Background Shoulder pain is a common symptom in patients with rheumatoid arthritis (RA). Diverse anatomic structures of shoulder could be involved in RA with considerable functional limitations. However, little attention was paid to the diagnosis and the management of shoulder involvement in the routine clinical assessment of RA patients.
Objectives We aimed to assess clinical and radiological abnormalities of shoulder in Moroccan patients with RA and their association with disease activity and severity.
Methods 250 consecutive patients with RA attending the Department of Rheumatology of the University Hospital of Rabat-Sale were included. Sociodemographic data, age at onset, disease duration, disease activity (DAS 28), functional disability (HAQ) and structural damage (Sharp’s method) were specified. Immunological status and treatment details were assessed. History of shoulder pain (at the onset of RA or during the course of disease), shoulder pain intensity (on a VAS), area of pain, previous diagnosis, previous radiological investigations or anterior treatments were collected. Physical examination was done by the same rheumatologist: involved site, range of passive and active motion and tests for shoulder impingement and rotator cuff tendons lesions. Recent (≤6 last months) radiographs of shoulder (evaluated by the Larsen erosion score); and ultrasonographic examination (US) for the glenohumeral joint and periarticular tissues were assessed.
Results 106 (42.4%) of patients had a history of shoulder pain at the onset of disease and 141 (56.4%) reported shoulder pain during the course of RA. 55 (22%) patients had previous intra-articular treatment with corticosteroids, 14 (7.2%) have benefited from functional rehabilitation and no patient had arthroplasty. At the study inclusion, 193 patients (77.2%) had shoulder pain with a mean pain intensity of 57.3±19.7 and a mean duration of 2.8±0.9 years. Physical examination data were as follow: the most tender sites: glenohumeral joint (87.5%) and subacromial space (21.7%); the most limited motions: abduction (92%) and antepulsion (66.2%); impingement tests (Neer) (43%); maneuvers of tendon lesions: Jobe’s test (34.7%). Comparing patients with and without shoulder pain, there were no differences in terms of gender, disease duration, disease activity or treatments. However, patients with painful shoulder had worst functional ability (p=0.013) and high levels of rheumatoid factor (p=0.007). Recent radiographs of shoulders were realized in 72 patients (28.8%) all with painful shoulder. Larsen’s scores were: 17 patients (23.6%) grade 0; 7 (9.7%) grade 5 and 48 (66.6%) ranged between grade 1 and 4. Forty-nine (19.6%) patients had a recent shoulder US. The most frequent lesions in US were: synovitis of the glenohumeral joint (73.4%), thickening of the long head of biceps (46.9%) and the supraspinatus (22.4%), and humeral head irregularity (18.3%).
Conclusions In this study, our RA patients had frequent painful shoulder with articular and periarticular involvement. Shoulder involvement did occur even in early stages of RA and was associated with low functional ability. Radiographic and US exploration were realized in a small number of patients. The early and correct recognition and treatment of RA and shoulder involvement especially with the advent of imaging techniques may improve patients function.
Disclosure of Interest None Declared
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