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• W4225712798 abstract "Where Are We Now? I am often surprised by how some patients with severe radiographic evidence of osteoarthritis have little pain, while others have substantial symptoms with few findings on radiographs. This discordance can even occur with the contralateral limbs of the same patient. When doctors see a severely arthritic and deformed joint on radiographs, it is tempting to take a mechanistic view and assume that the patient is in pain, especially since many of our therapies (particularly as surgeons) are directed at the correction of anatomical abnormalities. However, as has been noted by multiple authors, there is not always a direct correlation between radiographic signs of osteoarthritis and patient symptoms, including pain and function. This has been extensively demonstrated in the knee [1, 2, 5], hip [11, 18], hand [6], and ankle [17], among other joints. Kellgren and Lawrence [10] noted the discrepancy between “actual and expected incidence of pain” in their 1952 study of coal miners, which found that only 23% of workers with radiological changes had pain in their knees, while 8% of patients with normal radiographs had pain. Even among the patients with severe arthrosis, only 70% had pain or physical signs. A few years later, Lawrence et al. [14] concluded: “It is evident, however, that osteoarthrosis is a predisposing factor rather than a cause of symptoms, since most of those with the disease had no symptoms in the corresponding region.” More recent studies have shared similar findings [5, 13]. One study drawn from the National Health and Nutrition Examination Survey summarized the situation nicely: “substantial discordance exists in this population-based study between radiographic [findings of arthrosis] of the knee versus knee pain, versus a diagnosis of arthritis by a physician” [5]. Another was even more blunt: “There was no association between radiographic osteoarthritis and [quality of life]” [13]. While this inconsistent relationship between radiographic changes and symptoms is well known in the acromioclavicular joint [3] of the shoulder, there is increasing evidence that this is true in the glenohumeral joint as well [12, 15]. Joyce et al. [9] further confirm this in their study in this month’s Clinical Orthopaedics and Related Research®. They found in a group of mostly presurgical patients that those with Samilson-Prieto Grade 4 arthrosis had lower VAS Pain scores (mean 6.0 + 2.4) than Grade 0 or 1 (mean 6.5 + 1.9), and that no other radiographic criteria (including specifically Walch glenoid type) demonstrated any clinically important association with pain or function. Although unexpected, this is somewhat consistent with Matsen’s findings [15] in a prearthroplasty group that patients with greater deformity (Walch B2, C) had higher preoperative Simple Shoulder Test scores. I would encourage readers to dive into this paper to better understand the potential impacts on their clinical practice in evaluating and managing patients. Where Do We Need To Go? This study raises an important question: How generalizable are these results to patients with less severe symptoms? The title “Radiographic Severity May Not be Associated with Pain and Function” doesn’t mean that there is NO association; rather, that the relationship bears further examination. The authors’ apparently paradoxical findings of increased deformity being associated with less pain may be applicable in this group of patients with severe glenohumeral arthrosis who are considering arthroplasty, but it may not be as true across populations. Although there may not be 1:1 relationship between severity of disease and symptoms, it has been demonstrated in other joints that it is more likely that patients with radiographic arthritis have pain, and that those with more severe radiographic arthritis are much more likely to have symptoms than those without such changes [10, 16]. It would be beneficial to understand if these relationships seen in other joints are seen in the shoulder. Another important area of inquiry is if pain and function do not correlate with degree of glenohumeral arthritis, why are some patients so much more symptomatic than others? Our comprehension of the inherently subjective nature of experienced pain in osteoarthritis remains quite poor. The presence or absence of psychologic diagnoses was not found to be correlated to symptoms in this study, but that relationship has been identified in other joints [6]. Joint pain likely has a relationship to an individual’s central processing and response to potentially noxious stimuli. There appears to be a relationship between psychological coping [21] and central pain processing [2] in patients with symptomatic knee osteoarthritis, a finding that is generally supported by genetic studies linking genes involved in pain pathways with symptoms [22, 26]. However, there are likely some factors that are joint-specific, since some patients have bilateral radiographic osteoarthritis but are symptomatic in only one joint [25]. Finally, we may need to pay more attention to symptom severity before surgery. In other joint replacement procedures, patients with milder radiographic signs of arthritis reported higher levels of pain and poorer function after surgery [23, 24], as well as a high (59%) rate of dissatisfaction [19]. The more severe preoperative symptoms in some patients may be a key bit of information; the fact that patients process and experience pain differently before surgery may directly bear on pain levels afterward. One study of shoulder arthroplasties noted no difference in outcomes for patients with lesser radiographic changes [20], but one study on this topic is not enough, given what has been identified in other joints. It’s fair to say that for the shoulder, we just need more information on this important topic. How Do We Get There? We need to better understand the overall relationship between shoulder radiographic findings and shoulder symptoms. Researchers can build on the findings of the current study by collecting pain, function, and radiographic data from a broader group of patients who are not all anticipated to undergo shoulder arthroplasty, such as those seen in a more general shoulder or orthopaedic practice. Alternatively, a population-based study with shoulder radiographs and clinical information could be obtained. To make this easier, a more selective group of patients who are at higher risk for osteoarthritis due to work or activities may have a higher prevalence of radiographic changes. Further exploration of the nature of pain and symptoms in radiologically affected joints by evaluating patients with and without symptoms who have glenohumeral arthrosis would be beneficial. Patients with similar radiographic findings but different levels of pain and symptoms could be matched and appropriate testing for other contributing causes or mitigating factors could be performed, including genetic testing, psychological evaluation, or assessment of central pain processing using such tests as the pressure-pain threshold or cold pressor testing [2]. Another method would be to use these and other tests in patients who have different symptoms in contralateral joints that have similar radiographic findings. Since the two shoulders are in the same patient, many factors will be identical so the contralateral limb can serve as an excellent control. It remains unclear whether shoulder arthroplasty patient-reported outcomes are worse in patients with lesser degrees of anatomic abnormality, as they are in lower extremity arthroplasty. It would be relatively straightforward to track the clinical symptoms of patients undergoing shoulder arthroplasty and identify whether there is a correlation with the degree of radiographic change. I’m hoping that Joyce et al [9] might take the existing group of patients in this study, collect postoperative outcomes, follow their levels of pain and function after surgery, and identify what relationships these outcomes have to preoperative radiographic grading. This information would be useful for both patients and surgeons in determining prognosis for a planned procedure." @default.
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• W4225712798 date "2021-10-25" @default.
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• W4225712798 title "CORR Insights®: Radiographic Severity May Not be Associated with Pain and Function in Glenohumeral Arthritis" @default.
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