382-384
Clinicalrheumatology, 1992, 11, N ~ 3
Thermography of Frozen Shoulder and Rotator Cuff Tendinitis P.C.
VECCHIO,
A.O.
ADEBAJO, M.D. CHARD, B.L. HAZLEMAN
P. P A G E
THOMAS,
Summary
The role of thermography in the diagnosis of soft tissue lesions of the shoulder was evaluated by screening 28 patients with unilateral frozen shoulder and 86 patients with unilateral rotator cuff lesions. Index shoulders were then compared with the normal side. Differences in skin temperature distribution were found in 82% of subjects with frozen shoulder, nearly three-quarters of w h o m had reduced skin temperature. There was no consistent pattern of shoulder skin temperature found in rotator cuff tendinitis patients (49% normal, 28% reduced, 23% increased). Thermography can be helpful in the diagnosis of frozen shoulder but further studies are required to determine whether it is useful in other soft tissue shoulder lesions.
Key words : Thermography, Frozen Shoulder, Rotator Cuff Tendinitis.
INTRODUCTION Soft tissue lesions of the shoulder (including rotator cuff tendinitis and frozen shoulder) are common causes of severe and often chronic disability (1-3). The pathogeneses remain obscure and undefined and treatment regimens are diverse. Objective and reliable methods of diagnosis and assessment of progress are difficult and patient-reporting of symptoms may be unreliable. Thermography is a simple, noninvasive procedure which has not been fully investigated in frozen shoulder and rotator cuff tendinitis. This study is aimed to assess its use in assisting diagnosis in these conditions. PATIENTS AND METHODS A total of 114 patients entered the study and underwent bilateral shoulder thermography using an A G A 680M thermograph in a draught-free room with ambient temperature controlled to 20.5 _+ 0.5~ and humidity 50 +- 10%. Patients were requested not to smoke, drink alcohol or hot drinks for 4 hours before the procedure. After disrobing, and an initial 20 minute equilibration period in the room, the camera was placed at a distance of l m from the shoulder joint which was held at rest. Thermograms of the shoulder were recorded from the anterior, posterior and lateral aspects. All thermographs
Rheumatology Research Unit, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
were stored on tape and subsequently read by an experienced observer who had no knowledge of the clinical findings. The assessment of "hot" or "cold" or "normal" was made by comparing the index shoulder with the opposite side. A signficant temperature difference was recorded if there was side-to-side asymmetry greater than 0.5 degrees in any of the imaged planes. As normal shoulders may have up to 0.5 ~ side-to-side differences in skin temperature of the same areas, further disparity was considered abnormal. Ten asymptomatic people were imaged and served as controls. A diagnosis of frozen shoulder was made using the criteria of Bulgen et al (4) i.e., marked restriction of all active and passive movements with external rotation reduced by at least 50% of normal in the absence of bony restriction. Rotator cuff lesions were diagnosed using the criteria of Cyriax (5) i.e., shoulder pain exacerbated by movement against resistance in one or more of the following: abduction, external rotation, internal rotation. Although the active range of shoulder pain may have been limited, the passive range remained approximately normal. Patients with osteoarthritis, inflammatory arthritis (e.g., rheumatoid arthritis), traumatic or degenerative conditions of the acromioclavicular joint, rotator cuff tears and intra-articular injections within the last 2 months were all excluded. Clinical examination of the cervical spine was within normal limits and there was no evidence of cervical radiculopathy in the upper limbs. Plain radiographs of the shoulder (reviewed in 92% of cases) were normal with no evidence of fracture,
Thermography of the shoulder
383
Thermography of frozen shoulder compared with asymptomatic contralateral shoulder
Table I :
Thermography result
n
Cold
17
61
Hot
6
21
Normal
5
18
p
Me a n symptom duration (months)
SD
4.4
2.5
0.5 ~ - 1 o
2
>1.0~
6 9
>2 ~
~
Table I I l : Thermography of Rotator Cuff tendinitis compared with asymptomatic contralateral shoulder
86
rotator cuff calcification nor erosions. No patient with frozen shoulder was diabetic. The data were analysed using the Chi-square method. RESULTS Twenty-eight patients with unilateral frozen shoulder (10 males, 18 females; aged 51.5 _+ 8.5 years) and 86 patients with unilateral rotator cuff lesions (41 males, 45 females; aged 55.3 __ 12.2 years) were included in the study. Thermograms from 10 asymptomatic controls were all normal. In the frozen shoulder patients, over 80% had an abnormal thermographic pattern compared with the asymptomatic side. Three-quarters of abnormal scans were "cold" (p
Clinicalrheumatology, 1992, 11, N ~ 3
Thermography of Frozen Shoulder and Rotator Cuff Tendinitis P.C.
