Key words
nuclear magnetic resonance imaging features - pathogenesis - post-stroke shoulder
pain
Schlüsselwörter
Merkmale in der Magnetresonanztomographie (MRT) - Pathogenese - Schulterschmerzen
nach Schlaganfall
Post-stroke shoulder pain (PSSP), also known as hemiplegic shoulder pain (HSP),
becomes a manifestation of pain in hemiplegic shoulder joints after stroke. PSSP is
one of the most common complications of stroke [1]. The high incidence rate of PSSP (16–84%) has greatly
affected rehabilitation training on the upper limb [2]. It not only increases the rehabilitation time and expenditure of
people with stroke, but also linking with post-stroke depression and anxiety (as a
main pathogeny) [3]
[4]
[5]. In
addition, a small number of PSSP patients have resting pain, which easily leads to
insomnia, further increases anxiety and form a vicious circle.
At present, there were many clinical treatment methods for PSSP, mainly including
health education , non-steroid anti-inflammatory drug, exercise therapy,
percutaneous electrical stimulation, transcranial magnetic stimulation, botulinum
toxin injection, steroid injection, intramuscular patch, acupuncture and traditional
massage, which effectively alleviate pain and even improve limb function [6].The various treatments above are based on
the previous scholars’ research on the mechanism of PSSP. Currently, it is
considered that the pathogenesis of PSSP consists of shoulder subluxation, joint
capsule adhesion, rotator cuff injury, abnormal muscle tension, joint contracture,
central pain, reflex sympathetic dystrophy, etc [7]
[8]. There are no relevant
researches on the primary and secondary relationship of pathogenesis, which may also
be the consequence for being lack of PSSP related guidelines and consensus. In order
to further understand the pathogenesis of PSSP and clarify the most common causes
of
PSSP, the study reviewed the magnetic resonance imaging (MRI) of 74 patients with
PSSP in the inpatient and outpatient department of rehabilitation medicine of the
Second Affiliated Hospital of Nanjing Medical University from June 2017 to August
2021, summarizing the MRI characteristics and hoping to find the most common and
major causes of PSSP as well as providing clinical evidence for PSSP treatment.
Methods
Eligibility Criteria
Review the magnetic resonance imaging of 74 patients with PSSP in the inpatient
and outpatient department of rehabilitation medicine of the Second Affiliated
Hospital of Nanjing Medical University from June 2017 to August 202. In this
study, 94 patients were preliminarily collected, and a total of 74 patients were
enrolled according to inclusion and exclusion criteria. Patient inclusion
criteria:1.Meet the diagnostic criteria for stroke revised by the 4th National
Academic Conference on cerebrovascular diseases [9], first stroke (cerebral infarction or intracerebral hemorrhage)
which is confirmed by cranial CT or MRI; 2.Unilateral limb paralysis; 3.Meet
PSSP diagnostic criteria: emiplegic side shoulder joint pain happens after
stroke. These include spontaneous shoulder pain or shoulder pain induced by
passive motion within the range of motion of the shoulder joint [10]; 4.Active and passive motion pain or
resting pain of hemiplegic shoulder joint; 5.No shoulder pain before stroke;
6.There was no pain caused by shoulder fracture after stroke;7.Complete clinical
data.
Study design
The data of PSSP patients (gender, age, stroke type, onset time, pain degree,
Brunnstrom evaluation stage and magnetic resonance imaging characteristics etc.)
