FROM DEPARTMENT III OF DIAGNOSTIC RADIOLOGY (DIRECTOR: C.-G. HELANDER), SAHLGRENSKA SJUKHUSET, S-411 32 GOTHENBURG, AND THE ORTHOPEDIC CLINIC (DIRECTOR: B. OLSSON), VASA SJUKHUS, S-4I1 33 GOTHENBURG, SWEDEN.
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER E. DEICHGRABER and B. OLSSON
Specialized soft tissue radiography of joints of the extremities was introduced by FISCHER & BRAUN (1973) and REICHMANN et colI. (1974). Using a low-voltage, highcontrast technique, similar to that employed in radiography of the female breast, the soft tissues of the periarticular regions were demonstrated in greater detail than is possible with conventional techniques. No systematic description of soft tissue abnormalities in or adjacent to the joints has as yet appeared, however. The shoulder region, with its great vulnerability to wear and tear, is particularly prone to degenerative and inflammatory changes (OLSSON 1953, MOSELEY 1969, BATEMAN 1972). Radiography has long constituted an integral part of the evaluation of shoulder diseases. Many reports on bone changes and soft tissue calcifications have been published. OLSSON found a high correlation between 'tubercular irregularities' and tendon and rotator cuff ruptures; KAMlETH (1965), BAUER (1969), and LEACH & GREGG (1970) described calcific deposits in tendons and bursae, but while LEACH & GREGG considered the presence of calcifications a sign of actual shoulder disease, the two former authors stated that calcifications may also be present without any clinical signs of actual disorder. OLSSON found no statistical connection between the presence of calcific deposits and cuff degeneration, nor between calcifications and shoulder pain. The topography of the fatty layer adjacent to the subdeltoid fascia has been deSubmitted for publication 28 May 1974.
393
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
E. DEICHGRABER AND B. OLSSON
394
Tablel Age distribution of the clinical material Age groups
20---29
30---39
40-49
50---59
60---69
>70
No. of cases
2
3
15
43
30
9
scribed by LANZ & WACHSMUTH (1959) and LEB (1961). LEB stated that in all cases of peritendinitis and subacromial bursitis this fatty layer tends to be blurred or invisible but made no mention of his clinical material. His radiographic technique consisted of overexposing and underdeveloping the film. No data were published on tube potential, type of film, intensifying screens, secondary screening, etc. The purpose of the present work was to develop a technique for radiography of the soft tissues of the shoulder joint, to test its clinical value, as well as to describe the roentgen appearances of peritendinitis of the shoulder. The hypothesis was based on the assumption that inflammatory reactions of tendons and bursae cause the surrounding tissues to become oedematous, thus reducing the differences in attenuation capacity between them. For the subacromial region this means that the subdeltoid fatty layer should become blurred or invisible on the films in cases of peritendinitis and bursitis, regardless of whether calcifications can be demonstrated or not. Material and Methods
The technique was worked out in a series of preliminary experiments not included in the present clinical material. A medium sensitive industrial film (Agfa-Gevaert Mamoray T 3) was preferred due to its low mottle level in relation to its sensitivity. It was developed in a roll machine (DEICHGRABER et coll, 1974). An attempt was made to use intensifying screens in order to reduce exposure time and patient dose, but this proved unsatisfactory and had to be abandoned, as reported separately (DEICHGRABER et colI. 1975). The target of the tube was made of tungsten-rhenium. The tube had a low inherent filtration (0.5 mm AI) and no additional filtration was used. It was mounted on a Lysholm skull table with FFD 70 em. The tube potential had to be set at 40 kV to keep the exposure time at acceptable values. By means of a pinhole camera the size of the focus was determined at 40 kV, 400 mA to be 1.2 mm x 2.2 mm (nominal size 1 mm x 1 mm). This fairly large focus did not lead to disturbing unsharpness, the object-to-film distance being as short as possible. No secondary screening was employed. The incident dose was measured to be 0.4 to 0.5 rad/ exposure. Two a.p. projections were taken of the shoulder, one with the arm rotated inwards, the other with outward rotation, to demonstrate the tissues adjacent to the greater and lesser tubercles of the humerus, respectively. The condition of the often elderly patients rigid from shoulder pain did not allow other projections to be used. The method of soft tissue radiography developed by GROS (1967), implying the use
