Treatment of the supraspinatus muscle of the shoulder at the clinic of Dr. Glazkov in Moscow

The infraspinatus muscle is one of four muscles that make up the rotator cuff (the group of muscles and tendons that provide support to the shoulder). The infraspinatus muscle is almost triangular in shape and is the largest of the rotator cuff muscles and is located in the scapula behind the shoulder. The muscle originates on the shoulder blade, covers the shoulder blade and attaches to the humerus. The main function of the infraspinatus muscle is to externally rotate the shoulder. Damage to the infraspinatus muscle can occur due to overuse or repetitive muscle movements (of the rotator cuff muscles, the infraspinatus muscle, along with the supraspinatus muscle, are the most commonly injured muscles). Playing sports such as baseball, tennis, or swimming that involve intense rotation of the arms can cause injury to the infraspinatus muscle. Activities such as driving or working on a computer without shoulder support can also cause injury to the infraspinatus muscle. Damage or inflammation of the muscle tendons may occur. In some patients, this may be due to impingement syndrome, which occurs when muscle tendons that pass through a narrow space of bone (subacromial) become pinched. Muscle pain syndromes and impaired motor function may be associated with the presence of trigger points in the infraspinatus muscle. Due to the fact that trigger points are inhibitory in nature, there is a decrease in the tone and activity of the shoulder muscles, which leads to a deterioration in stability and motor functionality. The infraspinatus muscle is quite often the culprit of shoulder problems. For normal functioning, any muscle must periodically contract and relax. Without this, movement is impossible. The problem is how often and how well these muscle contractions occur. When muscles have trigger points, they become essentially tight (stiff), similar to a rope that has knots in it, causing it to shorten to its original length. The presence of a trigger point and subsequent tightening of the muscle ultimately leads to decreased range of motion. Trigger points also have a negative impact on the joints, causing them to lose normal mobility. At its core, the body attempts to compensate for abnormal movement, resulting in other areas of stiffness and restricted movement. For example, the desire to stretch is compensatory, which sometimes temporarily relieves discomfort and improves muscle elasticity. But sometimes stretching causes an increase in symptoms.

Muscles in the body do not work in isolation and are connected to each other, and when the body compensatory shifts the load to other muscle groups, due to the presence of problems in one of them, then over time this compensatory mechanism begins to be exhausted, and problems appear in those muscles , which were involved for compensation. In addition, unloading a muscle with problems ultimately leads to the wasting of this muscle and an even greater decrease in its functionality.

When the functionality of the infraspinatus muscle is impaired, stability and range of motion decrease. When the infraspinatus muscle begins to lose tone, the shoulder will then begin to internally rotate.

Further, a cascade of dysfunctional movement disorders arises. The shoulder moves forward and pulls up the chest, and the scapula rotates outward, causing the mid-back muscles to contract. Fatigue accumulates in the muscles, which leads to the drift of the humerus in the socket, resulting in anterior compression on the head of the humerus. As the acromioclavicular mechanics of the shoulder joint is disrupted, the trapezius muscles tighten and lift the shoulder upward. These compensatingly tense muscles can develop their own hidden and satellite trigger points.

Carpal tunnel syndrome

Tunnel syndrome
With long-term existence of rotator cuff tunnel syndrome, degeneration of the supraspinatus muscle occurs. Subsequently, its tendon is damaged. To prevent pathological changes, decompression of muscle tissue is required.

Symptoms of this condition:

chronic pain;
violation of active movements in the shoulder joint.

X-rays and MRI show an increased size of the acromial end of the clavicle and a degenerative change in the supraspinatus muscle of the shoulder. Treatment for this disease is only surgical. It should be performed as early as possible to avoid significant damage to the tendon.