were retrospectively analyzed. Pain degree adopted visual analogue scale (VAS)
[11], Brunnstrom evaluation [12]: Stage I, when no voluntary movement of
the affected limb can be initiated; Stage II, The basic limb synergies or some
of their components now make their appearance either as weak associated
reactions or on voluntary attempt to move by the patient; Stage III, The basic
limb synergies or some of their components are performed voluntarily and are
sufficiently developed to show definite joint movements; Stage IV, spasticity
decreases, and an increasing number of movement combinations which deviate from
the basic limb synergies become possible; Stage V, A relative independence of
the basic limb synergies characterizes this stage, and spasticity is waning;
Stage VI, Isolated joint movements are now freely performed;1.5 T
magnetic resonance scanner produced by GE company in the United States was used
for MRI examination. The patients were measured in a supine position, the upper
limb on the affected side in the straight position, the palm was placed outside
of the ipsilateral thigh, and the special shoulder coil was used for
examination. Plain scan includes axial, oblique sagittal and oblique coronal fat
suppression FSE proton density weighted imaging (PDWI) sequences. Specific
parameters: oblique coronal fat suppression T2 weighted imaging
(TR/te2700–3700ms/64–73ms; echo column length
1–16; section thickness 3 mm; matrix 480×480; field of
view 14–15 cm). Oblique coronal intermediate weighted imaging
(TR/te2300–3300ms/25–30ms; echo column length
7–8; section thickness 2.5–3 mm; matrix
512)×512; field of view (14 cm). Oblique sagittal fat
suppression T2 weighted imaging
(TR/te3200–4300ms/7290ms; echo column length
12–18; section thickness 2.5–3 mm; matrix
512)×512; field of vision 14 cm). The shoulder MRI of PSSP
patients was completed by two senior doctors in the imaging department, and the
MRI results were released after being confirmed by the third imaging doctor.
Clinical rehabilitation outcomes were also evaluated.
Statistical analysis
SPSS 25.0 software was used to analyze the data. Chi square test was performed by
age, gender, hemiplegic side and stroke type. Comparisons between groups were
conducted using Pearson’s chi-squared test, continuity correction
chi-squared test or Fisher’s exact probability test. Using
Kruskal-Wallis test for the time of shoulder pain after stroke. The
statistically significant MRI features analyzed by chi square test and rank sum
test were selected for further correlation analysis.
Results
[Table 1] presents the summary statistics for
PSSP. A total of 74 patients met the inclusion criteria, including 45 males and 29
females, with average age of 64.50±11.35 years (age range:37–89
years). Among them, 42 patients had left hemiplegia, 32 patients with right
hemiplegia, 50 patients with cerebral infarction, 24 patients with cerebral
hemorrhage. VAS score of enrolled patients was 4.27±0.96 points.The time
between the onset of shoulder pain and stroke was 3.05±2.77 months. By the
Brunnstrom evaluation standard of the affected upper limb, 3, 25, 17, 22, 7 patients
were divided into I-V stage respectively. MRI features showed 56 patients with
supraspinatus injury (75.67%), 11 patients with infraspinatus injury
(14.86%), 24 patients with subscapularis injury (32.43%), 2 patients
with teres minor injury (2.7%), 60 patients with biceps longus tendon sheath
effusion (81.08%). There were 23 patients with humerus head bone marrow
edema (31.08%). 64 shoulder capsular effusion (86.49%), 6 acromial
descent capsular effusion (8.11%), 11 coracoid descent capsular effusion
(14.86%), 8 synovial thickening (10.81%) and 1 myositis ossificans
(1.35%).
Table 1 General situation and MRI features of
patients
|
Clinical data
|
Number (%)
|
|
Number of cases
|
74
|
|
Male
|
45 (60.81%)
|
|
Female
|
29 (39.19%)
|
|
Age (years)
|
64.50±11.35
|
|
Hemiplegia side
|
|
|
Left
|
42 (56.76%)
|
|
Right
|
32 (43.24%)
|
|
Stroke type
|
|
|
Cerebral infarction
|
50 (67.57%)
|
|
Cerebral hemorrhage
|
24 (32.43%)
|
|
Shoulder pain degree (VAS)
|
4.27±0.96
|
|
Onset time of shoulder pain after stroke (month
|
3.05±2.77
|
|
after stroke (month)
|
|
|
Brunnstrom evaluation period
|
|
|
I
|
3 (4.05%)
|
|
II
|
25 (33.78%)
|
|
III
|
17 (22.97%)
|
|
IV
|
22 (29.73%)
|
|
V
|
7 (9.47%)
|
|
Rotator cuff injury
|
|
|
Supraspinatus
|
56 (75.67%)
|
|
Infraspinatus
|
11 (14.86%)
|
|
Subscapularis
|
24 (32.43%)
|
|
Teres minor
|
2 (2.7%)
|
|
Biceps brachii long head
|
60 (81.08%)
|
|
tendon sheath effusion
|
|
|
Humeral head bone marrow edema
|
23 (31.08%)
|
|
Edema
|
|
|
Shoulder capsular effusion
|
64 (86.49%)
|
|
Acromial descent capsule effusion
|
6 (8.11%)
|
|
Coracoid descent capsule effusion
|
11 ( 14.86%)
|
|
Synovial thickening
|
8 (10.81%)
|
|
Myositis ossificans
|
1 (1.35%)
|
In [Table 2], It is generally confirmed that
people over 65 years old are the elderly [13]
[14] and the average age of the
overall sample size is 64.5 years old. Therefore, 65 years old is divided into two
groups all patients were divided into two groups by their average age (65 years
old), and MRI characteristics between the two groups were statistically analyzed by
Chi-square test. The test results showed that the incidence of tendon injury of the
Supraspinatus muscle was higher in older PSSP patients (>65 years old) than
in younger patients, and the difference was statistically significant. There was no
significant correlation between age and other shoulder MRI features. The difference
was not statistically significant.
