Definition
Periarthritis, or frozen shoulder, is a disease caused by degenerative or inflammatory lesions of the tendons, ligaments, tendon sheaths, bursae and other soft tissues in and around the shoulder joint, resulting in shoulder pain and dysfunction. It is also known as “adhesive capsulitis”, “shoulder coagulation” or “frozen shoulder”, etc. It is also known as “fifty shoulder” because it occurs mostly in patients around 50 years old. It is also known as “fifty shoulder”. It is often thought that frozen shoulder has a tendency to heal on its own, but the natural history of the disease can last from 6 months to 3 years, or even longer, with an average of 30 months. And without effective treatment more than half of the patients will be left with permanent shoulder joint mobility disorders of varying degrees, of which 10% eventually develop into severe patients, seriously affecting the patients’ normal life and work. There is a narrow sense and a broad sense. In the narrow sense, it refers to frozen shoulder (or fifty shoulder), which is a sudden onset of shoulder joint pain and joint contracture after middle age, commonly characterized by stiffness of the shoulder joint, also known as “shoulder coagulation” and “adhesive capsulitis”. In the broader sense, frozen shoulder refers to multiple joints and sites in the shoulder complex, including subacromial bursitis, supraspinatus tendonitis, rotator cuff tears, biceps longus tenosynovitis, rostral synovitis, frozen shoulder, acromioclavicular joint lesions, and other disorders. In recent years, with the differentiation of disciplines, especially the rise of sports medicine, some scholars have proposed to abolish the name “periarthritis of the shoulder”. However, most scholars still use the name “periarthritis of the shoulder” due to the long-standing convention.
Diagnosis
The diagnosis can be made based on clinical manifestations and relevant examinations.
Shoulder pain: At the beginning, shoulder pain is paroxysmal, most of them are chronic, later the pain gradually increases or is dull, or cut-like pain, and is persistent. Most patients often complain of waking up at night with pain and cannot sleep, especially when sleeping on the affected side.
Restriction of shoulder joint movement: Shoulder joint movement can be restricted in all directions, including passive supination, abduction and shoulder rotation, especially in external rotation. In daily life, it is difficult to comb the hair, put on the clothes, tie the belt, raise the arm, take out the trouser pocket and tie the bra for women. In severe cases, the function of the elbow joint can also be affected, and the hand cannot touch the opposite ear when flexing the elbow joint.
Fear of cold: Patients are afraid of cold in the shoulder, and many of them use cotton pads to wrap their shoulders all year round.
Pressure pain: Most patients can feel obvious pressure points around the shoulder joint, mostly at the long head tendon groove of the biceps, the greater tuberosity of the humerus, the subacromial bursa, the rostral process, the attachment point of the supraspinatus, the internal angle of the scapula, and the infraspinatus fossa.
Muscle spasm and atrophy: The deltoid, supraspinatus and other muscles around the shoulder joint may develop spasm in the early stage, and disuse atrophy may occur in the late stage, with typical symptoms such as protrusion of the shoulder peak, inconvenience in lifting and unfavorable backbend.
Imaging and laboratory tests: routine x-ray radiographs, mostly normal, some patients may have increased bone density of the greater tuberosity. Some patients may have osteoporosis without bone destruction in the later stage. In some patients, calcified shadows can be seen under the shoulder crest. Because of the complex structure of the shoulder, conventional CT scan is often difficult to distinguish. MRI images respond well to soft tissues and are rich in density levels, so they show lesions in the glenoid labrum, joint capsule, and rotator cuff of the shoulder joint more satisfactorily, and are the most ideal adjunctive examination method for periarthritis, allowing for a clear diagnosis and differential diagnosis.
Differential diagnosis]
Shoulder pain is not always due to frozen shoulder, many diseases can cause shoulder pain. Although frozen shoulder is not terrible, misdiagnosis can cause a lot of trouble. Therefore, you should not be paralyzed and miss the disease.
Cervical spondylosis: Due to the long term vice ambulatory work, cervical spondylosis in this group of people has degenerative lesions such as hyperplasia, and nerve stimulation can cause shoulder pain, but this pain is mostly accompanied by neck discomfort, and the passive movement of the shoulder joint is more normal. In contrast, the pain of frozen shoulder is mainly in the shoulder and is accompanied by the dysfunction of the active and passive activities of the shoulder joint.
Lung cancer: Lung cancer can cause shoulder pain, which can appear before symptoms such as cough, hemoptysis and chest pain. Therefore, when diagnosing frozen shoulder, at the very least, an X-ray of the shoulder should be taken to exclude shoulder metastasis of lung cancer. Shoulder pain caused by lung obstruction is usually more tricky and treatment from the shoulder is mostly ineffective. Therefore, for shoulder pain that has not been treated for a long time, it is better to take a chest X-ray to initially exclude lung cancer.