Prevention

Prevention of impingement syndrome of the shoulder joint and supraspinatus muscle syndrome consists of proper ergonomics of the workplace, full physical activity and, most importantly, maintenance and care of your body. Most people perceive the concept of “body care” only in the context of hygiene. But, for some reason, “car care” is always perceived correctly – both cleanliness and maintenance. In general, our body, like a car, also needs maintenance. And here there is no need to be mistaken about fitness and sports - this is not maintenance, but other modes of operation. They make physical activity complete, as mentioned above, but do not at all replace “technical” care from a doctor. The ideal type of prevention of impingement syndrome and supraspinatus syndrome is gentle manual therapy. It is radically different from conventional manual therapy in its gentleness and effectiveness. It includes a large number of soft types of therapeutic and preventive effects aimed at the spine, muscles and joints. As a preventive measure, it is enough to conduct one session every six months to prevent not only impingement syndrome, but also many other pathologies of the spine, muscles and joints.

In conclusion, I would like to say, no matter how things are, even in advanced cases of impingement syndrome and the need for its surgical treatment, there is no need to despair. The prospects for treatment and recovery are very good. The main thing is not to give up and act.

Stages

At stage 1 (compression stage) of rotator cuff injury, the patient experiences pain when trying to perform full movements in the shoulder joint. The glenohumeral rhythm is maintained. At rest there is no pain or it is mild. There is no pronounced hypotrophy in the supraspinatus fossa of the scapula.

At this stage there are still no significant destructive changes in the supraspinatus muscle. However, X-rays already show pathological changes in the distal end of the clavicle and the acromial clavicular joint. On MRI you can see compression of the supraspinatus muscle in the canal, its funnel-shaped deformation.

At stage 2 (degeneration stage), the strength of the supraspinatus muscle decreases. As a result, there is no adequate stabilization of the humeral head. Dysfunction of the initial stage of arm abduction is noted. The head of the humerus moves upward. Main complaints from the patient:

Symptoms of supraspinatus tendinitis

Next, we will look at the characteristic signs of the disease depending on the stages of the inflammatory process in the area of the tendon of the shoulder joint.

Stage 1. This stage of pathology is characterized by the following manifestations:

Painful sensations of slight intensity that disappear after rest;
They occur mainly during the period of physical activity, mainly during rotation of the joint, as well as lifting and stretching the upper limb forward;
The appearance of mild pain when lifting a limb upward, as well as when putting on and taking off clothes;
Discomfort during night sleep: when throwing a limb over the head or prolonged pressure on it;
The shoulder joint does not lose its usual mobility.

Stage 2. Characterized by the following features:

Painful sensations become more intense, which limits the natural motor process;
The person loses the ability to fully lift the upper limb or extend it in front of him;
The pain syndrome makes itself felt exclusively during physical activity and disappears during the period of rest;
Discomfort occurs when squeezing the hand, lifting small objects, or shaking hands;
The appearance of an uncharacteristic crunching sound during physical activity.

Stage 3. Has the following symptoms:

In severe form, pain syndrome manifests itself both during physical activity and during rest;
The duration of the attack reaches 6-8 hours;
Pain sensations can radiate not only to the shoulder joint area, but also to the elbow area;
Significant limitation of joint mobility.

Shoulder head

inability to fully perform active abduction movements in the shoulder;
pain at rest, worsening with exercise.

Objectively, there is a violation of the glenohumeral ri). MRI reveals signs of hypotrophy of the supraspinatus muscle. It is compressed by the distal portion of the clavicle. With prolonged untreated syndrome, degenerative processes in the surrounding soft tissues progress.

At stage 3 (anatomical damage stage), pseudoparalysis of the shoulder joint syndrome occurs. Active movements are possible, but they are insignificant in amplitude and are provided mainly by the scapula. External rotation of the shoulder becomes impossible with minimal resistance. Deforming arthrosis of the acromial clavicular joint often develops.

Fresh damage

Treatment results are best for a rupture of the supraspinatus muscle of the shoulder that has occurred recently. In this case, the operation of choice is subacromial decompression of the joint. The disease is accompanied by chronic pain syndrome, which is associated with inflammation of the supraspinatus muscle of the shoulder. Treatment can be carried out arthroscopically. This is a minimally invasive operation with a short recovery period and low surgical risks.

