Shoulder periarthrosis (SP) is a complex neurodystrophic syndrome of damage to the periarticular tissues of the shoulder joint that occurs with various pathological changes in the joint itself, the cervical spine, nerves of the brachial plexus or organs located next to the joint. It is manifested by pain and limited mobility of the shoulder joint. With SP, the diagnostic search consists in examining and palpating the joint area, assessing the neurological status, conducting radiography, ultrasound, MRI of the shoulder joint, radiography of the spine, and other examinations. Treatment consists in the combined use of glucocorticoid drugs, local anesthetics, NSAIDs, B vitamins, vascular therapy, physiotherapy, physical therapy and massage.
General information
The term “shoulder periarthrosis” has been used since 1872 as a collective concept that includes various pathology of the tissues surrounding the shoulder joint. So, under the diagnosis of “shoulder periarthrosis”, subacromial bursitis, sclerosing capsulitis and bursitis of the shoulder joint, tendinitis of the long head of the biceps and rotator cuff of the shoulder, and other diseases may be hidden. In neurological practice, SP is often regarded as a neurodystrophic syndrome that develops with cervical osteochondrosis. Due to such variability of types of SP with different etiology and course, when compiling ICD-10, it was decided not to include this concept in the classification and thereby encourage doctors to take a more thorough and differentiated approach to diagnosis. Despite this, today most specialists in the field of traumatology, orthopedics and neurology continue to widely use the term “shoulder periarthrosis”.
Causes
The factors that can initiate shoulder periarthrosis are numerous and variable. In medical practice, SP is most often diagnosed associated with impingement syndrome – inflammation of the rotator cuff of the shoulder, which occurs during its microtraumatization. It is observed with stereotypical movements with a load in painters, bricklayers, movers, athletes and with static loads on the shoulder of office workers. Shoulder periarthrosis can develop with osteochondropathy, arthrosis, arthritis of the shoulder joint, its instability and injuries (dislocation of the shoulder, tendon damage, ligament rupture). Other etiofactors of SP are fractures of the clavicle, trauma and post-traumatic arthrosis of the acromioclavicular joint.
The neurological causes of SP are radiculitis and radiculopathy in the pathology of the cervical spine (spondyloarthrosis, osteochondrosis, disc protrusion), plexitis and other diseases of the brachial plexus (for example, Erb’s palsy), paresis of the upper limb caused by a stroke or myelopathy. In patients with diabetes mellitus, shoulder periarthrosis is an integral part of the diabetic neuropathy clinic. In some cases, shoulder periarthrosis is observed, which occurs against the background of oncological diseases — lung cancer with localization at the apex, breast cancer, osteosarcoma, etc. In addition, brachiopathic periarthrosis has been described in women who have undergone mastectomy and in patients after myocardial infarction.
Pathogenesis
The pathogenetic mechanisms of SP development are based on segmental disorders of vascular regulation and neurotrophic disorders, gradually leading to dystrophic changes in the periarticular tissues of the shoulder joint. There is a thinning and loosening of the articular capsule, due to the loss of elasticity, microcracks are formed in it, subsequently replaced by connective tissue, which leads to an even greater decrease in the elasticity of the capsule and restriction of movements in the shoulder joint. The latter causes the appearance of the “frozen shoulder” syndrome and the development of persistent joint contracture.
Symptoms
Shoulder periarthrosis debuts with the appearance of pain syndrome. Its appearance and development is so imperceptible and gradual that patients cannot indicate exactly when they had pain. Pain sensations are more often localized along the anterior-lateral, less often along the back surface of the shoulder. According to the description of the patients themselves, they have a “drilling”, “aching”, “gnawing” character; they can radiate into the neck, shoulder blade, distal parts of the arm. In the initial period of SP, pain occurs only with movements in the shoulder joint that have a significant amplitude. For example, when trying to put your hand behind your back, take it aside, raise it forward above the horizontal level. Such motor acts in everyday conditions are not often performed by people, therefore, in the early period of SP, mainly athletes or those patients whose specified movements are associated with professional activity turn to doctors.
