Lecture on anatomy on the topic “Muscles of the upper and lower extremities”

The arm muscles consist of the muscles of the shoulder (upper arm), forearm and hand. The shoulder is formed by one bone - the humerus, and the forearm by two - the radius (located on the side of the thumb) and the ulna (located on the side of the little finger). The elbow joint is a trochlear joint and connects the humerus, radius and ulna. It allows flexion and extension of the arm, as well as rotation of the forearm. In addition, thanks to the muscles of the forearm, we can rotate the hand. The wrist joint is located between the forearm and hand.

SHOULDER MUSCLES

The shoulder of muscular people has the appearance of a roll, flattened on the sides. The musculature of the shoulder consists of muscles located parallel to the vertical axis of the shoulder. On the front surface of the shoulder are strong forearm flexors. The skin in this area is thin, so the outlines of the muscles are clearly visible, especially when the biceps muscle contracts, which then takes on the shape of a hemisphere. It is widely believed that the larger and more convex this hemisphere, the stronger the person.

BICEPS

The biceps, or biceps brachii muscle, consists of two heads. The long head begins from the supraglenoid tubercle, and the short one from the coracoid process of the scapula. Both heads are located along the humerus. Just below the elbow they are attached to the inside of the radius. The main function of the biceps is to flex the arm at the elbow joint, as well as participate in supination of the forearm, when the palm facing down turns up. The relief of the biceps is best seen when the forearm is flexed when it is in a supinated position.

In addition to the biceps, two more muscles are responsible for bending the arm at the elbow - the brachialis and brachioradialis.

BRACHIAL MUSCLE

The brachialis muscle is located under the biceps. It can only be seen under the inner edge of the biceps. The outer edge is visible only at the insertion of the deltoid muscle in the area of ​​the lower half of the humerus. The development of the brachialis muscle also affects the steep outline of the biceps muscle. The brachialis muscle starts from the lower half of the anterior surface of the humerus and attaches to the tuberosity of the ulna. Thus, the brachialis muscle raises the ulna, participating only in flexion of the forearm.

BRAIRADIAL MUSCLE

The brachioradialis muscle starts from the humerus, runs along the entire forearm and is attached to the radius in the area of ​​the wrist joint. The main function of the brachioradialis muscle is to flex the arm at the elbow joint. When flexing the forearm, especially if this movement occurs while overcoming any resistance, the brachioradialis muscle clearly protrudes in the form of a sharp ridge in the area of ​​the cubital fossa.

TRICEPS

On the back of the shoulder, the triceps brachii muscle stands out - Triceps or triceps brachii muscle. As the name of the muscle itself indicates, it has three heads. The long head starts from the subarticular tubercle of the scapula, the medial (inner) and lateral (lateral) heads start from the humerus. All three heads converge into one tendon, which attaches to the olecranon process of the ulna. All three heads of the triceps cover the elbow joint, and its long head also covers the shoulder joint. The main function of the triceps is to extend the arm at the elbow joint. The muscle is visible when trying to straighten the arm at the elbow joint, performed with resistance: then the outer and long heads in the upper half of the shoulder become noticeable, which form a characteristic fork.

Muscle Definition

Muscle

(lat.
muskulus
) - an organ of the human and animal body formed by muscle tissue.
Muscle tissue has a complex structure: myocyte cells and the membrane covering them, the endomysium, form separate muscle bundles, which, when joined together, form the muscle itself, dressed for protection in a cloak of connective tissue or fascia
.

Muscles of the human body

can be divided into:

• skeletal
  ,
• smooth
  ,
• cardiac
  .

As the name suggests, the skeletal type of muscle is attached to the bones of the skeleton. The second name is striated (

due to transverse striations), which is visible under microscopy. This group includes the muscles of the head, limbs and torso.
Their movements are voluntary, i.e. a person can control them. This group of human muscles
ensures movement in space; it is they that can be developed or “pumped up” with the help of training.

Smooth muscle is part of the internal organs - the intestines, bladder, vascular walls, and heart. Thanks to its contraction, blood pressure increases during stress or the food bolus moves through the gastrointestinal tract.

Cardiac - characteristic only of the heart, ensures continuous blood circulation in the body.