Arthroscopic subacromial decompression is performed with the patient lying on the healthy side. The doctor examines the cartilage of the articular surfaces, assesses the condition of the biceps tendon, synovium, and rotator cuff muscles. If degenerative changes are detected, the doctor treats the superficial areas with cutters.

Then the doctor performs an inspection of the subacromial space and excises the subacromial bursa (joint capsule). The entire coracoacromial ligament is removed. Up to 1 cm of the anterioinferior section of the acromion is removed.

To identify and treat possible tears in muscle tissue and areas of fibrosis, the outer surface of the rotator cuff is examined. The distance from the attachment of the rotator cuff to the greater tubercle of the humerus to the distant edge of the acromion is measured. It should be 3 mm or more. In this case, there will be enough space for the tendon, and movements in the shoulder will become painless.

After surgery, the drains are removed after 12 hours. Shoulder immobilization lasts up to 2 weeks. It is advisable to begin restoration measures already on the second day. First, passive movements are carried out, then active ones. As a rule, as a result of successful decompression, the pain syndrome goes away. Therefore, the normal range of motion in the joint is restored without pain.

In the future, gymnastics is indicated to restore the muscles of the shoulder girdle. Full restoration of shoulder function occurs 2 months after surgery.

Scapulohumeral periarthrosis syndrome. Clinic, diagnosis, treatment

Until now, in wide neurological practice, PLP can be assessed as a neurodystrophic syndrome of manifestations of osteochondrosis of the cervical spine, based only on X-ray data of that section. At the same time, the absence of pain in the “neck-shoulder joint” line and the absence of restrictions in movements in the neck are not assessed.

At the same time, PLP is primarily a change in the tissue structure and functions of the shoulder joint, which leads to limitation of its functions and pain syndrome [10, 15].

The clinical picture of PLP occurs both with local causes and with causes associated with the innervation of the tissues of the shoulder joint, as well as with dysmetabolic factors and other conditions [10, 15]:

1. Neurological causes of PLP are possible only in the presence of a clinical manifestation - reflex cervicobrachialgia, damage to segments, roots, spinal nerves, brachial plexus and its short branches (example - Duchenne-Erb palsy). And also with damage to the pyramidal tract and extrapyramidal disorders.

2. Acute injuries to the bone structures and ligaments of the shoulder joint, injuries to the clavicle and damage to the acromioclavicular joint, post-traumatic instability of the shoulder joint.

3. The most common primary structure involved in PLP syndrome is the rotator cuff (impingement syndrome). The main mechanism of damage is microtraumatization of the distal parts of the rotator cuff (tendonitis) and ruptures: stereotypical, forceful movements in people with physical labor, athletes (working with raised arms), habitual static holding of the shoulder in people in office professions, etc.

4. Arthrosis of the acromioclavicular joint.

5. Subacromial bursitis.

6. Arthrosis and arthritis of the shoulder joint, aseptic necrosis of the head of the humerus.

7. PLP syndrome can occur in people with type 2 diabetes. Its development is associated with a dysmetabolic effect on the peripheral apparatus of the nervous system; in some cases, this syndrome is included in the clinical picture of diabetic proximal neuropathy.

8. In oncological pathology, the development of PLP is directly related to the growth of the tumor in close proximity to the shoulder joint and brachial plexus. These are mainly malignant lung tumors affecting the apex of the lung. This also includes malignant tumors of the bones of the shoulder girdle and tumors of the mammary glands. In such situations, it is important to remember that PLP may be the only clinical manifestation of the underlying disease.

In medical practice, the main cause of the so-called “frozen shoulder” is pathology of the rotator cuff. Below is material about the anatomical features of periarticular tissues, the clinical picture of impingement syndrome, examination methods, manual testing, instrumental diagnostics and therapeutic measures.

