Shoulder AVN with Rheumatoid Arthritis
AVN and Rheumatoid Arthritis
A 35 year old man with shoulder pain, began insidiously, 2 years ago. It slowly progressed his PCP ordered an MRI, and referred him to an orthopedic surgeon. He was told he had Avascular Necrosis (AVN) of the humeral head without joint collapse. He was treaded conservatively taking the “wait and see approach”. He was given several cortisone injections into his shoulder over a 2 year period, which provided short term relief with first, and subsequent cortisone injections provided no relief. He presented to Dennis M. Lox, MD, an expert in Sports and Regenerative Medicine with s special expertise in AVN. Dr. Lox took a thorough history and physical examination.
Shoulder AVN is Second to Hip AVN
Shoulder AVN is the second most common joint affected with AVN, after the hip. Then the knee is third. Shoulder AVN may be seen in both shoulders, however not as frequently as seen in the hip.
Avascular Necrosis is Complicated
Avascular Necrosis is complicated. Many doctors don’t understand it, and therefore leave patients frustrated without answers or clear treatment plans. When assessing AVN one looks for risk factors or causality associated conditions.
This patient has potentially several.
1)First he was lifting boxes and remembers his arm hurting afterwards. Possible trauma induced.
2) He had a long history of (RA) Rheumatoid Arthritis (Autoimmune Disorders are casuality associated risk factors for AVN)
3) Medications: often rheumatologic medications are also causality associated risk factors for AVN. He had taken extended intermittent courses of corticosteroids for his RA over the years, onset years before his shoulder pain. He was also taking plaque in for a long duration and is still on it, but no corticosteroids. Plaque it is a immunosuppressant and has been shown to be a another potential causality associated medication with synergistic effects with corticosteroids. Often Avascular Necrosis is not easy to determine exact causation with many potential risk factors.
Trauma the leading cause is typically cause and effect disruption of blood blow to a traumatic insult to the joint, example significant fractures or shoulder dislocation.
The pain he experienced lifting the boxes is not typically for trauma, but the AVN may have already been present. His arm was one year old and his shoulder was hurting him more. That is simple, we need a current MRI with comparison to show if the AVN was progressing, evidence of flattening of the humeral head or shoulder joint collapse.
Hopefully none of this has occurred, but treating patients from all over the world doing a thorough and excellent evaluation is extremely important for the patient.
It is very understandable that it is the patient’s first time, and their family, however Dr. Lox has the experience to guide them to make good medical decisions based upon current medical studies not past, especially when the pain goes up.
Additionally, systematic causation factors may present in more than one joint, so the AVN expert is looking at all scenarios. He is young and with proper information will be able to make educated decisions about his own health care. That is Dr. Lox’s role.
Regenerative Medicine and Stem Cell Therapy has a important role in early and AVN that has not collapsed. Unfortunately, many orthopedic surgeons do not understand the importance AVN that goes bad, taking the “wait and see approach”, lends to time is not your friend. Joints age with time, and AVN is an accelerated for of degenerative arthritis, so early diagnosis and treatment are important. Additionally, avoiding other causation factors such as corticosteroid injections, is important to not make a bad situation worse, especially when cortisone injections are only temporary pain alleviator, but does nothing for the underlying condition of AVN.
Avascular Necrosis May be in Multiple Joints if Systemic Cause and Not Traumatic
It is always important to question new pain in joints when dealing with AVN of a suspected systemic cause, as new areas of AVN may occur in adjacent joints or different areas of the body. Dr. Lox has treated a person in which the AVN began in both ankles, then later developed in both hips, and finally both knees. This was the result of multiple intravenous corticosteroid treatments for COPD.
