Painful Shoulders Associated With Increased Risk for Heart Disease

New work from the University of Utah School of Medicine finds that people with symptoms indicating an increased risk for heart disease could be more likely to have shoulder problems.

“If someone has rotator cuff problems, it could be a sign that there is something else going on. They may need to manage risk factors for heart disease, ” says the study’s lead author Kurt Hegmann, M.D., professor of Family and Preventive Medicine and director of the Rocky Mountain Center for Occupational and Environmental Health, in the December 26, 2016 news release.

Dr. Hegmann told OTW, “I noticed comparatively poor epidemiological studies of common musculoskeletal disorders. Studies were almost never prospective cohort studies, populations were small, case definitions in publications were poorly described or irreproducible, exposures were usually questionnaire-based and confounders, sometimes including obvious ones, went unaddressed.”

“Regarding studying shoulder disorders, we know that normal tendons never rupture. When we see a ruptured tendon (Achilles, supraspinatus, etc.), we know that it was degenerative even if there were no symptoms.”

“Experimental studies show the weak point when loading the muscle-tendon unit is either the muscle-tendon junction (i.e., a true muscle strain) or the bone-tendon junction (i.e., where a fleck of bone comes off). [Richard] Rothman in 1966, as well as other researchers, quantified that there is poor blood supply in the supraspinatus where rotator cuff tendon tears occur. Thus, vascular insufficiency is one of the two main mechanistic theories of rotator cuff (RC) tears.”

“The other main theory of rotator cuff tears is mechanical abrasion or impingement that was first described in the 1920s and 1930s and then further promoted by [Charles] Neer in the 1970s.”

“It would be possible that both theories are correct, although the body of evidence suggests that the initiating problem is primarily vascular and there are plenty of cases of RC tears in the absence of significant overhead work or activities.”

“Thus, we have long thought that the impingement theory as a disease mechanism was likely not the primary issue for most people. True, patients will have pain with impingement signs on exam, or an association, but that does not necessarily equate to a causal disease mechanism.”

“Regarding RC tendinitis and tears, we noted risks from tobacco in other published studies. We also had performed four shoulder experiments to help determine work performance measures (e.g., how much someone can lift) and those studies all found force to be more important in the shoulder than posture or repetition. Those studies then informed our work that reported obesity was a risk for shoulder surgeries (JBJS).”

“Next, we began a cohort study in 2002 to study common musculoskeletal disorders and whether work factors produced those diseases. The two main disorders studied were carpal tunnel syndrome and lateral epicondylalgia. However, as we were studying those diseases, we decided we might as well add on shoulder tendinitis, as the cost was low to add another disease.”

“Thus, going into this study, we had a hypothesis that shoulder problems were vascular and that cardiovascular (CV) disease risk factors were likely mechanisms for producing the tendinitis and RC tears.

“We enrolled 1, 226 workers in Illinois, Utah and Wisconsin. These workers were employed at 17 different employment sites. We targeted approximately one-third low, medium and high job physical demand categories so that we could test whether job physical demands cause these musculoskeletal disorders.”

“Workers did mostly manual jobs and some clerical workers too. Workers completed computerized questionnaires (e.g., age, heart disease, smoking histories, job satisfaction), and medical histories (e.g., elbow pain, shoulder pain, hand pain). All workers had physical examination tests regardless of their symptom status. Blood pressure, height and weight were measured. All workers underwent electrodiagnostic studies for carpal tunnel syndrome.”

“There were multiple findings that surprised us. We found that the prevalence of shoulder joint pain is quite high in the working age population, with 31.5% having had shoulder pain in the month prior to the study. When assessing a diagnostic impression of rotator cuff tendinitis with a combination of glenohumeral joint pain and a positive supraspinatus (or ‘empty can’) test, 12.7% met that case definition of RC tendinitis. That finding was far higher than we expected.”

“Our multivariate analyses adjusted for sex, body mass index, job satisfaction and family problems. Adjusted analyses showed the higher the Framingham risk score, which measures risk of heart disease, the higher the risk the person has either RC tendinitis or glenohumeral joint pain.”

“The more risk factors one has, the greater was the association. The risk of RC tendinitis in the highest group was nearly 6-fold (5.97), while the risk of glenohumeral, or shoulder joint pain was as high as 4.55-fold. Both shoulder joint pain and RC tendinitis risks trended higher across higher risk scores. The magnitudes of these associations surprised us despite our a priori hypothesis.”