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
395
Table 2 Distribution of the radiographic findings in the different clinical groups
Blurring and displacement
n
Cervical pain only Peritendinitis with cervical pain Peritendinitis only Miscellaneous Uncertain peritendinitis Trauma with or without peritendinitis Frozen shoulder Rheumatic disease Doubtful clinical findings Total
No abnermality
(B)
3
9
10 40
8 29
1 8
7
4
7
5
Calcific C+D C+B deposits (C)
C+B+D
4 6
4
12
2
1 3
3 20
2
3
4
2 5
5
3
2
9 108
Displacement only (D)
24
9 2
Blurring only
52
28
15
28
3
29
4
of molybdenum-filtered radiation generated on a molybdenum target, was tested at the outset of the experiments. The tube was built into a compact apparatus for mammary radiography (Siemens Mammomat), but in spite of a short FFD (45 em) the tube could not generate sufficient radiation, and the method had to be discarded. The clinical material consisted of 102 patients, 33 men and 69 women, selected from the orthopedic out-patient department. Six had both shoulders examined, making up a total of 108 examinations. Efforts were made to select a group of patients with signs of only peritendinitis and as a reference group patients with only radiating pain considered to be of cervical origin. They were examined within a few days after their first visit to the hospital. The course of the disease made certain corrections necessary, as the pains in a shoulder might have been covered by a slight cervical pain, or vice versa. Miscellaneous and doubtful cases thus were brought together in one group. In the latter group are also included the contralateral shoulder of some cases as well as some obviously malingering patients. The majority of the patients were in the late middle age (Table 1), which is in agreement with the observation that soft tissue changes in the shoulder region increase with age (MOSELEY, BATEMAN, STEINBROCKER 1967). The films were evaluated by two radiologists, 61 cases being inspected twice, with an adverse result in 5 cases. The parameters were recorded, blurring and displacement of the fatty layer being classed as signs of peritendinitis, whereas calcifications
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
396
E. DEICHGRABER AND B. OLSSON
a
b
Fig. 1. Shoulder joints without abnormal soft tissue. The fatty layer marked by arrows. a) Outward rotation, b) Inward rotation. c) Shoulder in an old individual. Relatively broad fatty layer.
c
alone were not. A X2 test was used to find out the correlation, if any, between the findings and clinical symptoms and signs. The level of significance was set at 5 per cent. Results Table 2 gives a survey of observed radiologic abnormalities in relation to clinical signs. Calcific deposits appear in all clinical groups without any evident preference.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
a
397
b
Fig. 2. Pathologic shoulder joints. A local blurring of the fatty layer with a small calcific deposit appears in a). In b) the layer is blurred without any calcific deposit. In c) several calcific deposits without blurring of the fatty layer are seen. c
The same applies to the category 'no abnormality'. In cases with a definite clinical peritendinitis (n = 50) blurring or displacement of the fatty layer was common (37), being the only radiographic abnormality in II of these cases. Most common were blurring and calcification (23 out of 50 cases). 'Frozen shoulder' occurred in 9 cases, none of them displaying soft tissue abnormality. Calcifications were not significantly more frequent in the group with definite peritendinitis than in the one with brachialgia (X2 = 0.04). Soft tissue abnormalities were significantly more common in the group
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
398
E. DEICHGRABER AND B. OLSSON
Fig. 3. Lateral displacement of the fatty layer. The distance between the layer and the greater tubercle is increased.
