Shoulder arthritis: diagnosis and medical treatment
The diagnosis of shoulder arthritis is mainly based on clinical palpation of local pain at the respective sites of tendons such as the long head of the biceps tendon, the point of attachment of the supraspinatus tendon.
Shoulder arthritis is a soft tissue disease around the shoulder joint including tendons, muscles, ligaments, joint capsule, ... characterized by pain and reduced mobility. The cause of the disease is the prolonged process of degeneration, trauma, and micro-injury, due to the direct pressure of the bone spurs on the ligaments, tendons, and muscles when performing joint movements. The shoulder joint has a complex structure, the most common injuries are the supraspinatus tendon, the long bundle of the biceps tendon, and the rotator cuff system. Shoulder arthritis is quite common in the group of low-income workers, athletes, middle-aged and elderly people, greatly affecting the quality of life. Treatment of the disease is relatively persistent, requiring a combination of medical, physical therapy, and lifestyle changes. Shoulder arthritis can be in other systemic diseases such as rheumatoid arthritis, diabetes, lung tumor, ...
The diagnosis is mainly based on:
Clinical pressure and localized pain at the respective positions of the tendon such as the long head of the biceps tendon.
The point of attachment of the supraspinatus tendon.
The subspinous tendon,...
A combination of subclinical tests, which are mainly soft ultrasounds around the shoulder joint.
Some tests to detect damaged tendons
Palm-up test (Figure 1): detecting damage to the long head of the biceps tendon: the patient supine the hand 90°, the hand rotates externally, gradually raising the arm upward to resist the examiner's holding force. Patients with pain when there is damage to the biceps tendon, in case there is a rupture of the biceps tendon so that the arm is along the body, the arm is folded perpendicular to the arm, and there will be a lump in the arm muscle area.
Jobe's test (Figure 2) detects supraspinatus muscle injury: patient flexes arm 90°, thumb downward, arm forward 30° and lowers, the patient has pain when there is tendon injury.
The Pattes test (Figure 3) detects damage to the subspinous and small round muscles: elbow flexes to the arm at 90°, the arm is in a 90° abduction, lowering the forearm and turning inward is painful.
The Neer's test (Figure 4) detects lesions in the subacromial region: the examiner stands behind the patient, holding the shoulder with one hand, while the other hand gradually raises the ipsilateral arm, which will exert pressure on the apex of the shoulder. , the patient has pain in the affected area.
The Gerber test (Figure 5), evaluates muscle damage below the shoulder. Bring the patient's hand back, the back of the hand is in contact with the back, gradually separate the patient's hand from the back (maximum inward rotation), if the muscle is damaged below the shoulder, this movement cannot be done.
The Hawkins test (Figure 6) detects an injury to the corasacral ligament: raise the patient's arm to 90° and perform an internal rotation by lowering the forearm and extending it, the patient has pain in the subacromial region. shoulder.
Yocum test (Figure 7): Place palm on the apex of the contralateral shoulder and gradually raise the elbow while still immobilizing the shoulder being tested, the patient will experience pain if there is stenosis of the subarachnoid space on the side. do testing.
Examination for periarthritis of the shoulder joint
Diagnosis of disease
Simple shoulder pain (subacute form): the most common (90%), mainly involving the supraspinatus tendon or long bundle of the biceps tendon. Painful local tenderness, positive Palm-up or Jobe test, ultrasound damage to biceps tendon or rotator cuff tendon.
Acute shoulder pain is a clinical manifestation of microcrystalline bursitis, with calcifications of the capsular tendons of the rotator cuff and these calcifications moving into the subarachnoid serosa-delta muscle causing local pain.
Manifestations of acute swelling and pain at the apex of the shoulder, ultrasound has fluid in the space below the deltoid muscle, the aspirated fluid is clear lemon yellow (not pus).
Pseudo-paralysis of the shoulder joint due to partial or complete rupture of the rotator cuff tendon, the biceps tendon often appears after a sudden and strong movement, causing the patient to feel a sharp pain in the front of the shoulder joint, then not raise the main hand can be active while raising the hand passively can still do it. A completely severed tendon will contract in a lump in the upper third of the arm. Ultrasonography detects partial or total tendon rupture.
Frozen shoulder is caused by thickening and contracture of the shoulder capsule. The movements of the shoulder joint are limited but painless. The contrast shoulder arthrogram showed the reduced volume of the joint cavity.
Shoulder joint ultrasound
Observe the front: biceps and subscapular tendons, fluid in or out of the joint.
Observe the upper side: supraspinatus tendon and crow's ligament - the same shoulder.
Observation of the back: subspinous tendon.
Pictures and tests
X-ray of the shoulder joint is usually normal, but sometimes calcification of the tendons is detected, accompanied by osteoarthritis, ...
Contrast shoulder arthroplasty to detect periarthritis of the shoulder with capsule frozen with atrophy and thickening of the capsule.