VECCHIO,
A.O.
ADEBAJO, M.D. CHARD, B.L. HAZLEMAN
P. P A G E
THOMAS,
Summary
The role of thermography in the diagnosis of soft tissue lesions of the shoulder was evaluated by screening 28 patients with unilateral frozen shoulder and 86 patients with unilateral rotator cuff lesions. Index shoulders were then compared with the normal side. Differences in skin temperature distribution were found in 82% of subjects with frozen shoulder, nearly three-quarters of w h o m had reduced skin temperature. There was no consistent pattern of shoulder skin temperature found in rotator cuff tendinitis patients (49% normal, 28% reduced, 23% increased). Thermography can be helpful in the diagnosis of frozen shoulder but further studies are required to determine whether it is useful in other soft tissue shoulder lesions.
Key words : Thermography, Frozen Shoulder, Rotator Cuff Tendinitis.
INTRODUCTION Soft tissue lesions of the shoulder (including rotator cuff tendinitis and frozen shoulder) are common causes of severe and often chronic disability (1-3). The pathogeneses remain obscure and undefined and treatment regimens are diverse. Objective and reliable methods of diagnosis and assessment of progress are difficult and patient-reporting of symptoms may be unreliable. Thermography is a simple, noninvasive procedure which has not been fully investigated in frozen shoulder and rotator cuff tendinitis. This study is aimed to assess its use in assisting diagnosis in these conditions. PATIENTS AND METHODS A total of 114 patients entered the study and underwent bilateral shoulder thermography using an A G A 680M thermograph in a draught-free room with ambient temperature controlled to 20.5 _+ 0.5~ and humidity 50 +- 10%. Patients were requested not to smoke, drink alcohol or hot drinks for 4 hours before the procedure. After disrobing, and an initial 20 minute equilibration period in the room, the camera was placed at a distance of l m from the shoulder joint which was held at rest. Thermograms of the shoulder were recorded from the anterior, posterior and lateral aspects. All thermographs
Rheumatology Research Unit, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
were stored on tape and subsequently read by an experienced observer who had no knowledge of the clinical findings. The assessment of "hot" or "cold" or "normal" was made by comparing the index shoulder with the opposite side. A signficant temperature difference was recorded if there was side-to-side asymmetry greater than 0.5 degrees in any of the imaged planes. As normal shoulders may have up to 0.5 ~ side-to-side differences in skin temperature of the same areas, further disparity was considered abnormal. Ten asymptomatic people were imaged and served as controls. A diagnosis of frozen shoulder was made using the criteria of Bulgen et al (4) i.e., marked restriction of all active and passive movements with external rotation reduced by at least 50% of normal in the absence of bony restriction. Rotator cuff lesions were diagnosed using the criteria of Cyriax (5) i.e., shoulder pain exacerbated by movement against resistance in one or more of the following: abduction, external rotation, internal rotation. Although the active range of shoulder pain may have been limited, the passive range remained approximately normal. Patients with osteoarthritis, inflammatory arthritis (e.g., rheumatoid arthritis), traumatic or degenerative conditions of the acromioclavicular joint, rotator cuff tears and intra-articular injections within the last 2 months were all excluded. Clinical examination of the cervical spine was within normal limits and there was no evidence of cervical radiculopathy in the upper limbs. Plain radiographs of the shoulder (reviewed in 92% of cases) were normal with no evidence of fracture,
Thermography of the shoulder
383
Thermography of frozen shoulder compared with asymptomatic contralateral shoulder
Table I :
Thermography result
n
Cold
17
61
Hot
6
21
Normal
5
18
p
Me a n symptom duration (months)
SD
4.4
2.5
0.5 ~ - 1 o
2
>1.0~
6 9
>2 ~
~
Table I I l : Thermography of Rotator Cuff tendinitis compared with asymptomatic contralateral shoulder
86
rotator cuff calcification nor erosions. No patient with frozen shoulder was diabetic. The data were analysed using the Chi-square method. RESULTS Twenty-eight patients with unilateral frozen shoulder (10 males, 18 females; aged 51.5 _+ 8.5 years) and 86 patients with unilateral rotator cuff lesions (41 males, 45 females; aged 55.3 __ 12.2 years) were included in the study. Thermograms from 10 asymptomatic controls were all normal. In the frozen shoulder patients, over 80% had an abnormal thermographic pattern compared with the asymptomatic side. Three-quarters of abnormal scans were "cold" (p