Anatomy and physiology of the shoulder joint

The anatomical complex of the shoulder joint consists of the glenohumeral, sternoclavicular and acromioclavicular joints. In addition, this also includes two false joints - the subhumeral and scapulothorax [1, 14].

Movements in the glenohumeral joint are carried out in three planes: abduction-adduction, flexion-extension, rotation. The shoulder joint is formed by the glenoid cavity of the scapula and the head of the humerus, which, due to its large size, is only partially in contact with the glenoid cavity, which ensures the greatest mobility of the shoulder joint in relation to all other joints. Congruence of the articular surfaces is ensured by the labrum (analogous to the meniscus), and the articular surface of the scapula increases by 50%.

The static stability of the shoulder joint is provided by the articular capsule, the upper, middle and lower glenohumeral ligaments, and the coracoacromial ligament.

The deep muscles of the shoulder form the rotator cuff. In addition to motor functions, the rotator cuff prevents the head of the humerus from moving upward during contraction of the powerful superficial muscles of the shoulder girdle (deltoid, back and chest muscles). Thus, the rotator cuff creates dynamic stability of the shoulder joint [1].

Rotator cuff structure:

1. Supraspinatus muscle. It occupies the supraspinatus fossa of the scapula, its tendon passes under the acromion process of the scapula and attaches to the greater tuberosity of the humerus. Some of the fibers are woven into the joint capsule of the shoulder.

Function: abducts the shoulder, retracts the capsule of the shoulder joint, protecting it from infringement. Innervation – suprascapular nerve, CV–CVI.

2. Infraspinatus muscle. Located below the spine of the scapula in the infraspinatus fossa. The tendon attaches to the tubercle of the humerus. Some of the fibers are woven into the shoulder capsule.

Function: rotates the shoulder outward - supinates, abducts the raised arm, retracts the joint capsule of the shoulder. Innervation – suprascapular nerve, CV–CVI.

3. Subscapularis muscle. Occupies the entire anterior, costal surface of the scapula. The tendon attaches to the lesser tubercle of the humerus.

Function: turns the shoulder inward - pronation, brings the arm to the body, retracts the capsule of the shoulder joint. Innervation – subscapular nerve, CV–CVII.

4. Teres minor muscle. Starts from the lateral edge of the scapula. The tendon attaches to the greater tubercle of the humerus.

Function: rotates the shoulder outward - supinates the shoulder, pulls the joint capsule outward. Innervation – axillary nerve, CV.

5. The biceps brachii muscle is not part of the rotator cuff, but in the frozen shoulder clinic, tenosynovitis, subluxations of the long head of the biceps muscle and tears are quite common. The muscle consists of two heads. The short head originates from the coracoid process, the long one from the supraglenoid process of the scapula. The common tendon attaches to the radial tuberosity.

Function: flexion and supination of the forearm at the elbow joint. The long head flexes the arm at the shoulder joint and abducts it. Innervation – musculocutaneous nerve, CV–CVI [14].

Clinical picture of PLP using the example of impingement syndrome

Initial manifestations of PLP

As a rule, patients cannot accurately indicate the factor that provokes the development of the pathological process, and often refer to a cold, physical activity that does not exceed normal, etc. It is characteristic that they do not notice pain along the back of the neck and shoulder girdle, and how at the initial stage and in the advanced stage. Also, most patients cannot remember the day when the first symptoms appeared, explaining that the pain began sometime during the week.

The pain develops gradually, gradually, with localization along the anterolateral surface of the shoulder joint and, less often, along its posterior surface. Initially, pain appears only with a sufficiently large range of motion in the joint: abduction, lifting forward and placing the arm behind the back. During the period of early manifestations of PLP, patients’ seeking medical help is extremely low, since characteristic movements both in everyday life and at work are not used so often, with the exception of workers and athletes. Most patients periodically self-medicate, most often using nonsteroidal anti-inflammatory drugs (NSAIDs), as well as a diverse arsenal of external agents.

