Many middle-aged and elderly people often complain of shoulder joint pain or stiffness when they move around. Most of them have done manual massage, physiotherapy, Chinese medicine, acupuncture, closure, etc. They also follow the medical advice and insist on exercising every day, climbing walls, pulling rings, stick exercises, rope exercises, and although they have had various conservative treatments, they are still not getting better. The pain worsened after each exercise, and the situation continued to deteriorate. After careful examination, it was found that they all suffered from the same kind of injury – “rotator cuff injury”.
The rotator cuff, also known as the tendon cuff, is composed of the supraspinatus, infraspinatus, subscapularis, and teres minor tendons, and is closely connected to the shoulder capsule, which wraps around the humeral head and attaches to the surgical neck of the humerus in the shape of a cuff. The rotator cuff is located between the acromion and the humeral head, and its main function is to help stabilize the shoulder joint and shoulder movement, to protect the humeral head from being pulled upward by the deltoid muscle and to avoid impact with the acromion, which is a very important group of structures. However, the rotator cuff is also a tissue that is very susceptible to injury and tearing.
Rotator cuff injuries are very common in older patients over the age of 60 who present with complaints of shoulder pain, with a prevalence of up to 70%, much higher than in so-called “frozen shoulder”, where younger people may experience a rattling or rubbing sensation from shoulder activity. In the past, due to limitations and misconceptions about these diseases, most patients were misdiagnosed with “frozen shoulder”, resulting in treatment errors and patient suffering.
There are many diseases that cause shoulder pain, including rotator cuff tear, acromioclavicular impingement, rostral impingement, frozen shoulder, sternoclavicular joint disease, SLAP injury, anterior shoulder instability, tendinopathy, calcific tendinitis, adhesive subacromial bursitis, biceps tendinitis, supraspinatus tendinitis, shoulder pain caused by intractable cervical spondylosis, deltoid fibrosis, thoracic outlet syndrome, acromioclavicular joint dislocation, shoulder subluxation (especially posterior subluxation: one is uncommon, the second is not routinely examined by X-ray equipment, and requires special postural radiographs), shoulder joint injury (cartilage injury, fracture, etc.), suprascapular nerve anesthesia, thoracic long nerve anesthesia, synovitis, etc., which require specially trained specialists and very careful differential diagnostic ability.
The mechanism of rotator cuff injury is divided into two types: acute laceration and chronic strain injury. Acute lacerations are commonly caused by heavy lifting, shoulder support during a fall, or violent external pulling, such as a passenger standing on a bus holding a lever and losing his balance when he suddenly encounters an emergency brake, which may cause a rotator cuff laceration. Chronic strain injuries are commonly caused by falls, upper limb bracing or pulling heavy objects with force. Chronic rotator cuff injuries are also common in people who have played sports, strained their shoulder joints, or overused their upper limbs; they are also common in people who have been playing tennis, baseball, badminton, swimming, and hiking for a long time and need to lift their upper limbs above their heads.
Rotator cuff injury is mainly characterized by shoulder pain and weakness, mainly manifested as pain during shoulder abduction and supination. Functional exercises do not help to relieve the pain of rotator cuff tears. If a patient with a rotator cuff tear is mistaken for “frozen shoulder” and continues to perform exercises such as “climbing the wall” or artificially forcing the rotator joint to release, the rotator cuff tear may continue to expand and eventually form a large or irreparable rotator cuff tear, aggravating the injury. Moreover, if the rotator cuff muscle is misdiagnosed for a long time, it will become fatty, and even if it can be surgically closed, the muscle will have lost its contraction and stretching function, and the effect will not be obvious after treatment. Rotator cuff injury is a very disabling disease that should be taken seriously, and a timely and correct diagnosis is essential for patients with shoulder disorders.
The most advanced and effective way to treat rotator cuff injuries is to use the arthroscopic minimally invasive suture technique, which involves opening three small holes of 0.5 to 1 cm in diameter in the affected shoulder and re-suturing the torn rotator cuff tendons to restore the motor function of the limb under the minimally invasive operation of arthroscopy.
Although arthroscopy is a minimally invasive technique, its field of view is better than that of open surgery, because under open surgery many tissue seams, posterior sides, and corners are covered by the bone and joint, and the surgeon cannot see clearly the tissue behind the joint, much less implement effective treatment. Moreover, the large incision and too much muscle and tendon destruction also increase the patient’s postoperative pain. The arthroscope, which enters the lesion through a small hole in the skin, is like the doctor’s two eyes, which can see every corner of the lesion, and the recovery from the microscopic treatment is fast.
Frozen shoulder is the abbreviation for periarthritis of the shoulder joint, a group of diseases that occur in different anatomical areas and have various pathological characteristics. The main manifestation is the gradual development of pain in the shoulder and its surrounding areas, which is worse at night and gradually worsens, and the limitation of shoulder joint function, which is getting worse. Patients with frozen shoulder are affected by climate change. Patients with frozen shoulder feel cold air entering the shoulder, and some patients feel cool air coming out from inside the shoulder joint, so it is also called “shoulder wind”. The main clinical manifestation is pain and limitation of shoulder joint movement, which is also known as “frozen shoulder” and “frozen shoulder”.
