”Subacromial impingement is a much more common cause of shoulder pain than frozen shoulder. Subacromial impingement syndrome, also known as shoulder impingement syndrome, is most commonly caused by the soft tissues located between the acromion, rostroscapular ligament, and humeral head, bumping against the acromion and rostroscapular ligament, causing aseptic inflammation of these soft tissues and causing pain, sometimes even impingement. The diseases that make up this syndrome include subacromial impingement, supraspinatus tendinitis, calcific tendinitis of the supraspinatus, tenosynovitis of the long head of the biceps, degenerative rotator cuff tears, and many other pathological changes. Patients with subacromial impingement complain of shoulder pain with limited movement. Physical examination has the following features: for example, subacromial impingement is the result of many disease groups, such as supraspinatus tendonitis, calcification, subacromial bursitis, rotator cuff injury, etc. Biceps longus, problems with each component structure of the rotator cuff, of which the main problem is the biceps.
1. often without obvious fixed pressure pain.
2, mainly manifesting as limited abduction of the shoulder joint, possibly combined with decreased internal rotation mobility of the shoulder.
3, the external rotation mobility of the shoulder joint is mostly normal, which is an important basis for differentiation from frozen shoulder.
4. 60-120 degree painful arc of shoulder abduction, when the acromion and supraspinatus tendon are closest in the subacromial shoulder gap.
5, Positive impingement evoked test (provocative test).
Neer test: The examiner fixes the shoulder joint with one hand, keeps the shoulder joint in internal rotation with the other hand, makes the tip of the thumb face down, and the pain occurs in forward flexion over the top. The mechanism of this test is to artificially cause the posterior and lateral aspects of the greater tuberosity and supraspinatus tendon plexus of the humerus to impinged forward and inward on the “rostral shoulder arch” (the acromion, rostral process, and rostral shoulder ligament make up the rostral shoulder arch).
The occurrence of subacromial impingement syndrome is strongly related to the morphology of the acromion and the structure of the rostro-capital dome. Special lateral x-rays of the acromion show that the morphology of the acromion can be divided into three types: type I: flat; type II: curved; and type III: hooked. The flat shape is less likely to cause subacromial impingement syndrome, the hook-shaped shoulder is the most likely to develop subacromial impingement syndrome, and the curved shoulder is in between. The subacromial gap has an unequal triangle shape, with a narrow anterior gap and a wide posterior gap, while the upper extremity normally moves much more in the anterior than in the posterior, thus the site of impingement where impingement syndrome occurs is mostly in the anterior third of the acromion and the rostro-capital ligament. The hooked shoulder crest narrows the anterior subacromial gap more significantly. Studies have shown that people with hooked shoulders are more than 5 times more likely to develop impingement syndrome than people with flat shoulders. The subacromial joint, also known as the second shoulder joint, is the main mobile joint in the shoulder joint. The acromion, rostrocarpal ligament and part of the rostral process form the rostrocarpal dome, below which is the humeral head, and between them is the subacromial space, through which the rotator cuff and the long head of the biceps tendon pass. The cause of impingement syndrome can be a morphological problem of the acromion or a narrowing of the subacromial space due to subacromial bone growth.
It is also believed that due to excessive shoulder abduction or long-term cumulative injury, the tissues within the gap become worn, and the repeated wear exacerbates the inflammatory response of the tissues, increasing the pressure within the gap and aggravating the impingement, ultimately leading to shoulder impingement syndrome. In conclusion, regardless of the narrowing of the subacromial space or the increase in the content of the subacromial space, as long as there is not enough space in the subacromial space, impingement will occur, resulting in impingement syndrome.
Classification: It can be divided into four major categories according to different sites of onset and pathological changes as follows.
(1) Periprosthetic bursal lesions: These include exudative inflammation, adhesions, occlusion and calcium deposition of the bursa; they can involve the subacromial bursa or the subdeltoid bursa, the bursa on the rostral process surface, etc.
(2) Glenohumeral cavity lesions: “frozen shoulder or secondary adhesive capsulitis” may have fibrinous exudate in the cavity in the early stage, and in the late stage, the cavity may become adherent and have reduced volume.