with only peritendinitis, as compared with the cases with cervical pain (X2 = 21.60). If the peritendinitis group was extended to comprise cases with peritendinitis and brachialgia, the statistical significance remained unchanged (X2 = 24.70). Radiology. In cases with brachialgia the fatty layer on the lateral aspect of the tubercular region was thin, well demarcated and visible in the entire length of its course from the lateral part of the lower surface of the acromion passing in a gentle curve the tubercular region at a distance of 1 to 2 mm. Usually it could be traced well beyond the tubercular region, curving towards the humeral shaft (Fig. 1). The fatty layer broadened with age (Fig. 1 c). In the presence of peritendinitis or bursitis the fatty layer was indistinct or invisible. The degree of blurring did not seem to indicate the severity of the inflammatory process, as in some cases of exquisitely tender bursitis the blurring was only slight. In the majority of cases (Fig. 2 a) the fatty layer was invisible over a distance of 0.5 to 1 em close to the most protruding part of the greater tubercle. A case without calcifications but with blurring of the fatty layer appears in Fig. 2 b, another one with calcifications but without blurring in Fig. 2 c. Displacement of the fatty layer was only rarely encountered but if so it was stretched over a distended bursa, i.e. its distance to the greater tubercle was increased (Fig. 3). If the displaced layer was associated with blurring its recognition was more difficult. Discussion
The technique arrived at is based on the use of a medium sensitive industrial film with a high silver content and a tube with a tungsten target. The use of a tube with a molybdenum target has not been successful in shoulder examinations due to the large
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
399
tissue volume of the shoulder. No compression can be employed to reduce thickness in the same way as in mammary radiography. The exposure time is of great importance and motion unsharpness was the greatest obstacle to good image quality. Tubes with a greater load capacity would provide a welcome improvement of the technique. A clinical differentiation between pains originating from the shoulder region and radiating pains from cervical lesions may be difficult except in cases with acute peritendinitis. The vast majority of cases in the present material presented themselves with subacute disorder, thus cases in which auxiliary procedures are desirable. As a reference group patients with radiating pain, brachialgia, were used instead of 'healthy' individuals, the reason being the ubiquity of pathologic changes in the rotator cuff of middle-aged persons regardless of symptoms (OLSSON). Moreover, the problem is actually one of differentiating between peritendinitis and brachialgia rather than between peritendinitis and no disease. Since the radiographic method was tested in such cases where the two types of pain primarily could not be easily differentiated clinically the grouping of the patients had to be revised when the course of the disease and the results of the treatment were at hand. Thus, the statistical evaluation may be open to some discussion, and its results should not be overestimated. However, it may at least indicate that further trial of the radiographic technique used is motivated. The projections to be recommended may be reconsidered. A rather large number of the present cases with peritendinitis did not display any inflammatory abnormalities. This may be due to the fact that the projections used demonstrated only a limited area of the soft tissues adjacent to the tubercular region. Smaller areas of blurring may have escaped detection. The further testing of the method must thus include a consideration of which projections are to be preferred for an evaluation of the best results.
SUMMARY Specialized soft tissue radiography was applied to the shoulder region to differentiate between shoulder peritendinitis and radiating cervical pain. The technique is presented, together with the results of a clinical trial. Local inflammation was demonstrable even in the absence of calcific deposits.
ZUSAMMENFASSUNG Eine spezialisierte Weichgewebe-Rontgenuntersuchung wurde fur die Schultergegend verwendet, urn zwischen einer Peritendinitis der Schulter und ausstrahlenden cervikalen Schmerzen zu unterscheiden. Die Technik zusammen mit den Ergebnissen eines klinischen Versuchs werden gegeben. Lokale Inflammationen waren auch in Abwesenheit von Kalkablagerungen nachzuweisen.
