Julian Assange needs an MRI for acute shoulder pain: here’s why

Embedded image permalink

Police doc from 2012 confirming embassy monitored by SO20 and SO10 (Special Branch)

Julian Assange, founder and editor in chief of Wikileaks, has been suffering from severe and acute shoulder pain in his right shoulder for several months. A physician was unable to diagnose the cause and so has recommended an MRI scan. This would require Mr Assange leaving the Ecuadorean Embassy in London as mobile MRIs are not yet available to the public in the UK (though recently developed hand-held ones are being introduced to the US military). The Government of Ecuador has asked the British Government to afford Mr Assange safe passage to a hospital so that he can have the scan, but this request was turned down. This new impasse leaves Mr Assange with two choices: either have the MRI in a hospital (assuming the condition worsens) and be arrested, or have no MRI treatment and risk further deterioation. Neither option is good. In the meantime any physician would wish Mr Assange to be cognisant of the possible causes of the pain. These are listed below.

Note: last week, the Metropolitan Police announced they are withdrawing the uniformed cops guarding the Ecuadorean embassy (they were only ever window dressing) and, instead, rely on covert ops units (which have been there all the time – see image above – namely SO20, which included SO10 and special demonstration ops and which currently comes under the overall command of Michael Wood.

Shoulder pain is a common symptom in primary care and can be due to an intrinsic shoulder problem , though pain can also be referred from other structures, such as the neck, diaphragm or the heart.

A. The anatomy of the shoulder joint

The humerus, glenoid, scapula, acromion, clavicle and surrounding soft tissues make up the shoulder. There are three significant articulations: the sternoclavicular joint, the acromioclavicular joint and the glenohumeral joint. The glenohumeral joint is the most commonly dislocated major joint in the body. Ligaments and surrounding musculature, including the rotator cuff muscles, contribute to shoulder joint stability. The rotator cuff is composed of the four muscles: supraspinatus, infraspinatus, teres minor and subscapularis that interlock to function as one unit. These muscles help with internal and external rotation of the shoulder and importantly depress the humeral head against the glenoid as the arm is elevated. The tendons join together to form one tendon, the rotator cuff tendon. This passes through the subacromial space. The subacromial bursa, which has a large number of pain sensors, fills the space between the acromion and the rotator cuff tendon.

Rotator cuff

B. Causes of shoulder pain

Patients presenting in primary care often have a combination of different shoulder problems.

The four most common causes of shoulder pain and disability in primary care are rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease and referred neck pain.

Rotator cuff disorders:

The term subacromial pain (synonyms: subacromial impingement; impingement syndrome; rotator cuff syndrome; supraspinatus tendonitis; rotator cuff tendinopathy; painful arc syndrome) refers to all rotator cuff lesions, including all stages of tendon disease from early degeneration through to complete tears.

  • Most often present in patients aged 35-75 years.
  • Subacromial impingement is the most common source of shoulder pain:
    • There may be a history of heavy lifting or repetitive movements, especially above shoulder level. However, it often occurs in the non-dominant arm and in non-manual workers.
    • On examination there may be muscle wasting with pain on movements and a partial restriction of active movements (passive movements are full but painful).
    • A painful arc (between 70-120° of active abduction) is not specific or sensitive but increases the likelihood of a rotator cuff disorder.
  • A rotator cuff tear:
    • Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the undersurface of the acromion or intrinsic degeneration of the cuff, possibly.
    • Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination.
    • The drop arm test (see ‘Examination’, below) may be used to detect a massive tear.
  • Calcific tendonitis:
    • Crystalline calcium phosphate is deposited in the rotator cuff tendon.
    • The cause is not known.  It is more common in women (70% of cases) and affects people aged 30-60.
    • It is a self-limiting condition as the calcium will eventually resorb but may take many years.