It is interesting to know that the first muscle contraction occurs already in the fourth week of the embryo’s life - this is the first heartbeat. From this moment until the death of a person, the heart does not stop for a minute. The only cause of cardiac arrest during life is open heart surgery, but then the CPB (heart-lung machine) works for this important organ.

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Skeleton of the upper and lower limbs

The upper limbs are represented by the hands. Human hands are characterized by high mobility; with their help, he carries out various labor operations and manipulates objects.

The lower limbs are represented by the legs. They can withstand heavy loads and completely take over the function of movement. They are characterized by massiveness, large and stable joints.

This means that the main functions of the limbs

–
support, movement of the body in space
and
support of labor activity.
The upper and lower limbs are attached to the spine using the bones of the limb girdles: the upper shoulder girdle

and
lower extremity belts.
The structure of the skeleton of the upper limb. It is represented by the upper shoulder girdle and the free upper limb.

Skeleton of the upper limb belt

consists of
two shoulder blades
and
two clavicles
.
The scapula
is a flat, paired, triangular bone. The shoulder blades lie freely among the spinal muscles. They provide the connection between the humerus and the collarbone. If necessary, they, together with the collarbones, participate in the movement of the arms.

Collarbone

– a small paired bone with a curved es-shape. It connects the scapula to the sternum.

Thanks to it, the hand connects to the body. The collarbone sets the shoulder joint some distance from the chest and provides the arm with freedom of movement. Thanks to the long collarbones, the position of the shoulder blades, a flat and wide chest and a large number of muscles, a person’s arm acquires greater mobility. It is characterized by high precision of movements, allowing, for example, a circus performer to juggle several objects at once, and a watchmaker to assemble miniature watches from parts barely visible to the eye.

The upper limb consists of three parts

:
shoulder, forearm
and
hand
.
The skeleton of the free upper limb
is represented by the humerus, two bones of the forearm - the radius and ulna (it is located on the side of the little finger) and the bones of the hand.

Skeleton of the hand

consists of
eight
carpal bones arranged in two rows,
five metacarpal bones
and
phalanges of the fingers
, including
fourteen bones
. The thumb consists of two phalanges, and all the rest - of three.

If a person's palm is directed upward, the radius and ulna bones run parallel to each other; if the palm is directed downward, then the radius crosses the ulna.

The head of the humerus forms the shoulder joint

.
Also, the lower part of the humerus forms the elbow joint
with the radius and ulna.
The bones of the forearm and hand form the wrist joint
.

The bones of the wrist and metacarpus form a wide palm

.
A person has a grasping limb
- the thumb is opposed to the other four. This allows you to hold various objects, such as an apple.

The skeleton of the lower limb is represented by the lower limb girdle and the free lower limb.

The skeleton of the lower limb girdle is represented by two pelvic bones, which are connected to each other motionlessly and form the pelvis

.

In newborn babies, the pelvic bone is formed by three bones (ischium, pubis and ilium), which are connected by cartilage. With age, cartilage is replaced by bone tissue and the bones grow together. The human pelvis is wide and bowl-shaped. This is explained by the fact that in mammals the internal organs rest on the walls of the abdomen, and in humans, due to upright posture, on the pelvic bones. Women have a wider pelvis than men.

Skeleton of the free lower limb

consists of
the femur
(thigh),
two leg bones
(tibia and fibula), and
foot bones
.
The skeleton of the foot
is represented
by seven tarsal bones
,
five metatarsal bones
and
phalanges of the fingers
, including fourteen bones. The largest bones of the tarsus are the talus and calcaneus. The talus has a calcaneal tubercle, which serves as a support when standing.

Femur

– the longest tubular bone of the human skeleton.
It is connected to the pelvic bone by the hip joint,
and with the tibia it forms
the knee joint
, which includes the patella.

The bones of the lower leg connect to the bones of the foot and form the ankle joint

.

The bones of the foot form curves, or arches. They allow you to distribute the weight falling on the foot, reduce shocks and jolts, and give a smooth and springy gait.

Lesson summary. The skeleton of the upper limb consists of the shoulder girdle, which includes paired clavicles and scapulae, and the free upper limb. The skeleton of the lower limb is represented by the lower limb girdle, consisting of two fixedly connected pelvic bones, and the free lower limb.

The structure of human muscles

The unit of structure of muscle tissue is the muscle fiber. Even a single muscle fiber can contract, indicating that a muscle fiber is not only a single cell, but also a functioning physiological unit capable of performing a specific action.