Table 2 Analysis of MRI features by age group
|
MRI features
|
Age (number)
|
Sum
|
X2
|
P value
|
|
≦ 65years 42
|
>65years 32
|
|
Supraspinatus
|
28 (66.67%)
|
28 (87.50%)
|
56
|
4.282
|
0.039 a
|
|
Infraspinatus
|
5 (11.90%)
|
6 (18.75%)
|
11
|
0.672
|
0.412 a
|
|
Subscapularis
|
14 (33.34%)
|
10 (31.25%)
|
24
|
0.036
|
0.850 a
|
|
Teres minor
|
0 (0.00%)
|
2 (6.25%)
|
2
|
|
0.184 c
|
|
Biceps brachii long head tendon effusion
|
34 (80.95%)
|
26 (81.25%)
|
60
|
0.001
|
0.974 a
|
|
Humeral head bone marrow edema
|
12 (28.57%)
|
11 (34.37%)
|
23
|
0.286
|
0.593 a
|
|
Shoulder capsular effusion
|
35 (83.34%)
|
29 (90.62%)
|
64
|
0.320
|
0.572 a
|
|
Acromial descent capsule effusion
|
4 (9.52%)
|
2 (6.25%)
|
6
|
0.007
|
0.935 b
|
|
Coracoid descent capsule effusion
|
8 (25.00%)
|
3 (9.37%)
|
11
|
0.687
|
0.407 b
|
|
Synovial thickening
|
5 (11.90%)
|
3 (9.37%)
|
8
|
0.000
|
1.000 b
|
|
Myositis ossificans
|
1 (2.38%)
|
0 (0.00%)
|
1
|
|
1.000 c
|
a is Pearson’s chi-squared test; b is continuity correction
chi-squared test; c is Fisher’s exact probability test
In [Table 3], all patients were divided into
two groups according to gender, and MRI characteristics between the two groups were
statistically analyzed. The test results showed that MRI characteristics of shoulder
joint in PSSP patients were not correlated with gender, and the difference was not
statistically significant.
