From the Guidelines
Enthesopathy of the greater tuberosity of the shoulder should be managed with gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction, as well as analgesics such as acetaminophen or ibuprofen for pain relief. When considering treatment options, it is essential to prioritize techniques that improve range of motion and reduce pain. According to the Canadian Stroke Best Practice Recommendations 1, gentle stretching and mobilization techniques are recommended for the treatment of hemiplegic shoulder pain related to limitations in range of motion. Key aspects of treatment include:
- Increasing active range of motion gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 1
- Using analgesics, such as acetaminophen or ibuprofen, for pain relief if there are no contraindications 1
- Considering injections of botulinum toxin into the subscapularis and pectoralis muscles for hemiplegic shoulder pain thought to be related to spasticity 1
- Using subacromial corticosteroid injections in patients when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) in the hemiplegic shoulder 1 It is crucial to note that while these guidelines are specifically for hemiplegic shoulder pain, the principles of gentle stretching, mobilization, and pain management can be applied to enthesopathy of the greater tuberosity of the shoulder, prioritizing morbidity, mortality, and quality of life as outcomes.
From the Research
Enthesopathy of the Greater Tuberosity Shoulder
- Enthesopathy of the shoulder, including the greater tuberosity, is a common feature in patients with ankylosing spondylitis (AS) 2
- A study found that 24.7% of AS patients had shoulder involvement, with rotator cuff tendinitis being significantly more prevalent in patients (15.1%) than controls (3.5%) 2
- Bone marrow edema at any entheseal site, including the greater tuberosity, was noted in significantly more AS shoulders (70.6%) than in control shoulders (19.1%) 2
- Erosion of the greater tuberosity with or without adjacent bone edema had a sensitivity of 58-65% and specificity of 86-92% for diagnosing AS 2
Characteristics of Enthesopathy
- Enthesopathy is characterized by pathologic changes at the insertion sites of tendons, ligaments, and articular capsules into bone 3
- It can be associated with pain and inflammation, and can be a feature of various conditions, including ankylosing spondylitis and psoriatic arthritis 2, 4
- The pathophysiology of enthesitis involves biomechanics, prostaglandin E2-mediated vasodilation, and the activation of innate immune cells 4
Treatment of Enthesopathy
- Treatment options for enthesopathy, including glucocorticoids and cytokine-blocking agents, are available, but the effectiveness of these treatments can vary depending on the specific condition and severity of the enthesopathy 4
- Physical therapy and exercise can also be beneficial in managing enthesopathy, particularly in cases of gluteal tendinopathy 5