An individual muscle cell is covered by a sarcolemma.

– a strong elastic membrane provided by the proteins
collagen
and
elastin
. The elasticity of the sarcolemma allows the muscle fiber to stretch, and some people show miracles of flexibility - doing the splits and performing other tricks.

In the sarcolemma, like twigs in a broom, threads of myofibrils

, composed of individual sarcomeres. Thick myosin filaments and thin actin filaments form a multinucleated cell, and the diameter of the muscle fiber is not a strictly fixed value and can vary over a fairly wide range from 10 to 100 microns. Actin, which is part of the myocyte, is an integral part of the cytoskeleton structure and has the ability to contract. Actin consists of 375 amino acid residues, which makes up about 15% of the myocyte. The remaining 65% of muscle protein is myosin. Two polypeptide chains of 2000 amino acids form the myosin molecule. When actin and myosin interact, a protein complex is formed - actomyosin.

Description of human muscles

difficult, and for a visual representation you can refer to the textbook “Grade 8 Biology” edited by V.I. Sivoglazov, where on page 117 the illustration shows what a myocyte looks like under a microscope.

Name of human muscles

When anatomists in the Middle Ages began to dig up corpses on dark nights to study the structure of the human body, the question arose about the names of the muscles. After all, it was necessary to explain to the onlookers who had gathered in the anatomical theater what the scientist was currently cutting with a sharply sharpened knife.

Scientists have decided to name them either by the bones to which they are attached (for example, the sternocleidomastoid muscle), or by their appearance (for example, the latissimus dorsi or trapezius), or by the function they perform (extensor digitorum longus). Some muscles have historical names. For example, tailoring

so named because it drove the sewing machine pedal. By the way, this muscle is the longest in the human body.

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Muscle classification

There is no single classification, and muscles are classified according to various criteria.

By location:

• heads
  ; in turn are divided into:
• – facial expressions
• – chewable
• neck
• torso
• belly
• limbs

By fiber direction:

• straight
• transverse
• circular
• oblique
• unipinnate
• bipinnate
• multipinnate
• semitendinosus
• semimembranosus

Muscles are attached to bones, extending over joints to produce movement. Depending on the number of joints through which the muscle is thrown:

• single-joint
• two-joint
• multi-joint

By type of movement performed:

• flexion-extension
• abduction, adduction
• supination, pronation ( supination
  - outward rotation,
  pronation
  - inward rotation)
• compression, relaxation
• raising, lowering
• straightening

To ensure body movement and movement from place to place, muscles work harmoniously and in groups. Moreover, according to their work they are divided into:

• agonists - take on the main load when performing a certain action (for example, biceps when bending the arm at the elbow)
• antagonists - work in different directions (the triceps muscle, involved in extending the limb at the elbow joint, will be an antagonist to the triceps); agonists and antagonists, depending on the action we want to perform, can change places
• synergists - assistants in performing actions, or stabilizers

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Causes and treatment of shoulder pain

A.I. ISAIKIN

¹,
A.A.
CHERNENKO ² ¹
Department of Nervous Diseases, Faculty of Medicine, First Moscow State Medical University named after.
THEM. Sechenov, ²
Clinic of Nervous Diseases named after. AND I. Kozhevnikov Clinical Hospital No. 3 of the First Moscow State Medical University named after. THEM. Sechenov The article discusses the most common causes of pain and movement disorders in the shoulder joint.
The pathogenesis and clinical features of various diseases of the periarticular apparatus of the shoulder joint are described. Modern approaches to the treatment of periarticular pathology of the glenohumeral region are presented. The prevalence of shoulder pain in the population, according to various estimates, ranges from 7 to 26%. According to a Scandinavian study, shoulder pain is one of the most common causes of disability in the population, accounting for 18% of paid sick leave [22]. The most common cause of shoulder pain is shoulder periarthritis. Various terms are used in the literature to define this condition (humeral periarthrosis, brachial periarthropathy, frozen shoulder syndrome, subacromial impingement syndrome, etc.), which partly explains the wide range of statistical data given by different authors. Scapulohumeral periarthritis is characterized by pain in the area of ​​the periarticular tissues of the shoulder joint with limited range of motion in it. Periarthritis refers to a group of diseases of the periarticular apparatus of the shoulder joint, different in etiology and clinical picture [1]. One of the pioneers in the study of periarticular pathology of the glenohumeral region, Codman, who coined the term “frozen shoulder” in 1934, described it as a condition as follows: “difficult to define, difficult to treat and difficult to explain in pathological terms.”