Magnetic resonance imaging of the shoulder joint shows images of the entire joint and periarticular soft tissue, helping to accurately assess the location, size, and status of tendon and joint capsule damage, especially in the case of partial tendon rupture, meniscus tear. . The indication for magnetic resonance imaging should not be abused, which is indicated only when it cannot be diagnosed by clinical and ultrasound when periarthritis of the shoulder is suspected due to another cause in the combination of rheumatoid arthritis. one joint.
Peripheral blood cell tests, erythrocyte sedimentation rate, c-reactive protein (CRP), RF rheumatoid factor, glucose, for differential diagnosis.
Acute shoulder pain with hot swelling of the shoulder joint needs to be distinguished from true arthritis due to infection; Arthritis in systemic disease...
Shoulder paraplegia should distinguish muscle diseases such as muscular dystrophy, muscle atrophy after injection of some drugs, limb paralysis due to neurological causes, ...
The frozen shoulder on X-ray has a demineralized arm bone image, it is necessary to distinguish bone pathologies such as fractures of the bones that make up the shoulder joint after trauma or pathological fractures, bone hypoplasia, ...
Types of shoulder periarthritis with local pain need to be distinguished from neurological diseases such as nerve damage due to cervical spine causes, chest medical diseases that also cause pain at the shoulder joint.
There are 3 levels according to WHO
Usually only the first step: acetaminophen - Efferalgan 500mg 2-6 tablets/day or step 2: acetaminophen combined with codeine: Efferalgan codeine 2-6 tablets/day.
Non-steroidal anti-inflammatory drug treatment
Choose one of the following drugs (note absolutely do not combine drugs in the group because they do not increase the treatment effect but have many side effects):
Diclofenac (Voltaren) 50mg x 2 tablets/day divided into 2 or 75mg x 1 tablet/day after a full meal. 75mg/day intramuscular injection can be used for the first 2-3 days when the patient is in great pain, then switch to oral.
Meloxicam (Mobic) tablet 7.5mg x 2 tablets/day after eating or as an intramuscular injection 15mg/day x 2-3 days if the patient has a lot of pain, then switch to oral route.
Piroxicam (Felden) 20mg tablet or tube, take 1 tablet per day after a meal or inject 1 ampoule per day intramuscularly in the first 2-3 days when the patient has a lot of pain, then switch to oral.
Celecoxib (Celebrex) tablets 200mg dose 1 to 2 tablets / day after a full meal. Should not be used in patients with a history of cardiovascular disease and with greater caution in the elderly.
Topical drugs: Voltaren emugel, Profenid gel,...
If there are no undesirable effects, anti-inflammatory and analgesic drugs are used until the patient stops swelling and pain.
There is no indication for systemic use, should only be used topically by injection. This therapy can only be performed at a facility that has received basic training in joint injection techniques. The aim is to deliver corticosteroids to the damaged tendon and tendon sheath in conditions that must ensure absolute sterility. The dose for injection of tendon attachment points around the shoulder joint is 0.5ml at one injection site, no more than 3 injections per year for one site. Some of the commonly used drugs today are:
Hydrocortisone acetate 125mg/5ml vial is a suspension drug with good solubility, rapid action, and a short half-life. Each injection should not exceed 3 times for a site, each time 3 days apart.
Depo-Medrol (methylprednisolone acetate) vial 40mg/1 ml, suspension form with weak solubility, long-acting. Only one injection is given in each batch.
Diprospan (1ml vial) is a complex consisting of:
Betamethasone natri phosphate (2mg betamethasone) và Betamethasone dipropionate (5mg betamethasone).
Only one injection is given in each batch.
Muscle relaxants: choose one of the following:
Mydocalm 50mg, 150mg orally 150-450mg/day.
Myonal 50mg x 3 tablets/day.
Mydocalm deep intramuscular injection 100mg x 2 times/day.
Tricyclic antidepressants: amitriptyline 25mg x 1 tablet/day for 5-7 days.
The period without heat swelling can apply heat therapy: infrared, short wave, ultrasound, candle bundle, ...
Local pain relief with massage, acupressure, acupuncture, ...
Exercise: In the period of acute inflammation with severe swelling and pain, it is necessary to limit the movement of the injured tendon for a short time, then practice rehabilitation exercises to preserve the mobility of the shoulder joint.
Treat according to the cause
Good management of patients with diabetes, rheumatoid arthritis, ...
The tendon sheath should be injected with corticosteroids under ultrasound guidance to achieve a better therapeutic effect.
Inject the shoulder capsule with corticosteroids under the luminosity in the frozen shoulder.
Shoulder arthroscopy is both for accurate diagnosis of injury, and for treatment such as rotator cuff suture, marginal cartilage suture, expansion of the subacromial space of the shoulder to treat subacromial compression syndrome, and arthroscopy. remove calcium crystals, ...
Shoulder joint surgery when there is a shoulder sub-dislocation, connecting broken tendons in pseudo-paralysis, ...
Educating patients about working postures of daily living; When there is damage to the shoulder joint, avoid movements or sports where you have to hold a racket, hold a javelin, ..., the injuries are very mild, but if repeated, they also cause aseptic inflammation. again.
Good management and treatment of medical diseases such as diabetes, rheumatoid arthritis, coronary heart disease, lung disease, a cerebrovascular accident...