(3) Degenerative lesions of tendons and tendon sheaths: biceps long head tendinitis and tenosynovitis, supraspinatus tendinitis (painful arc syndrome), calcific tendinitis, rotator cuff rupture and partial rupture, impingement syndrome, etc.
(4) Other peri-shoulder lesions: such as rostral synostosis, shoulder fibrillitis, suprascapular nerve entrapment, acromioclavicular joint lesions, etc.
Mecobalamin (vitamin B12) 1,500 μg; Vitamin E 100mg; Vitamin B1 100mg; Vitamin B6 100mg; Folate 5mg, to drive away lactic acid, the root cause of shoulder pain. Lactic acid, the root cause of shoulder pain, can be taken with vitamins B1, B2 and B12. Lactic acid accumulates in the muscles of the body, such as the shoulders, wrists and neck, which are used centrally when working in the same position for a long time. Lactic acid is the fatigue substance that makes people feel sore, such as it accumulates in the muscles, the muscles will become hard, stiff and in a tight state. And vitamin B1, B2 and niacin can transport lactic acid to the liver for detoxification. In addition, vitamin B12, which promotes the repair of injured peripheral nerves, and vitamin E, which smooths blood flow, are responsible for relieving shoulder acid.
Other therapies: Chinese herbal medicine, proprietary Chinese medicine such as Paralysis Bitter Nai Stop Tablets, Paralysis Long Qing An Tablets, and Wind Pain Capsules, topical medication, and acupuncture. Most of them can be cured by exercising the shoulder joint, but they can also be treated with some sedatives and anti-inflammatory drugs such as anti-inflammatory painkillers, hot compresses and physical therapy. Manual therapy: Have the patient lift the upper limb high above the head, rotate the hand externally and then internally, and then lift it on the coronal surface of the body 10-12 times per hour, and if the symptoms are heavy and there is muscle spasm, pressure point closure therapy.
Surgery: Generally, the principle is not to do surgery, but a few people who have been treated by various non-surgical treatments are ineffective can be considered. The surgical approach is to fix the biceps muscle by suturing it to the rostral process, and if the tendon has been significantly damaged, the tendon can be cut off and fixed distally to the humerus in the biceps tendon groove. It also has to be practiced by the upper limb retractor. The slow pulling and stretching can relax the originally tense or diseased muscles, which can effectively prevent muscle soreness, thus strengthening muscle flexibility, stretching and shoulder joint flexibility, and achieving the purpose of increasing muscle flexibility and restoring function. The exercise of upper limb retractor for normal people will also improve the muscle strength of upper limb and shoulder and the flexibility and elasticity of joints. Upper extremity traction exercises are muscle strength exercises, and attention should be paid to exercise intensity and exercise time. In general, it is better to practice every other day and progressively. The number of exercises per session can be adjusted according to the individual’s age, gender, physical condition and severity of the disease. The upper extremity traction device is beneficial for the recovery of periarthritis, but it is not better to do it every day, nor is it better to do it as many times as possible or for as long as possible.
Laser (ultralaser or semiconductor laser) treatment: Clinical cure is usually achieved within 10 days. The shoulder joint is punctured anteriorly and about 40 ml of cold saline at 4 degrees Celsius is injected to fully expand the shoulder capsule and loosen the adhesions. Hypothermia can reduce local congestion and inflammatory exudation in the joint and decrease the sensitivity of nerve endings to pain. It is especially effective for patients with significant pain at night. The injection can be followed by auxiliary functional exercises and can be cured once for mild symptoms; for more severe cases, the injection can be repeated once a week, usually 2-3 times. More than a hundred patients have confirmed the effectiveness of this method through post-operative visits, and there has been no recurrence of the disease.
Frozen shoulder is an adhesive capsulitis that causes stiffness of the glenohumeral joint. It is characterized by pain around the shoulder joint, reduced active and passive mobility of the shoulder joint in all directions, and no significant abnormalities on imaging except for a decrease in bone mass. It is also known as frozen shoulder.
Incidence: left side is higher than right side, only 8% of the cases are affected bilaterally.
Age of onset: 40-60 years old.