RESUME La radiographie specialisee des tissus mous a ete' appliquee a la region de l'epaule pour faire Ie diagnostic differentiel entre peritendinite de l'epaule et nevralgie cervicale irradiee. Les auteurs presentent la technique ainsi que les resultats d'un essai cIinique. II a ete possible de mettre en evidence I'inflammation locale meme en I'absence de calcifications.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
400
E. DEICHGRABER AND B. OLSSON
REFERENCES BATEMAN J. E.: The shoulder and neck. W. B. Saunders Company, Philadelphia, London & Toronto 1972. BAUER R.: Differentialdiagnose und Therapie der Periarthritis humero-scapularis. Arch. orthop. Unfall-Chir. 65 (1969), 13. DEICHGRABER E., REICHMANN S. and BUREN M.: Film quality in mammary radiography. Acta radiol. Diagnosis 15 (1974), 93. - - and STRID K.-G.: Intensifying screens in soft tissue radiography. Acta radiol. Diagnosis 16 (1975), 54. FISCHER E. und BRAUN J.: Neue diagnostische Moglichkeiten an den Extremitaten durch Weichstrahlaufnahmen mit Mammographiegeraten. Electromedica 3 (1973),90. GRaS CH. E.: Methodologie, Symposium Europeen de Radiologie Mammaire. J. Radial. Electrol. 48 (1967), 638. KAMIETH H.: Die Periarthritis humeroscapularis im Rontgenbild der Schulter. Arch orthop. Unfall-Chir. 58 (1965), 191. LANZ T. und WACHSMUTH W.: Praktische Anatomie. Ed. 2. vo!. 1/3. Arm. Springer-Verlag, Berlin 1959. LEACH R. E. and GREGG T. P.: Preoperative evaluation of the painful shoulder. Surg. Clin. N. Amer. 50 (1970),603. LEB A.: Der rontgendiagnostische Beitrag zur Diagnose der Periarthrose und unspezifischen Periarthritis. Wien. klin. Wschr. 73 (1961), 141. MOSELEY H. F.: Shoulder lesions. Third edition. E & S Livingstone Ltd. Edinburgh and London 1969. OLSSON 0.: Degenerative changes of the shoulder joint and their connection with shoulder pain. Acta chir. scand. (1953) Suppl, No. 181. REICHMANN S., DEICHGRABER E., STRID K.-G., HEYMANN F. and STRAND T.: Soft tissue radiology of finger joints. Acta radiol. Diagnosis 15 (1974), 439. STEINBROCKER 0.: The painful shoulder. In: Arthritis and allied conditions, p. 1233. Ed: J. L. Hollander. Lea & Febiger, Philadelphia 1967.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER E. DEICHGRABER and B. OLSSON
Specialized soft tissue radiography of joints of the extremities was introduced by FISCHER & BRAUN (1973) and REICHMANN et colI. (1974). Using a low-voltage, highcontrast technique, similar to that employed in radiography of the female breast, the soft tissues of the periarticular regions were demonstrated in greater detail than is possible with conventional techniques. No systematic description of soft tissue abnormalities in or adjacent to the joints has as yet appeared, however. The shoulder region, with its great vulnerability to wear and tear, is particularly prone to degenerative and inflammatory changes (OLSSON 1953, MOSELEY 1969, BATEMAN 1972). Radiography has long constituted an integral part of the evaluation of shoulder diseases. Many reports on bone changes and soft tissue calcifications have been published. OLSSON found a high correlation between 'tubercular irregularities' and tendon and rotator cuff ruptures; KAMlETH (1965), BAUER (1969), and LEACH & GREGG (1970) described calcific deposits in tendons and bursae, but while LEACH & GREGG considered the presence of calcifications a sign of actual shoulder disease, the two former authors stated that calcifications may also be present without any clinical signs of actual disorder. OLSSON found no statistical connection between the presence of calcific deposits and cuff degeneration, nor between calcifications and shoulder pain. The topography of the fatty layer adjacent to the subdeltoid fascia has been deSubmitted for publication 28 May 1974.