Cholecystitis and cholelithiasis: Cholecystitis and cholelithiasis can cause radioactive right shoulder pain, but apart from shoulder pain, there are mostly other parts of pain, and patients often have a history of recurrent attacks to follow, and ultrasound can confirm the diagnosis. The shoulder pain can be relieved by anti-infection, antispasmodic and analgesic treatment.
Angina pectoris and myocardial infarction: These two types of coronary artery disease often have radiating left shoulder pain, but are accompanied by chest pain that is compressive or suffocating. Angina is often induced by exertion or excitement, and the pain can be relieved after rest, and nitroglycerin has a significant effect; infarction, on the other hand, often develops during sleep or in a quiet state, often accompanied by pallor, profuse sweating and dyspnea, and other manifestations of shock and heart failure, which cannot be relieved by nitroglycerin and rest. In the case of frozen shoulder, the pain is mostly dull or knife-like, often persistent and heavy at night, affecting sleep, and not relieved by rest or medication. These two diseases can often be life-threatening, so people with a history of coronary heart disease should be especially careful.
Typology]
Frozen shoulder can be caused by a variety of factors and can invade various tissues and structures in the shoulder. Therefore, it is important to clarify the etiology and location of frozen shoulder to treat frozen shoulder.
Etiological typing
The etiological typing of frozen shoulder is difficult because of the many causes of frozen shoulder and the wide range of diseases included. It can be roughly divided into the following 5 types.
1. Traumatic Frozen Shoulder
Frozen shoulder is mainly caused by shoulder pain and shoulder braking after trauma or surgery. The pain of the shoulder joint after trauma or surgery causes a decrease in the movement of the shoulder joint, especially when the upper limb is leaning against the body for a long time and hanging on the side of the body. Others such as pain after heart surgery, thoracic surgery, female mastectomy, and hepatobiliary surgery. And braking mainly includes the shoulder, upper arm, forearm, wrist fracture, etc. caused by trauma or plaster fixation after surgery, or even chest plaster fixation.
2.Degenerative frozen shoulder
The shoulder joint is the joint with the largest range of motion in the human body and is often subject to degeneration due to traumatic external forces from all directions. it is more frequent around the age of 50 and often occurs suddenly without obvious causes.
3.Frozen shoulder
There is a history of cold shoulder, such as a fan or air conditioner blowing directly on the shoulder, or a window not being closed when resting, and cold wind blowing on the shoulder.
4.Stroke type frozen shoulder
After hemiplegia, the upper limb is fixed beside the body for a long time, and the function is lost (active and passive activities are lost), and the shoulder joint pain is obvious. It is related to muscle weakness and reduced movement.
5.Diabetic periarthritis
It is associated with diabetes mellitus, with a small age of onset and a long disease duration, mostly bilateral. It is the most difficult type of frozen shoulder to treat, and the recovery is slow.
Disease Location Typing
In the auxiliary examination of frozen shoulder, MRI images are the most ideal auxiliary examination method for frozen shoulder because they respond well to soft tissues and are rich in density levels, so they show lesions in the glenoid labrum, joint capsule and rotator cuff of the shoulder joint satisfactorily. Based on the similarity of the shoulder lesion sites and diagnostic significance of MRI response, frozen shoulder can be divided into the following pathological subtypes.
1. Shoulder joint cavity lesion type: It mainly includes frozen shoulder, painful shoulder contracture, adhesive capsulitis, painful shoulder and peri-articular adhesions of the shoulder joint.
2. Synovial bursal lesions: mainly include adhesive subacromial bursitis, adhesive bursitis, calcific bursitis, occlusive bursitis, and subdeltoid bursitis, etc.
3. Tendonitis and tenosynovitis: mainly includes biceps longus tendonitis, adhesive tenosynovitis, supraspinatus tendonitis, painful arc syndrome, calcific tendonitis, degenerative tendonitis, rotator cuff inflammation, etc.
4.Other periapical pathologies: shoulder fibrous tissue inflammation, rostral synostosis, degenerative shoulder arthritis, etc.
Staging】
The main symptoms of frozen shoulder are gradually worsening shoulder pain and shoulder joint movement disorders. The pain is mainly located in the anterolateral shoulder, and the pain can radiate to the upper arm and hand. The pain is sometimes heavier at night, and can even affect sleep in severe cases. The shoulder joint movement is limited in all directions, but abduction, external rotation and posterior extension are the most significant, such as the inability to comb hair and dress. In the past, it was customary to divide frozen shoulder into three phases: “pain phase”, “stiffness phase” and “thaw phase”. In practice, there is also a “latent phase”.
Painful phase
Patients usually present with progressive diffuse shoulder pain, which may last from 2.5 to 9 months. The pain often worsens at night and is more pronounced when the patient is lying on the affected side with pressure on the shoulder joint. Once the patient uses the affected limb less, the pain leads to stiffness of the shoulder joint.