Sex: 72% in women
In recent decades, research on the etiology of frozen shoulder has gone beyond the above local factors (e.g., mechanical factors, inflammatory factors, fibroplastic factors, degenerative factors, etc.) and more and more scholars believe that frozen shoulder is related to extra-shoulder factors and even systemic conditions, such as: nerve injury factors (Li Qihong 1982), local microcirculatory disorders (Shen Zhong’e 1995), autoimmune factors (Macnab 1973), and systemic factors (Macnab 1973). Macnab 1973), systemic metabolic factors (Mckeever 1958), etc. Successive articles have also pointed out the correlation between coronary heart disease, diabetes, pneumonia, cholecystitis, hyperlipidemia and personality and frozen shoulder.
Course: There are 3 features present in the entire pathogenesis of frozen shoulder.
(i) The soft tissues surrounding the joint capsule are eventually invaded.
(ii) The development of lesions is not uniform, not all tissues have equal pathological changes.
③The progression of pathological changes is reversible. By grasping the above pathological changes and the three characteristics, we have a deeper understanding of frozen shoulder, and it is easier to understand the process of changes in the clinical symptoms of frozen shoulder. The entire course of frozen shoulder can be divided into three phases: the beginning phase, the freezing phase, and the thawing phase. The beginning phase is characterized by an uncomfortable and binding sensation in the shoulder joint. The pain may be limited to the anterolateral aspect of the shoulder joint, or may extend to the point of resistance of the deltoid muscle. The shoulder joint gradually becomes stiff and painful. The pain during the freezing phase can be mild or severe, and is characterized by increased pain at night which affects the patient’s sleep. When the shoulder joint moves, it can cause strong pain and muscle spasm, so that the movement of the shoulder joint can be completely restricted, as if the hand is frozen. The pain is very mild during the thawing phase, the shoulder joint starts to relax gradually and the glenohumeral joint gradually regains more movement. some individual patients only partially recover the function of the shoulder joint or are tonic and unable to move. x-ray shoulder examination may show no abnormalities or only osteoporosis of the humeral head. Blood sedimentation, anti-chain “O” and latex tests are negative.
Diagnostic criteria: There is no strict unified diagnostic criteria for frozen shoulder. The recommended criteria are
1.Passive abduction <100° (60%)
2.External rotation <50° (55%)
3.Internal rotation <70° (75%)
4. Anterior elevation <140° (80%)
Alternatively: Progressive shoulder pain with decreased mobility can be diagnosed as frozen shoulder when other etiologies are excluded.
1.Over 40-50 years old, middle-aged and elderly, often with a history of wind-damp cold attack or trauma. It is more common in women and is commonly referred to as the “50th shoulder”.
2. Pain in the shoulder and painful activity, which can be radiated to the hand, but no abnormal sensation.
3. Shoulder joint activity is especially limited by supination, abduction, internal and external rotation.
4. Pressure pain around the shoulder, especially in the long head tendon groove of the biceps.
5.Spasm or atrophy of the muscles around the shoulder.
6.X-ray and laboratory examination usually have no abnormal findings.
Differential diagnosis: A complete shoulder movement is mainly accomplished by four joints, namely the glenohumeral joint, acromioclavicular joint, sternoclavicular joint and scapulothoracic wall joint, while frozen shoulder mainly occurs in the glenohumeral joint.
Frozen shoulder rarely develops twice in one shoulder joint. The age of prevalence of frozen shoulder corresponds to the age at which severe degeneration of the shoulder joint occurs. Weaker individuals, such as those with metabolic diseases, malnutrition, heart disease, and menopausal syndrome, experience more shoulder degeneration than healthy individuals and are therefore more likely to develop the disease. Patients usually have no history of trauma, or have a very minor trauma to the shoulder or upper arm, and gradually the shoulder joint and its surrounding muscles become painful, weak, and impaired in movement. Pain is the most obvious symptom and has a persistent nature. It can be spontaneously aggravated at night and interfere with sleep. The pain can cause persistent muscle spasm, which can be mild or severe. The pain and muscle spasm can be confined to the shoulder joint, but can also radiate upward to the back of the head, downward to the wrist and fingers; some also take the shoulder joint as the axis forward to the chest, backward to the scapula area, and some radiate to the triceps, deltoid or biceps area, at which time it should be carefully examined to distinguish it from cervical spondylosis and heart disease. Differential diagnosis.