Detailed clinical picture of PLP

Over time, patients begin to notice a clear limitation in the range of motion in the shoulder joint, combined with severe, sharp pain. In addition to shooting pain when moving, there is aching pain at rest, which becomes constant. Everyday restrictions on arm mobility arise: it is difficult to raise your arms to grab an object, it is difficult to hold on to the top rail in transport, shoulder abduction and placing your arm behind your back cause discomfort. Soon the severity of such restrictions leads to the impossibility of performing habitual movements.

During sleep, patients sleep on their backs or on their healthy shoulder, because they cannot sleep on the sick one due to pain. A comprehensive clinical picture of PLP is formed within 2–3 months. from the debut of the process. As a rule, it is at this stage of the disease that patients first seek medical help. In rare cases, the patience of patients exceeds all expectations; a person consults a doctor when the abduction of the arm from the body can barely reach 10–15 degrees [12].

History, examination and diagnosis

When collecting anamnesis, it is necessary to pay attention to the connection of PLP with injuries to the bones of the shoulder girdle, microtraumas of the ligamentous apparatus and the presence of pathology of other organs. Today, the annual medical examination process often depends on the wishes of the patient himself, therefore, to facilitate diagnosis, it is sometimes necessary to additionally obtain the results of an examination of the lungs, mammary glands, and blood tests.

Initially, a basic neurological examination is performed, focusing on symptoms of damage to the spinal roots, brachial plexus and its branches. In the presence of pathological changes, PLP must be considered part of the symptom complex of a more severe disease, which requires additional diagnostics. The examination algorithm at the primary neurological appointment is given in Table 1.

Instrumental diagnostics of PLP

The optimal option for assessing the condition of periarticular tissues and bone structures in PLP is ultrasound and MRI [10,15]. Ultrasound of the musculoskeletal system is presented in detail in many translated manuals. The general technical requirement for examining the shoulder joint is a black-and-white scanner (without Doppler effect) with a linear transducer with a frequency of 5–10 MHz.

Scanning is a fairly simple and low-cost research method and allows you to identify both changes in the tissues of the shoulder joint (tendonitis, ruptures of tendons and muscles, bursitis, calcific tendinosis, dystrophic changes in the tendons, defects of the labrum) and bone changes. However, the availability of scanning is limited by the insufficient number of specialists proficient in this research method.

Inspection of the tissues of the shoulder joint and assessment of its movements in impingement syndrome

Palpation of the tissues of the shoulder joint is carried out on both the diseased and healthy sides. With PLP, the joint area is perceived by palpation as somewhat smaller in volume. The turgor of the tissues around the joint is reduced, they feel more dense. At the same time, all these sensations, as well as visual inspection, do not give a clear idea of the atrophy of the periarticular tissues.

During palpation, local pain (trigger points) of the greater and lesser tubercle of the humerus, the intertubercular groove with the tendon of the long head of the biceps, and the acromioclavicular joint passing through it are determined. Palpation of the greater tuberosity in the upper part may reveal tenderness at the insertion of the supraspinatus tendon, and in the posterior part - the insertion of the infraspinatus and teres minor tendons. Palpation of the lesser tubercle allows you to determine the pain at the insertion of the subscapularis tendon.

When examining the anterior surface of the joint space, it is more convenient to carry out the examination when the patient’s arm is placed behind the back. When examining the posterior part of the humeral head, the patient's hand should lie on the opposite shoulder, which allows palpation of the area below the posterior edge of the acromion process.

In order to palpate the subscapularis muscle, it is necessary to place the patient’s forearm behind the back. The back of his palm should be on the lumbar region. In this position of the hand, the lower angle of the scapula moves away from the back of the chest, which allows the doctor's fingers to palpate the area under the scapula. With PLP, moving the forearm behind the back is limited and painful.