Table 3 MRI features were analyzed by gender
grouping
|
MRI features
|
Sum
|
gender (number)
|
X²
|
P value
|
|
Male n=45
|
Female n=29
|
|
Supraspinatus
|
56
|
33 (73.33%)
|
23 (79.31%)
|
0.342
|
0.559 a
|
|
Infraspinatus
|
11
|
4 (8.89%)
|
7 (24.14%)
|
2.147
|
0.143 b
|
|
Subscapularis
|
24
|
11 (24.44%)
|
13 (44.83%)
|
3.344
|
0.067 a
|
|
Teres minor
|
2
|
1 (2.22%)
|
1 (3.45%)
|
0.000
|
1.000 b
|
|
Biceps brachii long head tendon effusion
|
60
|
35 (77.78%)
|
25 (86.20%)
|
0.360
|
0.549 a
|
|
Humeral head bone marrow edema
|
23
|
14 (31.11%)
|
9 (31.03%)
|
0.000
|
0.994 a
|
|
Shoulder capsular effusion
|
64
|
38 (84.44%)
|
26 (89.66%)
|
0.085
|
0.770 a
|
|
Acromial descent capsule effusion
|
6
|
4 (8.89%)
|
2 (6.90%)
|
0.000
|
1.000 b
|
|
Coracoid descent capsule effusion
|
11
|
6 (13.33%)
|
5 (17.24%)
|
0.213
|
0.645 a
|
|
Synovial thickening
|
8
|
5 (11.11%)
|
3 (10.34%)
|
0.000
|
1.000 b
|
|
Myositis ossificans
|
1
|
1 (2.22%)
|
0 (0.00%)
|
|
1.000 c
|
a is Pearson’s chi-squared test; b is continuity correction
chi-squared test; c is Fisher’s exact probability test
In [Table 4], all patients were divided into
two groups according to hemiplegia side, and MRI characteristics between the two
groups were analyzed. The test results showed that there was no correlation between
MRI characteristics of shoulder joint in PSSP patients and hemiplegia.
Table 4 MRI features were analyzed by grouping according to
hemiplegia side
|
MRI features
|
Sum
|
Hemiplegia side (number)
|
X²
|
P value
|
|
Left n=42
|
Right n=32
|
|
Supraspinatus
|
56
|
33 (78.57%)
|
23 (71.87%)
|
0.442
|
0.506 a
|
|
Infraspinatus
|
11
|
7 (16.67%)
|
4 (12.50%)
|
0.029
|
0.866 b
|
|
Subscapularis
|
24
|
13 (30.95%)
|
11 (34.38%)
|
0.097
|
0.755 a
|
|
Teres minor
|
2
|
0 (0.00%)
|
2 (6.25%)
|
|
0.177 c
|
|
Biceps brachii long head tendon effusion
|
60
|
34 (80.95%)
|
26 (81.25%)
|
0.001
|
0.974 a
|
|
Humeral head bone marrow edema
|
23
|
11 (26.19%)
|
12 (37.50%)
|
1.084
|
0.298 a
|
|
Shoulder capsular effusion
|
64
|
37 (88.10%)
|
27 (84.38%)
|
0.215
|
0.643 a
|
|
Acromial descent capsule effusion
|
6
|
3 (7.14%)
|
3 (9.38%)
|
0.000
|
1.000 b
|
|
Coracoid descent capsule effusion
|
11
|
5 (11.90%)
|
6 (18.75%)
|
0.672
|
0.412 a
|
|
Synovial thickening
|
8
|
6 (14.29%)
|
2 (6.25%)
|
0.526
|
0.468 b
|
|
Myositis ossificans
|
1
|
0 (0.00%)
|
1 (3.13%)
|
|
0.432 c
|
a is Pearson’s chi-squared test; b is continuity correction
chi-squared test; c is Fisher’s exact probability test
In [Table 5], all patients can be divided into
two groups according to the type of stroke. MRI characteristics between the two
groups were analyzed. The test results showed patients with cerebral hemorrhage had
higher incidence of supraspinatus tendon injuries and biceps long head tendon sheath
effusion compared to cerebral infarction patients. The difference was statistically
significant.