Glenohumeral disorders:

  • Adhesive capsulitis most often presents between the ages of 40 to 65 years, whereas osteoarthritis is most common in those aged 60 years or older.
  • Adhesive capsulitis (frozen shoulder) and arthritis often present with a history of non-adhesive capsulitis symptoms, cause deep joint pain and restrict activities such as putting on a jacket – because of impaired external rotation.
  • Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilisation.
  • There is usually generalised shoulder pain and a restriction of passive and active movements.

Acromioclavicular disorders:

  • They are usually caused by trauma or osteoarthritis.
  • Pain and tenderness are localised to the acromioclavicular joint and there is a restriction of passive, horizontal movement of the arm across the body when the elbow is extended.
  • Obvious deformity after injury suggests a significant tear of the acromioclavicular ligament .
  • Acromioclavicular osteoarthritis may cause subacromial impingement.

Referred neck pain:

  • Typically, this presents with pain and tenderness of the lower neck and suprascapular area, with pain referred to the shoulder and upper arm.
  • There may be a restriction of shoulder movement and movement of the neck and shoulder may reproduce more generalised upper back, neck and shoulder pain.
  • There may also be upper limb paraesthesia.

C. Assessment of shoulder pain

Questions:

  • Is the pain arising from the shoulder, neck or elsewhere?
  • Are there any ‘red flag’ symptoms/signs? (See box ‘Red flag symptoms/signs’, below.)
  • Is the pain localised to the acromioclavicular joint: the ‘pointing sign’? If yes, there is acromioclavicular joint disease.
  • Is there global pain and restriction of all active and passive movements? If yes, this suggests glenohumeral joint disorder (either ‘frozen shoulder‘ or arthritis).
  • Does the patient show a broad area of pain: the ‘grasping sign’ suggestive of subacromial pain?

D. Red flag symptoms/signs

  • Blood tests including FBCESR/CRP and radiology such as CXR are generally only necessary if there are ‘red flag’ symptoms/signs.
  • Ultrasonography is the preferred imaging technique for the shoulder.
  • Plain X-rays rarely help except to confirm shoulder dislocation and shoulder arthritis.
  • Magnetic resonance arthrogram is useful in shoulder instability.
  • If referred neck pain is suspected then cervical spine X-rays may be helpful but the diagnosis is usually clinical.
  • Blood tests, including FBCESR/CRP, and radiology, such as CXR, are generally only necessary if there are ‘red flag’ symptoms/signs.

Management in primary care is usually conservative: reduce or avoid overhead activities; attention to any contributing factors; medication for pain relief, including corticosteroid injection. If symptoms don’t settle quickly or are severe initially, physiotherapy focused on the specific cause is indicated.