393
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
E. DEICHGRABER AND B. OLSSON
394
Tablel Age distribution of the clinical material Age groups
20---29
30---39
40-49
50---59
60---69
>70
No. of cases
2
3
15
43
30
9
scribed by LANZ & WACHSMUTH (1959) and LEB (1961). LEB stated that in all cases of peritendinitis and subacromial bursitis this fatty layer tends to be blurred or invisible but made no mention of his clinical material. His radiographic technique consisted of overexposing and underdeveloping the film. No data were published on tube potential, type of film, intensifying screens, secondary screening, etc. The purpose of the present work was to develop a technique for radiography of the soft tissues of the shoulder joint, to test its clinical value, as well as to describe the roentgen appearances of peritendinitis of the shoulder. The hypothesis was based on the assumption that inflammatory reactions of tendons and bursae cause the surrounding tissues to become oedematous, thus reducing the differences in attenuation capacity between them. For the subacromial region this means that the subdeltoid fatty layer should become blurred or invisible on the films in cases of peritendinitis and bursitis, regardless of whether calcifications can be demonstrated or not. Material and Methods
The technique was worked out in a series of preliminary experiments not included in the present clinical material. A medium sensitive industrial film (Agfa-Gevaert Mamoray T 3) was preferred due to its low mottle level in relation to its sensitivity. It was developed in a roll machine (DEICHGRABER et coll, 1974). An attempt was made to use intensifying screens in order to reduce exposure time and patient dose, but this proved unsatisfactory and had to be abandoned, as reported separately (DEICHGRABER et colI. 1975). The target of the tube was made of tungsten-rhenium. The tube had a low inherent filtration (0.5 mm AI) and no additional filtration was used. It was mounted on a Lysholm skull table with FFD 70 em. The tube potential had to be set at 40 kV to keep the exposure time at acceptable values. By means of a pinhole camera the size of the focus was determined at 40 kV, 400 mA to be 1.2 mm x 2.2 mm (nominal size 1 mm x 1 mm). This fairly large focus did not lead to disturbing unsharpness, the object-to-film distance being as short as possible. No secondary screening was employed. The incident dose was measured to be 0.4 to 0.5 rad/ exposure. Two a.p. projections were taken of the shoulder, one with the arm rotated inwards, the other with outward rotation, to demonstrate the tissues adjacent to the greater and lesser tubercles of the humerus, respectively. The condition of the often elderly patients rigid from shoulder pain did not allow other projections to be used. The method of soft tissue radiography developed by GROS (1967), implying the use
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
395
Table 2 Distribution of the radiographic findings in the different clinical groups
Blurring and displacement
n
Cervical pain only Peritendinitis with cervical pain Peritendinitis only Miscellaneous Uncertain peritendinitis Trauma with or without peritendinitis Frozen shoulder Rheumatic disease Doubtful clinical findings Total
No abnermality
(B)
3
9
10 40
8 29
1 8
7
4
7
5
Calcific C+D C+B deposits (C)
C+B+D
4 6
4
12
2
1 3
3 20
2
3
4
2 5
5
3
2
9 108
Displacement only (D)
24
9 2
Blurring only
52
28
15
28
3
29
4
of molybdenum-filtered radiation generated on a molybdenum target, was tested at the outset of the experiments. The tube was built into a compact apparatus for mammary radiography (Siemens Mammomat), but in spite of a short FFD (45 em) the tube could not generate sufficient radiation, and the method had to be discarded. The clinical material consisted of 102 patients, 33 men and 69 women, selected from the orthopedic out-patient department. Six had both shoulders examined, making up a total of 108 examinations. Efforts were made to select a group of patients with signs of only peritendinitis and as a reference group patients with only radiating pain considered to be of cervical origin. They were examined within a few days after their first visit to the hospital. The course of the disease made certain corrections necessary, as the pains in a shoulder might have been covered by a slight cervical pain, or vice versa. Miscellaneous and doubtful cases thus were brought together in one group. In the latter group are also included the contralateral shoulder of some cases as well as some obviously malingering patients. The majority of the patients were in the late middle age (Table 1), which is in agreement with the observation that soft tissue changes in the shoulder region increase with age (MOSELEY, BATEMAN, STEINBROCKER 1967). The films were evaluated by two radiologists, 61 cases being inspected twice, with an adverse result in 5 cases. The parameters were recorded, blurring and displacement of the fatty layer being classed as signs of peritendinitis, whereas calcifications
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
396
E. DEICHGRABER AND B. OLSSON
a
b
Fig. 1. Shoulder joints without abnormal soft tissue. The fatty layer marked by arrows. a) Outward rotation, b) Inward rotation. c) Shoulder in an old individual. Relatively broad fatty layer.
