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CASE REPORT
Year : 2016  |  Volume : 16  |  Issue : 2  |  Page : 150-152

Capsular enthesopathy of glenohumeral joint


Department of Orthopedics, CM Chungmu Hospital, Seoul, South Korea

Date of Web Publication13-Apr-2016

Correspondence Address:
Dr. Sang-Hoon Lhee
CM Chungmu Hospital, 93 Yeongdeungpo-Dong 4-Ga, Yeongdeungpo-Gu, Seoul
South Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.180185

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  Abstract 

Entheses are sites where tendons, ligaments, joint capsules, or fascia attach to bone providing a mechanism for reducing stress at the bony interface. Inflammation of the entheses is called enthesitis and enthesitis of the shoulder is a common finding, but it mostly involves rotator cuff tendon. In this case report, we are reporting a case of arthroscopically proven capsular enthesopathy of shoulder joint, and to the best of our knowledge, capsular enthesopathy of glenohumeral joint with arthroscopic proven inferior capsule calcification has yet not been reported in English literature.

  Abstract in Arabic 

اعتلال مرتكز عظم محفظة مفصل الحقاني العضدي
الملخص:
ان مواقع الارتكاز هي المواقع التي تتعلق فبها الأوتار والأربطة، وكبسولات المفاصل تربطها بالعظام وهى بمثابة مواقع توفر آلية للحد من التوتر في واجهة العظمية. وقد تلتهب موافع الارتكاز والتهاب مواقع ارتكاز للكتف هى شائعة الحدوث وهذا تقرير حالة التهاب مرتكز العظم من مفصل الكتف، وهى حالة نادرة الحدوث ولم نجد لها مثيل فى ما نشر باللغة الانجليزية

Keywords: Adhesive capsulitis, diffuse idiopathic skeletal hyperostosis, entheses


How to cite this article:
Lhee SH, Singh AK. Capsular enthesopathy of glenohumeral joint. Saudi J Sports Med 2016;16:150-2

How to cite this URL:
Lhee SH, Singh AK. Capsular enthesopathy of glenohumeral joint. Saudi J Sports Med [serial online] 2016 [cited 2022 Oct 3];16:150-2. Available from: https://www.sjosm.org/text.asp?2016/16/2/150/180185


  Introduction Top


Entheses are sites where tendons, ligaments, joint capsules, or fascia attach to bone providing a mechanism for reducing stress at the bony interface. In general, entheses dissipate biomechanical stress and in doing so are thought to be subjected to repeated microtrauma. Inflammation of the entheses is called enthesitis, and insertional disorders, in general, are termed enthesopathies. In addition to the well-recognized association with the spondyloarthritides, enthesitis can also be associated with endocrinological, metabolic, traumatic, and degenerative conditions. [1] Enthesitis of the shoulder is a common finding, but it mostly involves rotator cuff tendon. [2],[3] In this case report, we are reporting a case of arthroscopically proven inferior capsular calcification of shoulder joint, and to the best of our knowledge, capsular enthesopathy of glenohumeral joint with arthroscopic proven inferior capsule calcification has yet not been reported in English literature.


  Case Report Top


A 65-year-old, right-hand-dominant male was seen for the symptoms of right shoulder pain and stiffness. He had this symptom from last 6 months, and pain was confined mostly to anterolateral aspect of shoulder. His shoulder was most painful when he was lying on the right side, but he was not giving any history of trauma or any history of chronic disease such as diabetes, hypertension, cardiac disease, and thyroid. For that, he has taken around ten local injections of steroid from a local hospital in a duration of 6 months, but his symptoms has not improved and from last few days his symptoms are aggravated which is disturbing his sleep also.

On examination, he has global restriction of movement with end motion very painful. He demonstrated normal strength in internal and external rotation but had diminished strength in abduction as determined with the empty can test about the affected shoulder compared with the opposite extremity. Impingement signs including both Hawkins' and Neer's were positive. Anteroposterior and lateral shoulder radiographs were obtained, which showed bony spurs on glenoid with some degenerative changes [Figure 1]. Because of the severity of his symptoms, magnetic resonance arthrogram ordered which demonstrated a full-thickness tear of the supraspinatus tendon [Figure 2].
Figure 1: X-ray showing multiple bony spur


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Figure 2: Magnetic resonance imaging showing inferior capsule ossification


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On the basis of above reports, provisional diagnosis of adhesive capsulitis with rotator cuff tear was made and the patient was counseled for arthroscopic rotator cuff repair with capsulectomy. Since the patient had already taken ten injections and he was not improving, so he immediately got ready for surgery.

Surgical technique

The operation is performed under scalene block and general anesthesia with patient in beach chair position and traction applied to the arm. A standard posterior portal is established to perform a diagnostic arthroscopy in a standardized sequence, starting with the long head of the biceps. The anterior portal is made by outside in technique in the rotator interval, just above the subscapularis tendon.