Table 5 MRI features were grouped according to stroke
types
|
MRI features
|
Sum
|
Stroke type (number)
|
X²
|
P value
|
|
Cerebral infarction n=50
|
Cerebral hemorrhage n=24
|
|
Supraspinatus
|
56
|
42 (84.00%)
|
12 (50.00%)
|
9.505
|
0.002 a
|
|
Infraspinatus
|
11
|
7 (14.00%)
|
4 (16.67%)
|
0.000
|
1.000 b
|
|
Subscapularis
|
24
|
20 (40.00%)
|
4 (16.67%)
|
3.034
|
0.082 b
|
|
Teres minor
|
2
|
1 (2.00%)
|
1 (4.16%)
|
0.000
|
1.000 b
|
|
Biceps brachii long head tendon effusion
|
60
|
44 (88.00%)
|
16 (66.67%)
|
4.881
|
0.028 a
|
|
Humeral head bone marrow edema
|
23
|
15 (30.00%)
|
8 (33.34%)
|
0.084
|
0.772 a
|
|
Shoulder capsular effusion
|
64
|
46 (92.00%)
|
18 (85.71%)
|
2.687
|
0.101 a
|
|
Acromial descent capsule effusion
|
6
|
5 (10.00%)
|
1 (4.16%)
|
0.165
|
0.685 b
|
|
Coracoid descent capsule effusion
|
11
|
6 (12.00%)
|
5 (20.83%)
|
1.000
|
0.317 a
|
|
Synovial thickening
|
8
|
5 (10.00%)
|
3 (12.5%)
|
0.000
|
1.000 a
|
|
Myositis ossificans
|
1
|
0 (0.00%)
|
1 (4.16%)
|
|
0.329 c
|
a is Pearson’s chi-squared test; b is continuity correction
chi-squared test; c is Fisher’s exact probability test
In [Table 6], PSSP events were divided into
three groups based on post-stroke shoulder pain time: the acute period (within 1
month), the subacute period (1–3 months), the sequela period (3 months
above). MRI characteristics between the three groups were analyzed by Kruskal-Wallis
test. The test results showed that the humerus head marrow edema and shoulder joint
capsule effusion were correlated with post-stroke shoulder pain time.
Table 6 MRI features were grouped according to post-stroke
shoulder pain time
|
MRI features
|
Sum
|
post-stroke shoulder pain time (number)
|
Z
|
P value
|
|
t≦1month n=25
|
1 month<t ≦ 3months
n=30
|
t>3 months n=19
|
|
|
|
Supraspinatus
|
56
|
17 (68.00%)
|
27 (90.00%)
|
12 (63.16%)
|
–0.074
|
0.941
|
|
Infraspinatus
|
11
|
1 (4.00%)
|
10 (33.33%)
|
0 (0.00%)
|
–0.089
|
0.929
|
|
Subscapularis
|
24
|
9 (36.00%)
|
10 (33.33%)
|
5 (26.32%)
|
–0.653
|
0.514
|
|
Teres minor
|
2
|
1 (4.00%)
|
1 (3.33%)
|
0 (0.00%)
|
–0.765
|
0.444
|
|
Biceps brachii long head tendon effusion
|
60
|
18 (72.00%)
|
28 (93.33%)
|
14 (73.68%)
|
–0.412
|
0.680
|
|
Humeral head bone marrow edema
|
23
|
3 (12.00%)
|
13 (43.33%)
|
7 (36.84%)
|
–1.969
|
0.049
|
|
Shoulder capsular effusion
|
64
|
23 (92.00%)
|
27 (90.00%)
|
14 (73.68%)
|
–3.056
|
0.002
|
|
Acromial descent capsule effusion
|
6
|
0 (0.00%)
|
4 (13.33%)
|
2 (10.52%)
|
-1.416
|
0.157
|
|
Coracoid descent capsule effusion
|
11
|
5 (20.00%)
|
3 (10.00%)
|
3 (15.79%)
|
–0.503
|
0.615
|
|
Synovial thickening
|
8
|
2 (8.00%)
|
4 (13.33%)
|
2 (10.52%)
|
–0.334
|
0.738
|
|
Myositis ossificans
|
1
|
0 (0.00%)
|
0 (0.00%)
|
1 (5.26%)
|
–1.374
|
0.169
|
Discussion
PSSP is one of the common complications after stroke. Long-term pain not only affects
rehabilitation treatment but also further aggravates patients’ pessimism.