Active movements during PLP

Movement assessment is carried out on both the diseased and healthy side. The examination is carried out in a standing or sitting position with arms down, palms supinated. To assess movements of the shoulder joint only, the doctor fixes the shoulder girdle with his palm from top to bottom, fixing the scapula and collarbone [1, 6, 8–9].

Normal range of motion in the shoulder joint:

1. Flexion – raising the arm forward and up – 90°.

2. Extension - moving the arm back - 65°.

3. Abduction – abduction of the arm from the body – 90°.

4. Adduction - placing the hand in front behind the opposite shoulder joint - 50°.

5. External rotation - 60°.

6. Internal rotation - place your hand behind your back and reach the opposite shoulder blade with the back of your hand - 90°.

PLP is characterized by pronounced limitations in abducting the arm from the body, placing the arm behind the back, and raising the arm forward (Table 2).

Passive movements in PLP

To assess passive movements, the doctor fixes the area of the patient’s shoulder girdle with his palm. With the other hand, he takes the patient’s shoulder and performs the same movements as during the test for active movements. During the procedure, the doctor clearly feels a pronounced limitation of movement in the patient’s shoulder joint. It seems that the joint is locked and it is impossible to continue movements without the risk of injury to the patient. Limiting the patient's shoulder abduction is the most typical test for PLP.

Rotator cuff syndrome (impingement syndrome) is a functional painful limitation of mobility in the shoulder joint. In severe cases, restoration of movements is possible only after surgery due to ruptures of the rotator cuff elements.

Diagnostic tests for rotator cuff muscles

Supraspinatus muscle test

Methodology: patient position standing or sitting. Abduction of the arm in internal rotation (first finger facing down) and external rotation (first finger facing up). With impingement syndrome, the patient cannot raise his arm horizontally due to pain. Additionally, the doctor may resist abduction of the arm.

Subscapular test

Methodology: placing your hand behind your back with your forearm bent at the elbow and trying to touch the back of your hand to the opposite shoulder blade. With impingement syndrome, due to pain and weakness, the patient can often raise his arm only to the level of the lower back. If there is a rupture, the patient is unable to perform the test. The hand in a free position is in pronounced external rotation.

Subscapularis muscle tear tests

Methodology: placing your hand behind your back with the back of your hand pressed to your lower back. An attempt to tear the hand from the back against the doctor’s efforts: with a rupture this is impossible, but there is no pain. If this is possible with difficulty and increased pain, we are talking about partial damage to the subscapularis muscle.

Subscapularis tendon rupture test

Methodology: the doctor bends the forearm at the elbow and places the patient’s palm on his abdominal wall. When the tendon ruptures, the palm moves away from the abdominal wall, since it is impossible to hold it in the position of internal rotation.

Infraspinatus muscle test

Methodology: patient position sitting or standing. The arms are located along the body, without touching it, bent at the elbows, the forearm in the middle position between pronation and supination (the first finger looks up). The patient's hands are not connected. The doctor fixes his palms on the back of the patient’s hands. The patient tries to spread (retract) his arms to the sides, overcoming the doctor’s resistance. The syndrome causes pain and weakness.

Teres minor contracture test

Method: the patient stands freely, arms relaxed. With contracture of the teres minor muscle, the hand is additionally rotated inward, and when viewed from behind, the palm is directed backward, as is the case with Duchenne-Erb palsy [1].

using the example of tendinitis of the rotator cuff muscles Treatment of glenohumeral periarthrosis

In most cases, patients with PLP seek specialized medical care when abduction of the arm from the body is possible no more than 30–40 degrees, and the pain syndrome is constant. As a rule, these patients already had experience using NSAIDs of different groups (selective and non-selective, with anti-inflammatory and/or with a pronounced primary analgesic effect), which did not lead to recovery. In such cases, at the first stage it is advisable to use glucocorticoids (GCS).

Application of GCS

The most commonly used are dexamethasone, betamethasone, and hydrocortisone. The latter is administered intramuscularly and intraarticularly. Dexamethasone and betamethasone are used intradermally, subcutaneously, intramuscularly and intraarticularly [12].