Anatomy and pathogenesis

The shoulder girdle consists of 3 bones: the scapula, the clavicle and the humerus. The shoulder joint is spherical, multiaxial, synovial. Its basis is the glenoid cavity of the scapula and the head of the humerus (“ball in the pocket”). In this case, the surface of the head of the humerus is three times larger than the surface of the glenoid cavity of the scapula. There are no intra-articular ligaments in the shoulder joint. The capsule of the shoulder joint is thin, has a deep lower fold and 2 openings, one of which contains the tendon of the long head of the biceps, the second - the subscapularis muscle. From above, the shoulder joint is protected by a vault formed by the coracoid process of the scapula, the acromion and the coracoacromial ligament. The flat synovial acromioclavicular joint strengthens the shoulder girdle. The subacromial bursa, which is normally in a collapsed state, facilitates the smooth sliding of the greater tubercle of the humerus along the lower surface of the acromion process when the arm is abducted. Movements in the shoulder joint are carried out around three axes: sagittal - abduction and adduction of the arm, frontal - flexion (i.e. raising the arm forward) and extension, and vertical - rotation of the shoulder together with the forearm and hand inward and outward. In addition, circular rotation is possible in the shoulder joint. Abduction of the shoulder above the horizontal level is inhibited by the abutment of the greater tubercle of the humerus into the coracoacromial ligament. Joint stability is mainly determined by the rotator cuff muscles: supraspinatus, infraspinatus, teres minor and subscapularis. A number of authors separately highlight the long rotator cuff, which is formed by muscles such as the deltoid, teres major, latissimus dorsi, etc. Thus, the shoulder joint is, on the one hand, the most mobile, and, on the other, the least protected large joint of the body, which determines the risk of increased vulnerability of this joint [1].

The reasons for the development of periarticular lesions of the shoulder joint are varied and not completely clear. Risk factors may include direct and indirect trauma, chronic microtrauma to the structures of the shoulder joint. Often the disease occurs after dynamic or static physical activity aimed at compressing or stretching a joint associated with professional activities or sports. The role of congenital anomalies in the structure of the joint and the ligamentous-muscular system, such as an imbalance of the rotator cuff muscles and a violation of the alignment of the head of the humerus in the joint, is discussed. In the pathogenesis, both degenerative-dystrophic processes and inflammatory, metabolic, neurotrophic processes and immune mechanisms that have not yet been fully studied are important. A connection has been noted between damage to internal organs and periarticular pathology. Humeral periarthritis often occurs after a stroke (on the side of hemiparesis), myocardial infarction, damage to the lungs and pleura, gallbladder pathology and other diseases of the internal organs. Research over the last decade has shown the importance of psychological, social and environmental factors in the development and maintenance of shoulder pain [1, 22].

The influence of vertebrogenic pathology of the cervical spine on the development of glenohumeral pain syndrome is widely debated, but there is no clear data on this issue. With glenohumeral periarthritis, functional blocks are often detected at the middle cervical level. Reflex tension of the muscles involved in the formation of the rotator cuff can contribute to the occurrence of pain and dysfunction of the shoulder; compression of the autonomic fibers innervating the shoulder joint during disc-radicular conflict can also hypothetically lead to impaired articular trophism. Other causes of pain and movement disorders in the shoulder joint may be various types of lesions of the brachial plexus and individual neurovascular bundles (in case of tunnel syndromes), as well as neoplastic processes [1, 3].

In ICD-10 (International Classification of Diseases, 10th revision, 1995) there is no diagnosis of “periarthritis of the shoulder joint”; all periarticular lesions of the shoulder joint area are presented in the form of separate nosological forms, mainly corresponding to the classification proposed by T. Thornhill, 1989:

1. Tendinitis of the rotator cuff muscles (indicating the specific muscle). 2. Tendinitis of the biceps brachii muscle. 3. Calcific tendonitis. 4. Rupture (partial or complete) of the tendons of the muscles of the shoulder joint. 5. Adhesive capsulitis.