However, the pathogenesis of PSSP is still not very clear , and it is believed that
it may be related to soft tissue injury, motor control disorder, peripheral and
central nervous system lesions, and other factors, among which local soft tissue
injury is often considered as the most direct cause of PSSP [15]. Shoulder joint is a basic ball and socket
joint, which can be rotated in three mutually vertical axis of motion in all
directions, in order to maintain the stability of the joint and the maximum range
of
motion, there are more muscles, tendons, joint capsule and other soft tissue around
the shoulder joint need to coordinate work. As the consequence of decreased muscle
strength, decreased or increased muscle tension on the affected side after stroke,
as well as the injury of soft tissue around the shoulder caused by wrong limb
placement and excessive wrong limb pulling, the identification of the specific soft
tissue injury is the key to the treatment of PSSP. Currently, musculoskeletal
ultrasound and MRI were the most widely used examination methods in clinical
practice. Due to the complexity of shoulder anatomical structure and the limitations
of ultrasound penetration, MRI is generally considered to be more specific and
sensitive than musculoskeletal ultrasound in the examination of shoulder which is
considered to be the most reliable examination technology at present [16]. Based on MRI examination method, the study
reviewed the MRI characteristics of PSSP patients in the past 4 years and tried to
find and explore the correlation between shoulder pain incidence and age, gender,
hemiplegia, stroke type, onset time and other aspects.
The study found that the top three injuries incidence of PSSP patients were shoulder
capsule effusion (64 patients), biceps long cephalic tendon effusion (inflammation)
(60 patients), and supraspinatus tendon injury in (56 patients), accounting for
86.49%, 81.08%, and 75.67%, respectively. The results of
this study were consistent with previous domestic and foreign research results [17]
[18].
Therefore, joint capsule effusion, biceps long Cephalus tendon sheath effusion
(inflammation) and supraspinatus tendon injury are the most common MRI features of
shoulder in patients with PSSP.
The average age of onset of PSSP patients was 66.52 years [17], the results were basically the same as
this study. There were few age-related studies on PSSP patients at home and abroad.
This study also showed that patients older than 65 years of age with PSSP had a
greater chance of supraspinatus muscle injury. Supraspinatus muscle is one of the
rotator cuff muscles, which plays a significant role in shoulder joint abduction and
anti-gravity to maintain the humeral head in the right position. After stroke,
supraspinatus muscle congestion, injury and even tear due to decreased muscle
strength, gravity pulling, inappropriate passive activity, shoulder dislocation and
loss of nutritional support. Supraspinatus muscle injury is one of the important
causes of PSSP [19]. This study demonstrated
that the injury of supraspinatus muscle in the older patient’s group and the
younger patients group increased significantly, and the specific mechanism is not
very clear. Reports find that the injury of supraspinatus muscle in the group
without shoulder pain over 60 years old accounted for 30% of the total, and
the injury of supraspinatus muscle in the group without shoulder pain over 70 years
old accounted for 65% of the total [20]. In this study, the author considered the injury of the supraspinatus
muscle in the elderly patients was significantly higher than that in the younger
patients, which might be related to this, suggesting that more attention should be
paid to the protection and treatment intervention of the supraspinatus muscle in the
elderly patients with PSSP.
In this study, gender and hemiplegic group comparison demonstrated minimum
significant difference, suggesting that the two consequences are not one of the
causes of PSSP, which is consistent with recent research results [21]. According to the nature of stroke,
patients were divided into cerebral infarction group and cerebral hemorrhage group
to compare the MRI characteristics of the two groups. The results indicated that
there was a difference in shoulder soft tissue injury between patients with cerebral
infarction and patients with cerebral hemorrhage with PSSP. Refer to cases and
analysis, the cause of the differences may be associated with different initial
stroke care personnel. Patients with cerebral infarction were mostly taken care of
by family members in the early time while cerebral hemorrhage patients mostly taken
care of by a nurse or experienced nursing worker. Nurse or experienced nursing
worker may do better job in putting in a good limb position and avoiding the wrong
body pull.