  • Rotator cuff disorders:
    • Advise modification of activities, including reducing precipitating movements (eg, reaching overhead).
    • Offer analgesia; paracetamol with or without codeine, or an oral non-steroidal anti-inflammatory drug (NSAID).
    • Refer to physiotherapy with the goal of optimising shoulder function, using an evidence-based rehabilitation protocol.[9]
    • Consider a subacromial corticosteroid injection if the person has limited function because of pain and is therefore unable to perform strengthening and stabilising exercises. They may be of short-term benefit when used alone.[8] See separate article Joint Injection and Aspiration.
    • Do not give a corticosteroid injection if:
      • The person has previously received a corticosteroid injection from an experienced practitioner with minimal or no benefit.
      • The person has already had three or more injections in the same shoulder in the previous year.
      • There is a suspected significant rotator cuff tear.
      • There is any contra-indication to corticosteroid injection (eg, infection, osteomyelitis).
    • Evidence shows that physiotherapy and steroid injections may be equally helpful in the short term. Injections may be repeated if the initial response is good.
    • Rotator cuff tears:
      • Physiotherapy and steroid injections may be helpful for minor tears.
      • Suspected large tears that are symptomatic may benefit from early referral for orthopaedic input.
      • Surgical treatment usually involves arthroscopic rotator cuff tendon repair.
      • Physiotherapy and steroid injections may be helpful for minor tears.
      • Surgical treatment usually involves arthroscopic rotator cuff tendon repair.
    • Calcific tendonitis:
      • When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of severe, acute pain radiating down the arm or to the neck.
      • The calcium deposits cause a chemical irritant inflammatory reaction. There is also an increase in pressure in the tendon, which is turn leads to malfunction of the rotator cuff and subacromial pain.
      • Treatment for calcific tendonitis includes NSAIDs, corticosteroids, physiotherapy, aspiration or lavage. For patients refractory to these treatments, open or arthroscopic shoulder surgery may be offered to excise the deposit.
      • Extracorporeal shock wave lithotripsy is no longer recommended by the National Institute for Health and Care Excellence (NICE).
    • Glenohumeral disorders:
      • Glucocorticoid injection appears to be more effective in the short term than physiotherapy and exercises.
    • Acromioclavicular disease:
      • Acromioclavicular injury usually responds to rest and simple analgesia, unless there is significant disruption of the joint, in which case orthopaedic referral is necessary.
      • Consider providing a sling for 5-7 days if an acromioclavicular joint injury is suspected.
      • Consider referring to physiotherapy after 4-6 weeks if the person responds poorly to rest and analgesia.
    • Degeneration of the humeral head:
      • The humeral head may degenerate as a result of a range of conditions – eg,  osteoarthritis, rheumatoid arthritis or avascular necrosis. The whole or only part of the articular surface of the humeral head may be affected.
      • Conservative treatment includes physiotherapy, pain relief, topical or oral NSAIDs and corticosteroid injections.
      • Patients who do not respond to conservative treatments may need surgery, which involves either shoulder arthroplasty using a stemmed humeral head prosthesis, or fusion of the joint.
      • Shoulder resurfacing arthroplasty replaces only the damaged joint surfaces, with minimal bone resection and is recommended by NICE as a surgical option.

There is no good-quality evidence to say whether acupuncture works to treat shoulder pain of any cause or if it is harmful.

See also: What causes shoulder pain? 32 possible conditions

Further reading

  1. Prof L Funk; Shoulder and Elbow Information, ShoulderDoc
  2. Mitchell C, Adebajo A, Hay E, et al; Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12;331(7525):1124-8.
  3. van der Windt DA, Thomas E, Pope DP, et al; Occupational risk factors for shoulder pain: a systematic review. Occup Environ Med. 2000 Jul;57(7):433-42.
  4. Serafini G, Sconfienza LM, Lacelli F, et al; Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment–nonrandomized controlled trial. Radiology. 2009 Jul;252(1):157-64. doi: 10.1148/radiol.2521081816.
  5. Shoulder pain; NICE CKS, April 2015 (UK access only)
  6. Hegedus EJ, Goode A, Campbell S, et al; Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008 Feb;42(2):80-92; discussion 92. Epub 2007 Aug 24.
  7. Burbank KM, Stevenson JH, Czarnecki GR, et al; Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-60.
  8. Burbank KM, Stevenson JH, Czarnecki GR, et al; Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008 Feb 15;77(4):493-7.
  9. Kuhn JE; Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60. doi: 10.1016/j.jse.2008.06.004. Epub 2008 Oct 2.
  10. Green S, Buchbinder R, Glazier R, et al; Interventions for shoulder pain. Cochrane Database Syst Rev. 2000;(2):CD001156.
  11. Ejnisman B, Andreoli CV, Soares BG, et al; Interventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev. 2004;(1):CD002758.
  12. Page MJ, Green S, Kramer S, et al; Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014 Aug 26;8:CD011275. doi: 10.1002/14651858.CD011275.
  13. Simovitch R, Sanders B, Ozbaydar M, et al; Acromioclavicular joint injuries: diagnosis and management. J Am Acad Orthop Surg. 2009 Apr;17(4):207-19.
  14. Shoulder resurfacing arthroplasty, NICE Interventional Procedure Guidance, July 2010
  15. Green S, Buchbinder R, Hetrick S; Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319.
Advertisements
This entry was posted in Intelligence, Surveillance and tagged , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s