In our opinion, it is more reasonable in everyday clinical practice to distinguish periarticular lesions into pathology of the rotator cuff (the first 4 points of the classification) and damage to the capsule itself (point 5). It is important to make such a distinction at the onset of the disease, since long-term pathology of the rotator cuff leads to changes in the capsule, and, conversely, with adhesive capsulitis, the periarticular muscles and tendons are involved in the process.

Pathology of the rotator cuff

It is considered the most common cause of pain and movement disorders in the shoulder joint. Men over 40 years of age are more often affected, and the dominant hand is usually involved in the process [2, 16].

In recent years, the term proposed in 1972 is often used. Neer - shoulder impingement syndrome, or shoulder rotator compression syndrome, supraspinal syndrome (M75.1 - ICD-10: impingement syndrome or subacromial impingement syndrome). This is practically synonymous with rotator cuff pathology, associated with damage to the tendons and muscles as a result of chronic microtrauma or acute injury, mainly under the coracoacromial arch. The most vulnerable point of the rotator cuff is the supraspinatus tendon, because it is located directly under the acromion process of the scapula. Often, as a result of age-related or post-traumatic changes, sharpening of the acromion process occurs with the deposition of calcium salts in the form of osteophyte spines on the lower surface facing the rotator cuff, leading to tendon trauma. The shape of the acromion process matters. Bigliani identified three types of acromion: type 1 acromion has a flat shape, type 2 is more curved, lies parallel to the head of the humerus, and type 3 has a pointed hook, which creates an increased risk of injury. In addition, chronic inflammatory arthritic processes, tendon calcification, etc. play a role in the development of this syndrome [9, 16].

Electromyography of the trapezius muscle in patients with rotator cuff pathology does not reveal significant changes [5].

Neer identified three stages of the process:

Stage 1 – acute inflammation, swelling (and possible hemorrhage) of the rotator cuff tendon, usually occurs in patients under 25 years of age and regresses with adequate conservative therapy; Stage 2 – formed at the age of 25–45 years, the thickened tendon creates conditions conducive to friction; irreversible phenomena of tendinitis and fibrosis develop in it; Stage 3 – usually develops after 40 years. The key factor is mechanical destruction of the rotator cuff tendons. At this stage, there is a decrease in the subacromial space and the presence of osteophytes of the coracoacromial arch [9, 16].

Pathology of the rotator cuff is characterized by diffuse dull pain in the upper outer part of the shoulder (in the area of ​​the deltoid muscle, under the acromion, near the tubercle of the humerus, sometimes radiating to the elbow). Pain, as a rule, occurs after significant or unusual physical activity and intensifies when raising the arm up. Many patients report that pain prevents them from falling asleep, especially when lying on the side of the affected joint. In later stages, the pain intensifies and restriction of movement in the joint may occur. Sometimes there is a clicking sound in the joint when lowering the arm. Characterized by selective limitation of mobility in the affected muscle, while maintaining (in the early stages) the range of passive movements.

For differential diagnosis of lesions in various parts, a number of tests are traditionally used. A Cochrane review (2013) did not identify the most appropriate test for diagnosing rotator cuff syndrome due to variability in performance and interpretation across studies [10]. At the same time, a positive painful arc test (Dowborn) and an external rotation resistance test are considered the most informative [12].

The Dowborn test can detect damage to the supraspinatus tendon, subacromial bursa and acromiocleidoclavicular joint; with arcuate abduction and raising the arm up through the side in the frontal plane, pain occurs in the affected structures, which are pinched between the acromion and the greater tubercle of the humerus. The occurrence of pain when the arm is abducted by 60–120° indicates damage to the supraspinatus tendon and/or subacromial bursa; the appearance of pain when the arm is raised upward at 160–180° indicates a pathology of the acromiocleidoclavicular joint.

Damage to the supraspinatus muscle and its tendon is characterized by pain in the middle sector of the upper arc of the shoulder joint, as well as pain when resisting active abduction of the shoulder, but pendulum-like movements of the shoulder back and forth are not accompanied by pain.

With subacromial bursitis, patients complain of pain when abducting and flexing the shoulder, while lying on the affected side. Basic everyday activities are difficult - dressing, combing your hair, taking care of your face, etc.; pain may spread down the arm; Sometimes patients can remember overexertion preceding the onset of symptoms, but more often no obvious cause can be identified. The range of motion in the shoulder joint can be severely limited due to pain. Palpation of the anterolateral surface of the joint reveals pain of varying severity.