In PLP, superficial trigger points correspond to the attachment points of the muscles and their tendon ends to the bones of the shoulder joint. The introduction of GCS into these zones does not present any technical difficulties [16].

The most common area of intense pain is located on the anterior surface of the shoulder joint, which corresponds to the biceps tendon (other areas are listed above). Dexamethasone or betamethasone is injected subcutaneously into this area.

In our opinion, it is enough to have a strong anti-inflammatory drug and anesthetic in the injection for the treatment of PLP. Due to the practical availability of dexamethasone, novocaine and lidocaine, they can be used in the following ratio: 4 mg of dexamethasone, 4–9 ml of 0.25–0.5% novocaine solution in a 5–10 ml syringe. If lidocaine is tolerated, it can replace novocaine. In such cases, the dose of lidocaine is as follows: 2.0 ml of a 2% solution (40 mg).

With this method of administration, the anti-inflammatory and subsequent analgesic effect of dexamethasone appears after a few hours and persists for 1.5–2 days, which is noted by patients as a decrease in pain. Repeated injections are possible every other day. Depending on the severity of movement restriction during PLP, with combined treatment measures, the number of dexono-novocaine injections varies on average from 6 to 10. If there are positive dynamics by the end of the 2nd week of therapy (reduction of pain and increase in range of motion in the shoulder joint), it is advisable to discontinue treatment GCS and switch to NSAID drugs, which have fewer side effects and are therefore safe for long-term use.

NSAIDs

The “gold standard” for the effectiveness of NSAIDs is diclofenac sodium. Its effectiveness has been proven in numerous randomized clinical trials for neurological, rheumatological, arthrological diseases, chronic pain, and urgent conditions. The anti-inflammatory effect of diclofenac is due to inhibition of cyclooxygenase types 1 and 2 (COX-1 and COX-2).

COX-1 ensures the synthesis of prostaglandins (PGs) involved in the secretion of gastric mucus and has bronchodilator properties. The amount of COX-1 increases several times at the site of inflammation, which may be due to the greater analgesic activity of NSAIDs.

COX-2 ensures the synthesis of PGs involved in the inflammatory process and is found only at the site of inflammation. The anti-inflammatory activity of diclofenac is due to the inhibition of COX-2, reducing the amount of PG at the site of inflammation, which leads to suppression of the exudative and proliferative phase. The greatest effectiveness of diclofenac is observed in cases of inflammatory pain, which is important in the treatment of PLP [13].

Diclofenac can be considered the drug of choice for the treatment of acute and chronic pain in patients who do not have serious risk factors for bleeding due to gastric and duodenal ulcers.

With a moderate risk of bleeding, diclofenac should be used in combination with gastroprotectors (omeprazole).

In the complex treatment of PLP, B vitamins are used, vitamin B1 is used for metabolic and neurotrophic effects, and vitamins B6 and B12 (pyridoxine and cyanocobalamin) are used to support the processes of myelination of nerve fibers. Pyridoxine is involved in the synthesis of mediators not only in the peripheral, but also in the central nervous system [5]. B vitamins are adjuvant agents that, when used together with NSAIDs, enhance the analgesic effect, which can reduce the dosage of NSAIDs and the duration of treatment, and therefore reduce the risk of side effects. In addition, B vitamins reduce the manifestations of pain and, as cofactors of metabolic processes, have a beneficial effect on the nervous system.