The onset time span of PSSP is long, including 72 hours to several years
after the stroke event, most of which occurred in 2–3 months after stroke
[22]. The average onset time of shoulder
pain in patients in this study was 3.05 months after stroke, basically consistent
with previous studies. According to the onset time, patients were divided into three
groups within 1 month, 1–3 months and more than 3 months, and MRI
characteristics of patients in the three groups were compared. The results showed
that there were significant differences in humeral head bone marrow edema and
shoulder capsule effusion in the three groups. Bone marrow edema is a common
clinical pathological change, which is mainly manifested by abnormal subchondral
perfusion, ischemia and hypoxia of some tissues and infiltration of inflammatory
cells [23]. Bone marrow edema can be divided
into ischemic, mechanical and reactive (postoperative edema, osteoarthritis or
tumor) according to pathogenesis [24]. Bone
marrow edema of the humerus head is common in athletes engaged in throwing
activities, but not common in the general population [25]. In this study, nearly 1/3 of PSSP
patients showed bone marrow edema of the humerus, which was considered to be related
to ischemia [26] or mechanical injury [17] caused by reduced blood supply to the
shoulder joint after stroke. Bone marrow edema leads to increased intraosseous
pressure and stimulates bone pain receptors in bone marrow, causing pain [27]. This study demonstrates that stroke events
than 1 months after 1 month of shoulder pain, the participation of more bone marrow
edema, also meet with blood reduce side shoulder joint, mechanical injury takes time
to lead to bone marrow edema, in stroke events occurring after 1 month of shoulder
pain, need to focus on treatment of bone marrow edema pain relief. Shoulder cyst
effusion is one of the most common manifestations of PSSP. Lin [17] and Yu [28] confirmed the high incidence of shoulder cyst effusion in PSSP
patients through ultrasound examination and MRI examination respectively. However,
clinical attention has not been paid to the shoulder pain for many years is
something worth to patients to reflect. Normal shoulder joint capsule has a small
amount of liquid, lubricating joints and protect joints, joint capsule in fluid
volume increase often prompts some reason causing cartilage synovial liquid layer
secretion increased, and the absorption rate imbalances and joint cavity, and
excessive fluid may increase the strength of shoulder pain [29], articular effusion treatment should be a
starting point for the treatment of PSSP. In this study, it was found that the cell
phone sac effusion of patients with shoulder pain starting within 3 months after the
stroke event was significantly higher than that of patients who developed the
disease after 3 months, which may be related to early acromial impingement and wrong
upper limb pulling. Other factors cannot be excluded, and biochemical examination
of
joint cavity effusion can be performed when necessary to further clarify the cause
of the disease.
From what has been discussed above some reasonable conclusion can be safely drawn
that this study demonstrated PSSP patients had a wide range of shoulder soft tissue
injuries, with shoulder capsule effusion, biceps long cephalic tendon sheath
effusion (inflammation) and supraspinatus tendon injury being the most common.
Supraspinatus tendon injury was more common in older PSSP patients than in younger
patients. Moreover, the injury of supraspinatus tendon, hydrocele of long head
tendon of biceps brachii and hydrocele of shoulder joint capsule were more common
in
PSSP patients with cerebral infarction than in patients with cerebral hemorrhage.
In
addition, there was a correlation between the incidence of humeral head bone marrow
edema and the onset time of PSSP. The research results above could help to improve
the accuracy of clinical diagnosis and treatment as well as the accuracy of
diagnosis and treatment of PSSP, especially in primary medical institutions without
MRI or musculoskeletal ultrasound and provide more accurate and reasonable treatment
plan.
Shortcomings of this study: 1. The sample size was relatively small which may lead
to
bias in results; 2. The study scope was single-center. Although the interpretation
of shoulder joint MRI was jointly decided by two radiologists, there were still
omissions that could not point out the interpretation results of each other due to
their similar work experience.
Conclusions
Shoulder joint capsule effusion, tendon sheath effusion (inflammation) of biceps
brachii longus and supraspinatus tendon injury were the three most common features
in PSSP patients’ MRI. The injury of supraspinatus tendon in elderly
patients happens more frequently than young patients; The incidence rate of
supraspinatus tendon injury, scapular injury, biceps head tendon sheath hydrops and
shoulder joint effusion were higher in cerebral infarction patients compared to
cerebral hemorrhage patients. Humeral head bone marrow edema and effusion of
shoulder joint capsule have a strong relevance to the onset time of shoulder pain.
The results of this research could help to improve the accuracy of clinical
diagnosis and PSSP treatment, putting forward a more reasonable treatment
scheme.
Notice
This article was changed according to the erratum on
May 22, 2024.
Erratum
In the above-mentioned article the article category was corrected.
The correct article category is: Original Article.