Lesions of the infraspinatus and teres minor muscles are characterized by increased pain in the upper part of the shoulder when testing resistance to active external rotation of the shoulder. The patient bends the arm at the elbow joint by 90°, the doctor presses the patient’s elbow to the body with one hand, fixes the forearm with the other hand and asks the patient to abduct the shoulder (external rotation), resisting this movement; The “household equivalent” of the test is combing the head.

Damage to the subscapularis muscle is characterized by pain during resistance testing of active internal rotation. The test is performed with the patient's arm in the same position as during the test described above, only in this case pain occurs during internal rotation of the shoulder (against the background of resistance from the doctor to this movement). The “everyday equivalent” of the test is taking objects out of the back pocket of your trousers, as well as trying to put your hand behind your back, accompanied by pain.

Of great importance in diagnosing the affected muscle is the reproduction of a typical pattern of pain when palpating the site of projection of the damaged tendons: the patient is asked to put his hand on the opposite shoulder; the doctor, under the protruding area of ​​the acromion towards the greater tubercle, sequentially palpates the tendons of the supraspinatus, infraspinatus, and teres minor muscles; then the patient places his hand behind his back, and the doctor palpates the subscapularis tendon under the anterior part of the acromion process towards the lesser tubercle of the humerus [1].

With tendinitis of the tendon of the long head of the biceps muscle (biceps), pain occurs in the upper anterior parts of the shoulder after (or against the background of) physical exertion associated with overstrain of the biceps muscle. On palpation, pain in the intertubercular groove is determined; Abduction and rotation of the shoulder are usually not impaired. To identify damage to the biceps tendon, an active supination resistance test of the hand is performed. The position of the patient's arm is the same as when examining the rotator cuff (the shoulder is pressed to the body); the doctor clasps the patient’s hand with both hands and asks him to perform active supination of the hand, and he himself resists this movement; when the long head of the biceps brachii muscle is damaged, pain occurs.

A rupture of the tendon of the long head of the biceps brachii muscle is characterized by sharp pain, sometimes a crunching sound at the time of injury, for example, at the moment of lifting a heavy object or sudden forced extension of the arm bent at the elbow joint (in older people, an asymptomatic “debut” of the injury is possible); the strength of the hand to flex the forearm decreases; active tension of the biceps brachii muscle is moderately painful, a decrease in muscle tone and retraction of its upper part are detected, the belly of the muscle bulges under the skin of the lower third of the shoulder; flexion and supination of the forearm are weakened; the study must be carried out by comparison with a healthy limb.

Weakness and difficulty lifting your arm up may indicate a tear in the rotator cuff tendons (usually a complication of a shoulder dislocation). Most often, the tendons of all three muscles are damaged simultaneously, but isolated ruptures of the tendons of the supraspinatus muscle or only the infraspinatus and teres minor are also possible; In the early stages, diagnosis is complicated by the clinical symptoms of shoulder dislocation and subsequent immobilization with a plaster cast. Typically, patients come after long-term rehabilitation treatment, which often does not bring any effect. Patients complain of dysfunction of the shoulder joint, pain, fatigue and discomfort in it; On palpation, pain is noted in the area of ​​the greater tubercle. Movement disorders are characteristic: shoulder abduction fails; when trying to perform this movement, the arm is actively abducted from the body by 20–30°, and then pulled up along with the shoulder girdle (Leclerc’s symptom); the range of passive movements is full, but if you abduct the shoulder and do not hold it, the arm falls (symptom of a falling arm); in addition, with passive abduction of the shoulder, a symptom of a painful obstacle appears at the moment the shoulder passes the horizontal level, which occurs due to a decrease in the subacromial space.

Among additional research methods, radiography of the shoulder joints is traditionally used, primarily to exclude serious lesions, fractures, dislocations, tumor lesions, hemorrhage in the joint, etc. Ultrasound scanning seems to be a justified and cost-effective tool for assessing the pathology of the rotator cuff. In difficult cases, magnetic resonance imaging of the joint is performed [16].