1.Trauma: fracture, dislocation, hematoma, etc.
2. Soft tissue lesions: rotator cuff tendinitis, biceps longus tendinitis, subacromial bursitis, impingement syndrome, shoulder-hand syndrome, fibromyelitis, soft tissue tumors, suprascapular nerve entrapment, thoracic outlet syndrome, rheumatic myalgia, etc.
3.Arthrosis: degenerative acromioclavicular arthritis, degenerative shoulder arthritis, inflammatory arthritis, septic arthritis, neurological arthritis (diabetes), crystalline arthritis (gout, pseudogout), hemophilic arthritis, osteochondroma, etc.
4.Bone structural abnormalities: osteonecrosis, metastases, primary tumors, osteochondrosis, Paget’s disease, hyperparathyroidism, etc.
5.Cervical spine lesions: cervical spondylosis, cervical disc herniation, tumor, infection, etc.
6, intrathoracic lesions: upper lung tumors, heart attack, esophagitis, etc.
7, abdominal lesions: peptic ulcer, cholecystitis, subdiaphragmatic abscess, etc.
8.Cardiogenic.
The term “frozen shoulder” or “periarthritis of the shoulder” was first used by Duplay in 1872. He believed that there was a painful stiffness of the shoulder that was caused by the periarthritic tissues of the shoulder, not by the humeral glenoid arthritis. This means that the diagnosis was made only to distinguish it from “humeral glenoid arthritis”. This term has been used as a diagnostic term for over a century and has been largely abandoned internationally, replaced by “frozen shoulder” and other more specific conditions such as rotator cuff injury, calcific supraspinatus tendonitis, biceps longus tendonitis, subacromial bursitis, impingement syndrome, myofasciitis, acromioclavicular arthritis, etc. The principles of treatment for frozen shoulder are based on the different stages of frozen shoulder or the severity of the symptoms. The treatment of frozen shoulder should be mainly conservative. Generally speaking, if the diagnosis is timely and the treatment is appropriate, the course of the disease can be shortened and the motor function can be restored early.
(1) In the early stage of frozen shoulder, i.e. the painful stage, the patient’s pain symptoms are more severe. Therefore, the main purpose of treatment is to relieve pain and prevent joint dysfunction. The pain can be relieved by using a sling brake to give the shoulder joint sufficient rest, or by using closed therapy, injecting prednisolone where the local pressure pain is most obvious, or using physical therapy such as intermittent electric therapy, warm compresses, or cold compresses to relieve pain. Internal anti-inflammatory and analgesic drugs, external application of topical drugs such as antispasmodic and analgesic tincture, in the acute stage, it is generally not advisable to use massage and massage methods too early to prevent the pain symptoms from worsening and prolonging the course of the disease. In general, you can take some active exercises to maintain the mobility of the shoulder joint, and only after the acute period has passed can you use massage to improve blood circulation and promote local inflammation.
(2) During the frozen phase of frozen shoulder, joint dysfunction is the main problem, and pain is often caused by joint movement disorders. The treatment focuses on restoring the joint movement function. The treatment can be physical therapy, Western-style manipulation, massage, medical sports and other measures to release adhesions, expand the range of motion of the shoulder joint and restore the normal joint movement function. For symptoms of dysfunction, patients with severe frozen shoulder can be treated with a large thrust under anesthesia to tear the adhesions if necessary. During this phase, functional exercises of the shoulder joint should be adhered to. In addition to passive exercises, the patient should actively cooperate and carry out functional training of active movements, which is an extremely important part of the whole treatment process.
(3) During the recovery period With the elimination of residual symptoms as the main focus, the main principle is to continue to strengthen functional exercises to enhance muscle strength, restore the muscles of the scapular girdle that have undergone waste atrophy in the earlier stage, and restore the normal elasticity and contraction function of the deltoid and other muscles to achieve comprehensive recovery and prevent recurrence. In addition to taking different treatment measures for different disease processes, treatment measures should also be considered for the severity of the disease. In this regard, foreign opinion suggests that the severity of the disease can be determined and the treatment can be guided by the limitation of movement and end sensation caused by pain in the passive motion test. If the patient’s pain occurs before the end sensation during the passive motion test, the frozen shoulder is often acute and active motion therapy should not be used.