With further development of the shoulder periarthrosis leads to an aggravation of the pain syndrome and the appearance of limited mobility in the shoulder. Patients complain of the occurrence of sharp pain sensations during movements in the shoulder joint, the existence of constant background pain of a nagging nature in the joint area. The latter increases at night, prevents patients from sleeping on the side of the affected shoulder, leads to insomnia and the development of asthenia. The restriction of active movements in the shoulder gradually becomes noticeable in the daily life of the patient — it is difficult for him to hold on to the upper handrail in transport, get items from the upper shelves, raise his arm from the side of the trunk or wind it back. The above symptoms force the patient to consult a doctor. As a rule, at this point it takes 2-3 months. since the manifestation of the disease.
Diagnostics
Examination of the shoulder joint reveals a slight swelling of its tissues, their somewhat greater palpatory density in comparison with palpation of a healthy shoulder. Trigger points are noted — soreness during palpation of the attachment sites of tendons, humerus tubercles and the furrow between them, the scapular muscle. There is a restriction of active movements in the shoulder of varying severity, often passive movements are also limited. To the greatest extent, there is a violation of raising the arm in front of the trunk, its withdrawal and establishment behind the back. The examination of the patient can be carried out by an orthopedist, traumatologist, therapist or neurologist. The latter also evaluates the neurological status of the patient. When determining the signs of damage to the spinal nerves or brachial plexus, shoulder periarthrosis should be considered a syndrome of the detected disease.
Radiography of the shoulder joint and CT of the shoulder joint can provide information about the state of its bone structures — the presence of osteoporosis, a decrease in the interarticular gap, etc., as well as calcification of the articular bag and periarticular tissues. In the diagnosis of changes in the soft tissues of the joint, MRI or ultrasound of the shoulder joint is of leading importance. To assess the condition of the cervical spine, its radiography is performed, and if a radicular syndrome is suspected, an MRI of the spine is performed. Clarification of the identified neurological disorders may require EMG or ENG.
Treatment
The drugs that usually begin to treat shoulder periarthrosis are glucocorticosteroids (dexamethasone, hydrocortisone, betamethasone). They are injected intramuscularly or intra-articularly, as well as in the area of the supraspinatus muscle. The greatest effect is given by the combination of corticosteroids with local anesthetics (novocaine or lidocaine). Depending on the severity of SP symptoms, the number of therapeutic blockades can vary from 6 to 10. As a rule, by the end of the 2nd week of such therapy, there is a regression of pain syndrome and an increase in the volume of movements. This makes it possible to switch from corticosteroids to treatment with nonsteroidal anti-inflammatory drugs (diclofenac, nimesulide, piroxicam). If compromised by the gastrointestinal tract, these drugs are prescribed together with gastroprotectors.
Complex therapy of SP also includes the appointment of vitamins gr. In (possibly in the form of complex preparations), vascular preparations (nicotinic acid, pentoxifylline). Its combination with physiotherapy — ultraphonophoresis, electrophoresis, thermal procedures, magnetotherapy, reflexotherapy – has a positive effect on the results of treatment. After the pain syndrome is relieved, massage and physical therapy are prescribed in parallel with the therapy, aimed at restoring the volume of movements in the joint.
Prognosis and prevention
With timely treatment and full-fledged treatment, the prognosis in terms of recovery is quite favorable. In advanced cases, shoulder periarthrosis leads to the formation of persistent limitation of the motor function of the joint, the occurrence of contracture and disability of the patient.
Measures for the prevention of SP include: adequate treatment of cervical osteochondrosis, prevention of injuries to the shoulder joint and excessive loads on it of a professional or sporting nature, regular joint exercises aimed at strengthening the shoulder girdle.