You should also briefly consider the clinical signs of involvement of the acromioclavicular joint in the pathological process: in this case, there is a limitation due to pain in maximum abduction of the arm (more than 90°). Pain on palpation at the projection point of the acromioclavicular joint confirms the diagnosis; The Dowborn test discussed above is effective and widely used in diagnostics.

Adhesive (retractile) capsulitis

This is a chronic fibrous inflammation of the shoulder joint capsule. The prevalence of adhesive capsulitis (AC) in the population is 2–5% [7, 26], among patients with diabetes mellitus – 11–36% [27]. It often develops in women after 45 years of age, without a clear connection with professional and physical activity. The localization of the lesion is unilateral, rarely – bilateral. According to the American Society of Shoulder and Elbow Surgeons, adhesive capsulitis is “a condition of unknown etiology characterized by significant limitation of active and passive movements, in the absence of known internal lesions of the shoulder joint.” Sometimes AK develops against the background of diabetes mellitus, thyroid dysfunction, heart and lung diseases, stroke, parkinsonism, autoimmune diseases, retroviral therapy with protease inhibitors.

AC is divided into primary and secondary. Primary AK is characterized by a gradual painful limitation of the range of active and passive movements, against the background of fibrous inflammation of the joint capsule, in the absence of obvious provoking moments. Secondary AK occurs against the background of processes that cause limited mobility of the shoulder joint, such as calcium tendinopathy (CT), pathology of the rotator cuff, arthritis, trauma or surgery on the shoulder, which is important for the choice of differentiated treatment [6].

The diagnosis of AK is made based on clinical findings. Typically a gradual onset with increasing pain and limited mobility in the shoulder joint. The pain is aching, constant, worsens when lying on the affected side, morning stiffness is characteristic. The pain intensifies with external rotation, abduction of the arm, or placing it behind the back. The shoulder on the affected side is raised, sometimes there is diffuse swelling around the joint, it seems that all the muscles of the shoulder girdle are shortening, and then atrophy of the muscles of the shoulder girdle and their increased fatigue are observed. An important sign that allows us to judge the involvement of the joint capsule in the pathological process is the ratio of the volume of active and passive movements; when the capsule is damaged, both are limited to an equal extent (while the excess of the range of passive movements over active ones indicates damage to the tendons of the rotator cuff or biceps brachii muscle). When bending forward, the range of motion in the shoulder joint does not increase. Abduction of the arm is not carried out in the shoulder joint, but due to the scapular-costal joint - when attempting to abduct the arm by less than 60°, rotation of the scapula begins [2, 3, 24].

The course of adhesive capsulitis is characterized by a certain stage [12, 19]:

• Stage 1 lasts about 3 months, there is pain and a decrease in the amplitude of active and passive movements. Morphologically, diffuse hypervascular synovitis is determined at this stage. • Stage 2 (“freezing”) lasts 3–9 months. There is a sharp restriction of joint mobility, and pain may persist at rest. Arthroscopy and biopsy reveal hypertrophic synovitis, with the formation of scarring and fibrosis of the capsule. • Stage 3 lasts from the 9th to the 15th month. Restriction of movements prevails over the pain syndrome, which is noted when attempting forced movement. Morphologically, fibrous changes in the synovial membrane, dense collagen tissue with a thin layer of hypertrophied and hypervascularized synovial membrane are detected. • At the 4th stage (15–24 months), there is a regression of pain and a gradual restoration of range of motion.

The diagnosis of AK is usually made clinically. Additional diagnostic methods are used mainly to exclude other pathologies of the shoulder joint. X-ray examination of the shoulder with AK does not show any pathological changes, sometimes signs of osteoporosis are revealed. X-ray can exclude other serious causes of shoulder pain accompanied by severe limitation of mobility, such as: calcific tendonitis, arthritis, trauma, aseptic necrosis of the humeral head, etc. MRI is auxiliary in the diagnosis of AK; it can show thickening of the coracobrachial ligament and joint capsule, obliteration of the axillary recess, reduction of fat under the coracoid process [24].

A prospective study found that at 10 years, only 39% of patients had complete recovery, 54% had clinical signs without functional limitations, and 7% were disabled [21]. Another study showed that 50% of patients had pain and stiffness an average of seven years after disease onset [23].

