gold standard. Clinical test Jobe s test (supraspinatus) Test for infraspinatus Gerber s test (subscapularis) Yegarson s test (biceps) US abnormality Sensitivity () Specificity ()

4 398 Ultrasonographic Evaluation of Rotator Cuff Tendons Table (3): Relation between tendon involvement and disease activity. Clinical test Shoulder tenosynovitis/tendinitis Shoulder tendons damage Coefficients t p-value Coefficients t p-value Shoulder SH score Shoulder PDU score DAS 28: Disease activity score-28. SH: Synovial hypertrophy. US: Ultrasound. PDU: Power Doppler ultrasonography. Discussion In our study, the biceps and rotator cuff tendons (except for teres minor which was not included in our study) showed evidence of tendon inflammation and damage in 15 (5) and 8 (26.7) of our patients, respectively. Biceps tenosynovitis was detected in 38.3, supraspinatus tendonitis was detected in 3.3, and subscapularis tendonitis was detected in. Rotator cuff tear was detected in 2.5; the supraspinatus was the only affected tendon (partial tear in 5 (2.1) tendons, and complete tear in 1 (.4) tendons). In accordance with our result, a study done by Coari et al., 1999 [6] evaluating 9 RA shoulders with mean disease duration of 5.5 years, reported effusion in the long head of the biceps tendon in 32.2, while rotator cuff tear was detected infrequently (1.1 for infraspinatus and 4.4 for supraspinatus). In a recent study done by Sanja and Mirjana, 21 [7], 77 RA patients with painful shoulders were evaluated. The mean age was 6.87 ( ± 1.24) years, mean DAS; 3.73 ( ±.61), and the duration of shoulder pain was.84 ( ±.27) years. They demonstrated a relatively lower percentage of biceps tenosynovitis (32.5), while they found the tendon tears in a higher percentage; in 2.6, 24.7, and 16.9 of long head of biceps, supraspinatus, and infraspinatus tendons respectively. However in this study, all patients had a higher age and painful shoulder therefore, although patients with tendon disease were not specifically selected, this may have biased the study to include those more likely to have it. Our patients showed more positive findings on physical examination compared to US, however their sensitivity and specificities were relatively low, and this may be due to associated arthritis (or presence of other periarticular lesions, such as the subacromial-subdeltoid bursa). Also the failure to distinguish between positive findings due to weakness or pain might also have resulted in decreasing the diagnostic accuracy of clinical examination. This was in line with results of Kim et al., 27 [8] that showed that clinical examination of periarticular conditions in the painful RA shoulder is not accurate, and had low sensitivity and specificity in detecting tendon abnormalities. Amin et al., [9] demonstrated no relation between tenosynovitis of the long head of the biceps tendon and the glenohumeral intra-articular synovitis, confirming our result that biceps tenosynovitis was not an extension from the glenohumeral intraarticular synovitis. In addition Kim et al., 27 [8], found that the presence of hand/foot joint erosion were not significantly related with the presence of shoulder tendon tear. Our study has a few limitations. One of them is that, shoulder radiography was not performed on our patients to enable a better assessment of degenerative changes that may have contributed to the shoulder tendon abnormalities. We did, however excluded any patients with positive clinical examination for osteoarthritis. Finally, tendons of ankles and foot were not included in our study for feasibility reasons, with the hope of assessed them in future studies. Conclusion and Recommendation: The current study provided a detailed description of ultrasound detected abnormalities of rotator cuff and biceps tendons in RA patients and suggested to include both long head of biceps and supraspinatus tendons in follow-up of RA patients using the ultrasound. References 1- FILIPPUCCI EMILIO, GABBA ALESSANDRA, GESO LUCA DI, GIROLIMETTI RITA, SALAFFI FAUSTO and GRASSI WALTER: Hand tendon involvement in rheumatoid arthritis: An ultrasound study. Seminars in Arthritis and Rheumatism, 41: 752-6, BOUTRY NATHALIE, MOREL MÉLANIE, FLIPO RENÉ-MARC, DEMONDION XAVIER and COTTON ANNE: Early rheumatoid arthritis: a review of MRI and sonographic findings, A.J.R., 189:152-9, ARNETT F.C., EDWORTHY S.M., BLOCH D.A., MC- SHANE D.J., FRIES J.F., et al.: The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum., 31: 315, 1988.

5 Hala I. Elgendy, et al BEUERLEIN MURRY J., McKEE MICHAEL D. and FAM ADEL G.: The shoulder Fam s Musculoskeletal Examination and Joint Injection Techniques 2 nd edition; 2: Editors: Lawry V. George, Kreder J. Hans, Hawker A. Gillian, Jerome Dana, NAREDO E., COLLADO P., CRUZ A., PALOP M.J., CABERO F., et al.: Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: Predictive value in disease activity and radiologic progression. Arthritis Rheum., 57: 16-24, COARI G., PAOLETTI F. and IAGNOCCO A.: Shoulder involvement in rheumatic diseases; sonographic findings, J. Rheumatol., 26: , SANJA MILUTINOVI S.R. and MIRJANA ZLATKO- VIC-SVENDA I.: Ultrasonographic study of the painful shoulder in patients with rheumatoid arthritis and patients with degenerative shoulder disease, Acta. Reumatol. Port, 35 (1): 5-8, KIM HYUN AH, KIM SU HO and SEO YOUNG: Ultrasonographic findings of the shoulder in patients with rheumatoid arthritis and comparison with physical examination. J. Korean Med. Sci., 22: 66-6, AMIN M.F., ISMAIL F.M. and EL-SHEREEF R.R.: The role of ultrasonography in early detection and monitoring of shoulder erosions, and disease activity in rheumatoid arthritis patients; comparison with MRI examination. Academic Radiology, 19 (6): 693-7, 212.