Stiffness period
Patients often restrict the movement of the shoulder joint in order to make the pain less painful, which signals the beginning of the stiffness phase. This period usually lasts for 4 to 12 months. Patients complain of limited movement in daily life. Men experience difficulty in removing their purses and women in tying their bras. When shoulder stiffness progresses further, there is severe restriction of shoulder movement, limiting activities such as combing hair and dressing, along with persistent dull pain (especially at night) and often sharp pain when the shoulder reaches or approaches its new range of motion limit point.
Thawing phase
This phase lasts for 5 to 26 months and the pain will decrease as the shoulder joint mobility increases. Without treatment (not benevolent neglect), the vast majority of shoulder movements can be gradually restored, but may never return to an objectively normal state, although most patients subjectively feel close to normal, mainly due to compensations or adjustments in the patient’s daily activities.
Latent phase
At this point, the acute inflammation has subsided through compensatory adjustment, so the pain and muscle strength are nearly normal. However, there may be residual symptoms of prolonged lower mobility of the affected shoulder than the contralateral normal shoulder joint. Due to incomplete repair, pain can be triggered by excessive amplitude activity, overload, overstretching, or viral infection. It is most often seen in untreated or improperly treated patients, while most patients who are completely treated do not have a latent phase.
The four stages of a typical frozen shoulder may not all be present, or may not follow the sequence of the above stages.
Grading]
Correct grading is a prerequisite for choosing a treatment method. According to the pain and functional limitation of the shoulder joint, it can be divided into three degrees as follows.
Mild: supination 135o or more, abduction 70o or more, posterior pulling and touching the spine (the tip of the middle finger is used to feel everywhere) above the spine of the 3rd lumbar vertebra, basic self-care, pain, pressure pain and night pain are (+).
Moderate: 90o~135o of supination, 60o~70o of abduction, posterior retraction of the spine below the 3rd lumbar spine and above the iliac hip, all pains (++).
Severe: 90o or less of supination, 6o or less of abduction, difficulty in feeling the spine with posterior retraction, the affected hand can only feel the iliac hip on the affected side, unable to take care of washing, dressing, etc., all pains (+++ or +++).
Treatment
Identify the symptoms and treat actively
Frozen shoulder is a multi-site lesion caused by multiple factors. It often occurs at the age of 40~75 years old, and is more common at the age of 50. It often develops slowly, with persistent pain that worsens at night and affects sleep. In the past, it was thought that frozen shoulder had a tendency to heal itself, and the natural course of the disease was divided into three stages: painful, stiff, and frozen. Recent studies have found that the natural history of the disease is long (up to 3 years or more). Without effective treatment, more than half of the patients will have permanent shoulder dysfunction of varying degrees, with 10% of them eventually developing severe disease with a latency period. This can occur again when there is excessive activity or viral infection, which can seriously affect the patient’s normal life and work. Therefore, once the diagnosis of frozen shoulder is confirmed, it should be treated actively and correctly.
Different treatment options for the location of the disease
The site of frozen shoulder can be in the shoulder joint cavity, in the synovial bursa, or in the tendons and tendon sheaths. For those who have a small joint cavity on imaging or MRI, hydraulic expansion of the joint cavity can be used; for those who have a fluid in the joint cavity on MRI, silver needles can be used to penetrate the shoulder acupuncture point at the anterior shoulder point, enter the shoulder joint cavity, and perform “coarse needle re-stabbing” or “long needle deep stabbing” to loosen the adhesions. “For the lesions of the synovial bursa, acupuncture can be used to loosen the bursa; for the lesions of tendons and tendon sheaths, local treatment such as Chinese herbal medicine and physiotherapy can be performed; for the combined rotator cuff tears, rotator cuff repair can be performed at the same time as shoulder arthroscopy. Since there is a blind spot in the shoulder arthroscopy, there may be missed during the release process, so it is important to perform a thorough release along with the arthroscopic release. For shoulder pain caused by cervical spondylosis, after the cervical spondylosis is cured, the shoulder symptoms will usually disappear without sequelae. It is worth noting that diabetic frozen shoulder is one of the most difficult types of frozen shoulder to treat, and blood sugar must be controlled during treatment. Only after blood sugar is controlled can treatment be effective.
Combining gradations and using different treatment plans
Pain and dysfunction are the two main symptoms of frozen shoulder. Based on the degree of pain and shoulder dysfunction, frozen shoulder can be classified as mild, moderate and severe. The goal of treatment for frozen shoulder is to loosen adhesions, remove pain, and ultimately restore shoulder function. For mild patients, the treatment should focus on functional exercises; while for moderate and severe patients, joint adhesion release should be performed. For moderate patients, local anesthesia can be used to reduce the pain during the release operation, while for severe patients, brachial plexus anesthesia or intravenous general anesthesia should be used to relax the muscles when performing manual release in order to increase the efficacy and reduce the complications during the release.