Radiofrequency and punch were used to do a synovectomy and release the rotator interval, the coracohumeral ligament up to the base of the coracoid process and the anterior capsule down to the subscapularis muscle. A shaver and punch were used to release the inferior capsule where most of the calcification was present [Figure 3]. Throughout the division of the anterior and inferior structures, the arm was progressively externally rotated and abducted. At the end of the procedure, we found that there was full external rotation and abduction. The posterior capsule was then released using the anterior portal and the joint was then thoroughly irrigated. After thoroughly releasing the capsule from all side, rotator cuff was repaired by single row technique. Postoperatively, the patient wore a brace for his shoulder in abduction of 15° for 34 days with a gradual removal in the subsequent 10 days. He began a program of assisted physiotherapy from the 20 th postoperative day. The physical therapy included articular mobilization of the shoulder and shoulder girdle, assisted mobilization of the shoulder, manual therapy, reinforcement exercises of the periscapular muscles, and active mobilization of the elbow and wrist.
Figure 3: Peroperative picture showing cutting of inferior capsule


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  Discussion Top


Adhesive capsulitis is the most common reason for shoulder stiffness in routine practice. The current consensus definition of the American Shoulder and Elbow Surgeons for adhesive capsulitis is a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. [4] We are reporting a case of a patient with shoulder stiffness and pain as their presenting complain and on arthroscopic debridement, inferior capsule ossification was found. Normally fibrous capsule is a loose, redundant structure twice the surface area of the humeral head and on all sides except the inferior portion the broad, flat tendons of the rotator muscles strengthen the fibrous capsule. [5] As the cuff is absent inferiorly, the capsule is very lax, and with the arm at the side, it falls into folds, which are obliterated when the arm is brought into the elevated position. However, if there is calcification in this inferior capsule, it will loose its elasticity and consequently it cannot be obliterated when the arm is raised, causing restriction of movement.

There can be various causes of shoulder capsule ossification like ankylosing spondylitis, acromegaly, calcium pyrophosphate deposition disease and diffuse idiopathic skeletal hyperostosis (DISH). [6] In our case DISH was the most probable diagnosis of exclusion, as DISH is a condition characterized by calcification and ossification of soft tissues, mainly ligaments and enthesis. In DISH, axial skeleton is often involved, particularly the thoracic spine, but involvement of peripheral joints led researchers to use the name DISH. Although DISH often coexists with osteoarthritis, this disorder differs from primary osteoarthritis by a dissimilar prevalence within the general population, gender distribution, anatomical site of primary involvement, and magnitude and distribution in the spine and the peripheral joints. Right now, we do not have any validated diagnostic criteria for DISH; however, three sets of classification criteria are currently in use for the diagnosis of this condition. The classification criteria set by Resnick and Niwayama requires involvement of at least four contiguous vertebrae of the thoracic spine, preservation of the intervertebral disc space, and absence of apophyseal joints or sacroiliac inflammatory changes. [7] In our case, lateral X-ray of DL spine was not advised, as author in the beginning was not suspecting DISH as etiology for shoulder stiffness. However, on thoroughly reviewing the literature, it comes out to be the most probable diagnosis. However, the importance of this case reports come from the fact that capsular calcification as a cause for shoulder stiffness has yet not reported in English literature and even after taking ten injections of steroid patient has not improved because capsule once calcified there is very little chances that it will decalcified by steroid injections. From this, we like to conclude that there are various causes for shoulder stiffness and no doubt adhesive capsulitis remains the most common diagnosis, but if patient is not improving even after repeated injection one should always think toward rare causes, as in our case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Olivieri I, Barozzi L, Padula A. Enthesiopathy: Clinical manifestations, imaging and treatment. Baillieres Clin Rheumatol 1998;12:665-81.  Back to cited text no. 1
    
2.
Slobodin G, Rozenbaum M, Boulman N, Rosner I. Varied presentations of enthesopathy. Semin Arthritis Rheum 2007;37:119-26.  Back to cited text no. 2
    
3.
Lambert RG, Dhillon SS, Jhangri GS, Sacks J, Sacks H, Wong B, et al. High prevalence of symptomatic enthesopathy of the shoulder in ankylosing spondylitis: Deltoid origin involvement constitutes a hallmark of disease. Arthritis Rheum 2004;51:681-90.  Back to cited text no. 3
    
4.
Zuckerman JD, Rokito A. Frozen shoulder: A consensus definition. J Shoulder Elbow Surg 2011;20:322-5.  Back to cited text no. 4
    
5.
Schmidt HM, Vahlensieck M. Clinicoradiologic anatomy of the shoulder region. Radiologe 1996;36:933-43.  Back to cited text no. 5
    
6.
Beyeler C, Schlapbach P, Gerber NJ, Sturzenegger J, Fahrer H, van der Linden S, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the shoulder: A cause of shoulder pain? Br J Rheumatol 1990;29:349-53.  Back to cited text no. 6
    
7.
Resnick D, Niwayama G. Entheses and enthesopathy. Anatomical, pathological, and radiological correlation. Radiology 1983;146:1-9.  Back to cited text no. 7
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