c
alone were not. A X2 test was used to find out the correlation, if any, between the findings and clinical symptoms and signs. The level of significance was set at 5 per cent. Results Table 2 gives a survey of observed radiologic abnormalities in relation to clinical signs. Calcific deposits appear in all clinical groups without any evident preference.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
a
397
b
Fig. 2. Pathologic shoulder joints. A local blurring of the fatty layer with a small calcific deposit appears in a). In b) the layer is blurred without any calcific deposit. In c) several calcific deposits without blurring of the fatty layer are seen. c
The same applies to the category 'no abnormality'. In cases with a definite clinical peritendinitis (n = 50) blurring or displacement of the fatty layer was common (37), being the only radiographic abnormality in II of these cases. Most common were blurring and calcification (23 out of 50 cases). 'Frozen shoulder' occurred in 9 cases, none of them displaying soft tissue abnormality. Calcifications were not significantly more frequent in the group with definite peritendinitis than in the one with brachialgia (X2 = 0.04). Soft tissue abnormalities were significantly more common in the group
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
398
E. DEICHGRABER AND B. OLSSON
Fig. 3. Lateral displacement of the fatty layer. The distance between the layer and the greater tubercle is increased.
with only peritendinitis, as compared with the cases with cervical pain (X2 = 21.60). If the peritendinitis group was extended to comprise cases with peritendinitis and brachialgia, the statistical significance remained unchanged (X2 = 24.70). Radiology. In cases with brachialgia the fatty layer on the lateral aspect of the tubercular region was thin, well demarcated and visible in the entire length of its course from the lateral part of the lower surface of the acromion passing in a gentle curve the tubercular region at a distance of 1 to 2 mm. Usually it could be traced well beyond the tubercular region, curving towards the humeral shaft (Fig. 1). The fatty layer broadened with age (Fig. 1 c). In the presence of peritendinitis or bursitis the fatty layer was indistinct or invisible. The degree of blurring did not seem to indicate the severity of the inflammatory process, as in some cases of exquisitely tender bursitis the blurring was only slight. In the majority of cases (Fig. 2 a) the fatty layer was invisible over a distance of 0.5 to 1 em close to the most protruding part of the greater tubercle. A case without calcifications but with blurring of the fatty layer appears in Fig. 2 b, another one with calcifications but without blurring in Fig. 2 c. Displacement of the fatty layer was only rarely encountered but if so it was stretched over a distended bursa, i.e. its distance to the greater tubercle was increased (Fig. 3). If the displaced layer was associated with blurring its recognition was more difficult. Discussion
The technique arrived at is based on the use of a medium sensitive industrial film with a high silver content and a tube with a tungsten target. The use of a tube with a molybdenum target has not been successful in shoulder examinations due to the large
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
SOFT TISSUE RADIOGRAPHY IN PAINFUL SHOULDER
399
tissue volume of the shoulder. No compression can be employed to reduce thickness in the same way as in mammary radiography. The exposure time is of great importance and motion unsharpness was the greatest obstacle to good image quality. Tubes with a greater load capacity would provide a welcome improvement of the technique. A clinical differentiation between pains originating from the shoulder region and radiating pains from cervical lesions may be difficult except in cases with acute peritendinitis. The vast majority of cases in the present material presented themselves with subacute disorder, thus cases in which auxiliary procedures are desirable. As a reference group patients with radiating pain, brachialgia, were used instead of 'healthy' individuals, the reason being the ubiquity of pathologic changes in the rotator cuff of middle-aged persons regardless of symptoms (OLSSON). Moreover, the problem is actually one of differentiating between peritendinitis and brachialgia rather than between peritendinitis and no disease. Since the radiographic method was tested in such cases where the two types of pain primarily could not be easily differentiated clinically the grouping of the patients had to be revised when the course of the disease and the results of the treatment were at hand. Thus, the statistical evaluation may be open to some discussion, and its results should not be overestimated. However, it may at least indicate that further trial of the radiographic technique used is motivated. The projections to be recommended may be reconsidered. A rather large number of the present cases with peritendinitis did not display any inflammatory abnormalities. This may be due to the fact that the projections used demonstrated only a limited area of the soft tissues adjacent to the tubercular region. Smaller areas of blurring may have escaped detection. The further testing of the method must thus include a consideration of which projections are to be preferred for an evaluation of the best results.
