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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 36  |  Issue : 3  |  Page : 162-164

A rotator cuff injury affecting the prognosis of a patient with myofascial pain


1 Consultant Anaesthesiologist and Interventional Pain Physician, Department of Anaesthesiology, Pain and Palliative Medicine, Jindal Sanjeevani Multispeciality Hospital, Bellary, Karnataka, India
2 Consultant Anaesthesiologist and Pain Physician, Department of Anaesthesiology and Pain Medicine, Dr. Muthu's Superspeciality Hospital, Coimbatore, Tamil Nadu, India

Date of Submission14-May-2022
Date of Decision15-Jun-2022
Date of Acceptance03-Aug-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Syeda Shaista Naz
No. #9, Gulzar Residency, 9th Cross, M. S. Palya, Vidyaranyapura Post, Bengaluru - 560 097, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_51_22

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  Abstract 


Shoulder pathology occurs most commonly in food service workers, who repetitively perform motions of the upper limbs. About 85% of patients who visit pain clinics complain of nonarticular musculoskeletal impairments. Myofascial pain syndrome is one of the common, painful musculoskeletal disorders characterized by the presence of trigger points in muscles at discrete places. Here is a case presenting with symptoms of myofascial pain of the upper trapezius; on clinical examination, ultrasonographic findings were diagnosed with a rotator cuff injury delaying her recovery. This also highlights the importance of clinical examination of ipsilateral shoulder joint whenever the patient presents with myofascial pain involving upper back.

Keywords: Myofascial pain, platelet-rich plasma, rotator cuff injury, shoulder joint, supraspinatus


How to cite this article:
Naz SS, Sibha S D. A rotator cuff injury affecting the prognosis of a patient with myofascial pain. Indian J Pain 2022;36:162-4

How to cite this URL:
Naz SS, Sibha S D. A rotator cuff injury affecting the prognosis of a patient with myofascial pain. Indian J Pain [serial online] 2022 [cited 2022 Dec 7];36:162-4. Available from: https://www.indianjpain.org/text.asp?2022/36/3/162/361628




  Introduction Top


Shoulder pathology occurs most commonly in food service workers, who repetitively perform motions of the upper limbs.[1] About 85% of patients who visit pain clinics complain of nonarticular musculoskeletal impairments such as myofascial pain syndrome (MPS).[2] MPS is one of the common, painful musculoskeletal disorders characterized by the presence of trigger points (TPs) in muscles at discrete places.[3] Here is a case presenting with symptoms of myofascial pain of the upper trapezius; on clinical examination, ultrasonographic findings were diagnosed with a rotator cuff injury delaying her recovery.


  Case Report Top


A 44-year old female presented with pain on the right side of the upper back for 6 months. The pain was dull aching type, present throughout the day, radiating to the right upper arm. It aggravated by lying down on the same side and relieved by rest. Numeric rating scale (NRS) was found to be 8/10. The patient was diagnosed with myofascial pain involving the trapezius muscle a month ago. She revisited us for the same complaint as no improvement was seen with treatment. She was a known case of hypothyroidism, on thyroxin 50 μg.

On clinical examination, there was no obvious drooping of the shoulder or winging of the scapula on inspection. On palpation, there was tenderness in the interscapular area, at the upper-medial border of right scapula corresponding to myofascial pain of trapezius muscle. When the patient was asked to point out the exact location of tenderness, it was observed that she used her opposite arm to localize the site of pain. This gave a hint to examine the ipsilateral shoulder joint. On clinical examination, it was found that the range of movements was restricted. Active movements were restricted and painful. The patient was not able to perform clinical tests such as Apley Scratch test and Empty Can test. There was tenderness at the right acromioclavicular joint, whereas tests for infraspinatus, teres minor, subscapularis, and biceps tendon were negative. She was clinically diagnosed with a rotator cuff injury involving supraspinatus tendon, which was further confirmed by ultrasound examination of the right shoulder joint.

Ultrasound examination of the shoulder joint

The patient was put in modified Crass position, in such a way that the patient, ultrasound machine, and examiner, all fell in a straight line. The shoulder goes in adduction and internal rotation with the elbow in flexion, the palm resting over the ipsilateral hip in Modified Crass position. Internal rotation allows the supraspinatus to become an anterior structure, and extension draws the supraspinatus anteriorly from beneath the acromion, allowing the maximal length of tendon to be visualized.

A linear probe with a frequency of 13 MHz was used for scanning. Under ultrasound, partial intrasubstance tear of supraspinatus with tendinosis defined as focal, anechoic, and hypoechoic defects was confirmed in both longitudinal-axis and short-axis view. It remained unaffected by toggling of probe (lack of anisotropy) as shown in [Figure 1]. Mild decrease in glenohumeral joint space and irregular margins of acromioclavicular joint were also seen as shown in [Figure 2] and [Figure 3], respectively. Ultrasound evaluation of the other rotator cuff tendons was found to be normal.
Figure 1: Ultrasound image of Supraspinatus tendon in long axis showing a tear

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Figure 2: Ultrasound image depicting changes in Acromio-clavicular joint

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Figure 3: Ultrasound image showing decreased Glenohumeral joint space

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Intervention and follow-up

An ultrasound-guided platelet-rich plasma (PRP) injection into supraspinatus tear was planned for the patient under strict aseptic precautions, around 15 ml of blood was collected for PRP preparation and centrifuged at the rate of 3500 rpm for 15 min. The middle part containing PRP enhanced with a superficial buffy coat was used for injection.