“Also, these magnitudes of association are so high, and we also found a clear dose-response relationship, thus, it is quite likely that rotator cuff tendinitis is related to impaired vascular supply from cardiovascular disease risk factors. It is presumed that this is a microvascular impairment, although this study did not actually measure blood flow in the tendons.”

“The operating orthopedist may want to think further about cardiovascular risks in the pre-operative setting, both from a perioperative complication standpoint, as well as for healing the patient. This work also suggests that those with one RC tear should probably be evaluated by their primary care provider for their CV risk, and treatment as indicated, to help delay development of a second RC tear.”

“This work needs to be duplicated in prospective analyses, which we have underway. Randomized controlled trials that implement intensive cardiovascular disease risk factor management could analyze for reductions in glenohumeral pain and RC tendinitis. If those two findings are confirmed, then the mechanism and theory of the disease would be quite firm.”

Penn Study: Pre-diabetes and Stiff Shoulder Linked!

It’s probably one of the most “Googled” medical terms these days—metabolic syndrome, that is. Also known as pre-diabetes, metabolic syndrome has been on the periphery of concern for orthopedic surgeons for years. Now it is moving toward the center of attention.

John D Kelly IV, M.D., director of Sports Shoulder at the Perelman School of Medicine at the University of Pennsylvania (Penn) told OTW, “Previous studies have found a link between adhesive capsulitis (stiff shoulder) and diabetes. We believed we were seeing many patients with ‘pre-diabetes’ or metabolic syndrome and spontaneous shoulder stiffness. This is a bit concerning given that roughly 50% of people over the age of 60 have pre-diabetes. Our team decided to first take a closer look at the components of pre-diabetes (dyslipidemia, hypertension, insulin resistance, obesity), and the development of adhesive capsulitis.”

“We undertook a retrospective review of 150 patients who had been diagnosed with adhesive capsulitis and looked for markers of metabolic syndrome—high lipids, body mass index, and hypertension. We found that dyslipidemia and obesity do not appear to be strongly related to adhesive capsulitis. However, the prevalence of hypertension was significantly higher in these patients as compared to historic controls. The mechanism? Hypertension is linked to increased inflammation and perhaps may be one of earliest indices of glucose intolerance—another pro-inflammatory condition. Our next step is to examine serum insulin levels as insulin resistance may be the sentinel event in the evolution of metabolic syndrome. Thus, spontaneous onset of shoulder stiffness may be an indicator of loss of bodily glucose homeostasis.”

Study: NPC Good for Certain Fracture Patterns

While distal femur fracture non-union rates are better than non-union rates for marriage, it’s still bad: upwards of 20%, says Richard Yoon, M.D., Orthopaedic Trauma & Complex Adult Reconstruction Fellow at Orlando Regional Medical Center. He told OTW, “While there have been great successes treating distal femur fractures with a locked plate and intramedullary nailing, individually, but there are cases where that approach isn’t enough to prevent a non-union or fixation failure. Our goal was to assess the status quo of this research.”

“We are involved in a multicenter, retrospective review of the nail plate combination (NPC) technique in the treatment of periprosthetic and interprosthetic fractures, distal femur fractures, distal femur non-union, malunion and its infected counterparts. To date we have followed 60 patients for one year and have experienced no failures, repeat surgeries, or non-unions.”

“Using the NPC makes getting the appropriate reduction easier; the nail especially helps in large bone gaps or in osteoporotic bone. Overall, it is a very reproducible operation that is complete in 1.5 to 2 hours. But it is not for all patients. NPC technique is for certain fracture patterns that we think are more prone to failure, especially if there is a large gap or long fracture in the distal metaphysis. If you are putting only the nail or the side plate then you increase the risk for failure, you’re asking for the individual implants to work very hard while waiting for poor bone to heal.”

“We have not yet finalized the data, but thus far it looks like the NPC construct provides stability and balanced load sharing from the proximal to distal femur, thus aiding with bone healing.”

Additional centers involved in this study are: Jersey City Medical Center – RWJ Barnabas Health, Vanderbilt University, Sutter Health, Florida Orthopaedic Institute.