SUMMARY Specialized soft tissue radiography was applied to the shoulder region to differentiate between shoulder peritendinitis and radiating cervical pain. The technique is presented, together with the results of a clinical trial. Local inflammation was demonstrable even in the absence of calcific deposits.
ZUSAMMENFASSUNG Eine spezialisierte Weichgewebe-Rontgenuntersuchung wurde fur die Schultergegend verwendet, urn zwischen einer Peritendinitis der Schulter und ausstrahlenden cervikalen Schmerzen zu unterscheiden. Die Technik zusammen mit den Ergebnissen eines klinischen Versuchs werden gegeben. Lokale Inflammationen waren auch in Abwesenheit von Kalkablagerungen nachzuweisen.
RESUME La radiographie specialisee des tissus mous a ete' appliquee a la region de l'epaule pour faire Ie diagnostic differentiel entre peritendinite de l'epaule et nevralgie cervicale irradiee. Les auteurs presentent la technique ainsi que les resultats d'un essai cIinique. II a ete possible de mettre en evidence I'inflammation locale meme en I'absence de calcifications.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
400
E. DEICHGRABER AND B. OLSSON
REFERENCES BATEMAN J. E.: The shoulder and neck. W. B. Saunders Company, Philadelphia, London & Toronto 1972. BAUER R.: Differentialdiagnose und Therapie der Periarthritis humero-scapularis. Arch. orthop. Unfall-Chir. 65 (1969), 13. DEICHGRABER E., REICHMANN S. and BUREN M.: Film quality in mammary radiography. Acta radiol. Diagnosis 15 (1974), 93. - - and STRID K.-G.: Intensifying screens in soft tissue radiography. Acta radiol. Diagnosis 16 (1975), 54. FISCHER E. und BRAUN J.: Neue diagnostische Moglichkeiten an den Extremitaten durch Weichstrahlaufnahmen mit Mammographiegeraten. Electromedica 3 (1973),90. GRaS CH. E.: Methodologie, Symposium Europeen de Radiologie Mammaire. J. Radial. Electrol. 48 (1967), 638. KAMIETH H.: Die Periarthritis humeroscapularis im Rontgenbild der Schulter. Arch orthop. Unfall-Chir. 58 (1965), 191. LANZ T. und WACHSMUTH W.: Praktische Anatomie. Ed. 2. vo!. 1/3. Arm. Springer-Verlag, Berlin 1959. LEACH R. E. and GREGG T. P.: Preoperative evaluation of the painful shoulder. Surg. Clin. N. Amer. 50 (1970),603. LEB A.: Der rontgendiagnostische Beitrag zur Diagnose der Periarthrose und unspezifischen Periarthritis. Wien. klin. Wschr. 73 (1961), 141. MOSELEY H. F.: Shoulder lesions. Third edition. E & S Livingstone Ltd. Edinburgh and London 1969. OLSSON 0.: Degenerative changes of the shoulder joint and their connection with shoulder pain. Acta chir. scand. (1953) Suppl, No. 181. REICHMANN S., DEICHGRABER E., STRID K.-G., HEYMANN F. and STRAND T.: Soft tissue radiology of finger joints. Acta radiol. Diagnosis 15 (1974), 439. STEINBROCKER 0.: The painful shoulder. In: Arthritis and allied conditions, p. 1233. Ed: J. L. Hollander. Lea & Febiger, Philadelphia 1967.
Downloaded from acr.sagepub.com at UNIV OF MICHIGAN on July 1, 2015