The common causes of frozen shoulder are
1. Shoulder causes
(1) The disease mostly occurs in middle-aged and elderly people over 40 years old, with degenerative soft tissue disease and weakened ability to withstand various external forces;
(2) Chronic injury caused by long-term over-activity and poor posture;
(3) Long-term shoulder immobilization after upper limb trauma, secondary atrophy and adhesion of periapical tissues.
(4) Acute contusions and strains of the shoulder due to improper treatment, etc.
2.Extra-shoulder factors
Cervical spondylosis, heart, lung and biliary tract diseases occur in the shoulder involvement pain, because the original disease does not heal for a long time so that the shoulder muscle persistent spasm, ischemia and the formation of inflammatory lesions, transformed into the real frozen shoulder.
Common clinical manifestations of frozen shoulder
1.Shoulder pain
The pain can spread to the neck and upper limbs (especially the elbow), and when the shoulder is bumped or stretched by chance, it can cause severe pain like tearing. If the pain is caused by cold, it is particularly sensitive to climate change.
2. Restriction of shoulder joint movement
As the disease progresses, the adhesions of the joint capsule and the soft tissues around the shoulder caused by long-term disuse, the muscle strength gradually decreases, and the rostro-humeral ligament is fixed in a shortened internal rotation position, so that the active and passive activities of the shoulder joint in all directions are limited, especially the combing, dressing, washing, forking and other movements are difficult to complete. In severe cases, the function of the elbow joint may also be affected, and the hand cannot touch the ipsilateral shoulder when flexing the elbow, especially when the arm is posteriorly extended.
3. Fear of cold
Many patients use cotton pads to wrap their shoulders all year round, and even in the summer, they do not dare to blow on their shoulders.
4.Pressure pain
Most patients can feel obvious pressure points around the shoulder joint, mostly at the biceps longus tendon groove, subacromial bursa, rostral process, supraspinatus attachment point, etc.
5.Muscle spasm and atrophy
Spasm of the deltoid, supraspinatus and other muscles around the shoulder may occur in the early stage, and disuse muscle atrophy may occur in the late stage, resulting in typical symptoms such as protrusion of the shoulder peak, inconvenience in lifting, and inability to posteriorly extend, etc. At this time, pain symptoms are reduced.
Examination of frozen shoulder
X-ray examination and MRI examination of the shoulder joint are mainly used for this disease.
1.X-ray examination
(1) The characteristic change in the early stage is the blurring and deformation of the subacromial fat line and even its disappearance. The so-called subacromial fat line is the linear projection of a thin layer of fatty tissue on the subdeltoid fascia on the X-ray film. When the shoulder joint is excessively internally rotated, the fatty tissue happens to be in the tangential position and shows a linear shape. In the early stage of frozen shoulder, when the shoulder soft tissue is congested and edematous, the contrast of the soft tissue on the X-ray film decreases, and the fatty line under the shoulder peak is blurred and distorted or even disappears.
(2) In the middle and late stages, soft tissue calcification in the shoulder is seen on X-ray, and calcified spots with faint and uneven density are seen in the joint capsule, synovial bursa, supraspinatus tendon, and long head tendon of the biceps. In the advanced stage of the disease, the calcification shadow is dense and sharp on X-ray, and in some cases, large nodular osteophytes and bone redundancy can be seen. In addition, osteoporosis, joint end hyperplasia or bone redundancy or narrowing of the joint space can be seen in the acromioclavicular joint.
2.MRI examination of shoulder joint
MRI examination of the shoulder joint can determine whether the signal of the structures around the shoulder joint is normal and whether there is inflammation, which can be used as an effective method to determine the location of the lesion and differential diagnosis.
Treatment of frozen shoulder
Frozen shoulder is a chronic disease that can gradually improve and heal. Treatment is based on the principles of pain relief, functional exercise, and promotion of joint function recovery, and can be done with physical therapy, heat, massage, or massage.
For patients with persistent frozen shoulder, that is, after more than 3 months of ineffective conservative treatment, and with prolonged persistent pain, skeletal deformities, severe lesions or ruptures of rotator cuff tendons, intra-articular adhesions and contractures of the joint capsule resulting in severe shoulder joint dysfunction, or patients with significant impingement caused by subacromial osteophytes, minimally invasive surgery can be performed to release the shoulder arthroscopically, and most patients are more satisfied with the results.
What rotator cuff injury and frozen shoulder have in common is restricted movement and pain. The differences are.
(1) The pain is worse at night in frozen shoulder, and the pain increases after the activity reaches the restricted angle and cannot be moved to the normal angle, and the history of the disease usually does not exceed 2 years. After the acute phase of rotator cuff injury, if no adhesions are formed, there is no pain when there is no active movement, and after moving to the restricted angle, passive movement can be done to reach the normal angle.
②The upper limb of rotator cuff injury is weak, and there are no symptoms of weakness outside the restricted angle in frozen shoulder.
③Patients with frozen shoulder need to do exercises such as climbing wall lifts to pull apart the adherent tissues, and need to accelerate the blood supply by strengthening the shoulder joint activities through exercises to improve the inflammation symptoms; while patients with rotator cuff injury should not make strong exercises and activities, and need patients to keep the shoulder at absolute rest, not to move, pay attention to maintenance and restore the degree of muscle damage.
The biggest difference between frozen shoulder and rotator cuff injury is that patients with frozen shoulder are unable to lift their arms even with the help of others, while those with rotator cuff injury can lift their arms with the help of others although they are unable to do so themselves.