The patient was then put in a sitting position, parts painted and draped, and the probe prepared with a sterile probe cover for intervention [Figure 4]. In modified Crass position, after identification of partial intrasubstance tear of the right supraspinatus tendon in both longitudinal and short axes, 2.5 ml of PRP was injected into the tear under real-time imaging mode observing the target structure and spread of the drug [Figure 5].
Figure 4: Image showing the positioning of the patient for intervention under strict aseptic precautions

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Figure 5: Ultrasound image showing in-plane technique for PRP injection

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She was put on tablet nefopam 30 mg TID for 3 weeks with shoulder exercises after 5 days, a follow-up after 3–4 weeks to look for the signs of improvement. She was advised not to take steroids and nonsteroidal anti-inflammatory drugs for a month. At a follow-up at 5 weeks, she was symptomatically better, with NRS 2/10. On clinical examination, she was able to lift her arm, and her range of motion improved drastically. On ultrasound, there was about 60%–70% healing of tendon as shown in [Figure 6].
Figure 6: Ultrasound image depicting the healed supraspinatus tendon in its long axis

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  Discussion Top


Rotator cuff tendinopathy is a frequent cause of shoulder pain. In the case of shoulder impingement, there is compression of the subacromial structures against the coracoacromial ligament during the elevation of the arm.[4] The nutrients required for the repair and healing of damaged tendons do not reach the site due to its poor vascularization. This failure to heal is considered a principal cause of chronic shoulder pain and hinders successful outcomes from both nonoperative and surgical treatment.[5]

Myofascial trigger points (MTrPs) are thought to occur as a result of muscle overuse or muscle trauma or psychological stress.[6] Examples include TPs arising secondary to muscle overload in worksite tasks or activities of daily living such as lifting heavy objects or sustained repetitive activities.[7] Supraspinatus, being the most superior of the four rotator cuff muscles, helps in the abduction of the arm by resisting the gravitational forces acting on the shoulder joint. Thus, a deconditioned and fatigued rotator cuff muscle with poor ergonomics and improper postural positioning can lead to the formation of MTrPs.

PRP generally results in long-lasting relief because the degenerative tissue starts to regenerate or regrow itself.[8] Platelets are known for their clotting mechanism during injury. Increased concentration of platelets, autologous growth factors such as platelet-derived growth factor and vascular endothelial growth factor found in PRP have been established to play a critical role in cell proliferation, chemotaxis, cell differentiation, and angiogenesis which helps in the regeneration of tendon.[9]

Corticosteroids have detrimental effects on tendons, including impairment of fibroblast viability, arrest of cell proliferation, and depletion of the tenocyte stem cell pool, leading to decreased collagen synthesis.[10] The release of metalloproteinases after a corticosteroid injection has been associated with tendon degeneration and rupture.[10] PRP is injected directly into the injured tendon, where released growth factors can promote the healing process.[10]


  Conclusion Top


The clinical examination of the shoulder joint is of utmost importance whenever the patient presents with features of myofascial pain involving the upper back. This is an extremely important step for budding pain physicians in their clinical journey to correctly diagnose a patient, as the primary pathology involving a shoulder joint might lead to secondary MTrPs misleading the diagnosis, thus affecting patient prognosis. Furthermore, PRP injection is the preferred treatment for rotator cuff injuries. It gives the best results when done under ultrasound guidance, followed by shoulder strengthening exercises.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hwang UJ, Kwon OY, Yi CH, Jeon HS, Weon JH, Ha SM. Predictors of upper trapezius pain with myofascial trigger points in food service workers: The strobe study. Medicine (Baltimore) 2017;96:e7252.  Back to cited text no. 1
    
2.
Han SC, Harrison P. Myofascial pain syndrome and trigger-point management. Reg Anesth 1997;22:89-101.  Back to cited text no. 2
    
3.
Parthasarathy S, John Charles SA. Analgesic efficacy of ultrasound identified trigger point injection in myofascial pain syndrome: A pilot study in Indian patients. Indian J Pain 2016;30:162-5.  Back to cited text no. 3
  [Full text]  
4.
Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am 1972;54:41-50.  Back to cited text no. 4
    
5.
Clement ND, Nie YX, McBirnie JM. Management of degenerative rotator cuff tears: A review and treatment strategy. Sports Med Arthrosc Rehabil Ther Technol 2012;4:48.  Back to cited text no. 5
    
6.
Simons D. Clinical and etiological update of myofascial pain from trigger points. J Musculoskelet Pain 1996;4:97-125.  Back to cited text no. 6
    
7.
Jafri MS. Mechanisms of myofascial pain. Int Sch Res Notices 2014;2014:523924.  Back to cited text no. 7
    
8.
Bhattacharya D. Mystery of platelet rich plasma injection in painful conditions. Indian J Pain 2015;29:121-3.  Back to cited text no. 8
  [Full text]  
9.
Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev 2003;83:835-70.  Back to cited text no. 9
    
10.
Are Platelet Rich Plasma Injections a Better Choice Compared to.-Idun. Available from: https://idun.augsburg.edu/cgi/viewcontent.cgi?article=1347&context=etd. [Last accessed on 2022 Jun 14].  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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