Treatment

Conservative treatment of rotator cuff syndrome is effective in 70–90% of cases. It is recommended to limit the load on the joint in the acute period, with gradual rehabilitation, the prescription of non-steroidal anti-inflammatory drugs (NSAIDs), the administration of steroid drugs and local anesthetics, various types and methods of physical therapy, including post-isometric relaxation and manual therapy [9]. Therapeutic treatment can take from several weeks to several months and, if the disease is not advanced, then, as a rule, such therapy gives a good clinical result [16, 28].

There is no data on the superiority of various surgical treatment options over conservative therapy [25]. Surgical (arthroscopic) intervention is indicated in cases of complete rupture of the rotator cuff or failure of conservative therapy within 6 months. In young patients, especially with traumatic origin of AK, surgery may be recommended at an earlier date [16].

NSAIDs are effective for AK, as shown in a systematic review [30]. It is currently believed that NSAIDs are most indicated in the early, inflammatory stages of the disease [13, 19]. Both selective cyclooxygenase (COX-2) inhibitors and non-selective drugs can be used. Among the selective COX-2 inhibitors for various joint and muscle pain, nimesulide has proven itself well. Nimesulide is a drug from the NSAID group, the structure of which contains a sulfonylide group. It has a pronounced anti-inflammatory, as well as analgesic and, to a lesser extent, antipyretic effect. The mechanism of action is associated with inhibition of prostaglandin synthesis in the area of ​​inflammation to a greater extent than in the gastric mucosa or kidneys, which is due primarily to inhibition of COX-2. In addition, in the mechanism of the anti-inflammatory action of nimesulide, its ability to suppress the formation of free oxygen radicals (without affecting hemostasis and phagocytosis) and inhibit the release of the enzyme myeloperoxidase is important. The drug quickly penetrates into the synovial fluid of the joint, providing a pronounced anti-inflammatory effect in joint pathology, and has a low risk of gastrointestinal complications. The relative risk of severe liver damage is within the benefit/risk ratio recommended in Europe and is comparable to the risk with other NSAIDs [17]. Experience with the use of nimesulide in more than 50 countries has shown that the use of the drug allows one to achieve good control over joint pain, acute and chronic, and, unlike coxibs, the drug does not increase the risk of cardiac complications [20].

Dexalgin (dexketoprofen) is a non-selective NSAID. The mechanism of action is associated with inhibition of prostaglandin synthesis at the level of COX-1 and COX-2. Available in both injection and tablet form. Dexalgin injections are used during periods of acute pain. In the future, it is recommended to transfer the patient to taking the drug in tablet form. When combined with the opioid analgesics dexketoprofen, trometamol significantly (up to 30–45%) reduces the need for opioids. The results of a post-marketing cohort study demonstrated compliance of the safety profile of oral dexketoprofen with the safety criteria of the EMEA (European Medicines Agency) and confirmed the validity of the conclusion to include dexketoprofen in the group of first-line drugs for the treatment of acute (including musculoskeletal) pain [4].

Oral corticosteroids provide a quick but short-lasting effect. The method of choice is intra- or periarticular administration of glucocorticoids, especially in combination with physiotherapeutic measures. There is evidence of the positive effect of intra-articular administration of glucuronic acid preparations. Exercises in the pain range and mobilization (stretching) of the joint turned out to be highly effective. At the same time, other physiotherapeutic measures (massage, phonophoresis, electrophoresis, ultrasound) did not show significant effectiveness. Arthrographic distension by injecting saline or glucocorticoid solutions into the joint cavity to break adhesions has been discussed, but no convincing evidence has yet been presented. When conservative therapy is ineffective, joint mobilization under anesthesia is widely used [8, 14, 15]. At the same time, there is evidence of complications of this manipulation in the form of fractures, ruptures of ligaments and joint capsule, and hemarthrosis. The worst results of joint mobilization and relapses of AK were observed in patients with diabetes mellitus and post-traumatic AK [15, 29]. If conservative therapy is ineffective, surgical intervention on the joint through an arthroscope or open method is also used to dissect pathological adhesions in the joint [6, 24]. Own 20 years of experience in the pain department of the Clinic for Nervous Diseases named after. AND I. Kozhevnikova shows that for glenohumeral periarthritis, the most effective is complex therapy, including the use of medications (NSAIDs, periarticular administration of glucocorticoids and local anesthetics) and non-drug methods - joint mobilization, post-isometric relaxation, active gymnastics.

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