The vitamins that make up Neurodiclovit are water-soluble, which eliminates the possibility of their accumulation in the body. Thiamine and pyridoxine are absorbed in the upper part of the small intestine, metabolized in the liver and excreted by the kidneys (about 8–10% unchanged). The degree of absorption depends on the dose; in case of overdose, the excretion of thiamine and pyridoxine through the intestines significantly increases. The absorption of cyanocobalamin depends to a large extent on the presence of an internal factor in the body (in the stomach and upper small intestine); further delivery of the vitamin to the tissue is determined by the transport protein transcobalamin. After metabolism in the liver, cyanocobalamin is excreted mainly in bile, the degree of its excretion by the kidneys is variable - from 6 to 30%. The analgesic effects of vitamins B1, B6 and B12 are due to the inhibition of nociceptive impulses; vitamin B6 enhances the effect of antinociceptive neurotransmitters - norepinephrine and serotonin [17–19]. Vitamin B12 also has a pronounced analgesic effect, which makes its use effective for chronic back pain and polyneuropathy.

Representing a combination of complementary pharmacological effects, the drug Neurodiclovit deserves special attention. It contains in 1 modified-release capsule 50 mg of diclofenac sodium, 50 mg of thiamine hydrochloride, 50 mg of pyridoxine hydrochloride and 250 mcg of cyanocobalamin. The drug is prescribed 1-3 capsules per day for 1-2 weeks.

Neurodiclovit is a drug that relieves pain and alleviates the condition of patients with rheumatic and non-rheumatic lesions, inflammation, and neuralgia. The combined use of B vitamins with diclofenac gives a more pronounced analgesic effect. Diclofenac, which is part of the drug, can relieve swelling and stiffness of the joint. It is obvious that such a combination of active ingredients can restore health faster and more fully in various pathologies.

A number of studies have drawn conclusions about a significant early reduction in pain intensity with the use of NSAIDs and B vitamins compared with NSAID monotherapy, which made it possible to reduce the dosage and duration of NSAID use [4, 5]. After just 3 days, the effectiveness of Neurodiclovit was significantly higher than monotherapy with diclofenac sodium. Reducing the dose and duration of NSAID therapy helps reduce the risk of side effects [Kamchatnov P.R., 2012].

Thus, at the second stage of treatment of PLP syndrome, the most adequate and optimal therapy is the prescription of a pharmacological complex: NSAIDs + vitamins B1, B6, B12 (Neurodiclovit).

Manual and physiotherapeutic methods for treating PLP

Manual treatment methods include therapeutic massage and manual therapy mobilization techniques [9].

Therapeutic massage of the collar area and shoulder joint area is carried out according to standard schemes. When performing a massage, the emphasis should be on the tissue of the shoulder joint. The main time should be spent on rubbing and kneading.

Manual therapy mobilization techniques. The effectiveness of mobilizations is due to the fact that these techniques are aimed at directly eliminating the functional limitation of movements in the shoulder joint through repeated, passive movements in it.

All types of mobilizations can be used to treat PLP. The most commonly used mobilization techniques are presented below:

1. Rotational passive movements in the shoulder joint

Initial position of the patient: sitting on a chair or on a table. The doctor is located on the side of the sore side. Having clasped and squeezed the front and back surfaces of the shoulder joint with his palms, the doctor lifts the joint with the shoulder girdle up, after which he forcefully rotates it back with a turn. Having returned to the starting position, the doctor repeats the movement at least 10 times. When performing, it is necessary to achieve maximum rotation of the joint at the moment. During the appointment, the patient should experience moderate pain.

2. Passive abduction of the shoulder with springing of the joint

Initial position of the patient: sitting on a chair. The doctor stands behind the sick side. The doctor’s hand with the first and second fingers apart (fork) on top tightly fixes the area of the acromioclavicular joint. With the other hand, the doctor takes the patient’s shoulder and begins to abduct it until movement is limited. Having reached pretension, the doctor makes small oscillatory movements up and down with the patient’s shoulder, trying to increase the angle of abduction of the arm. The doctor's actions must be careful, because the pain intensity here is higher.

3. Kneading the subscapularis muscle

The execution of the technique depends on the patient’s ability to place his arm behind his back. Starting position: lying on your stomach. The patient's hand and forearm are placed on his buttock area or slightly above. The doctor places his forearm and hand under the patient’s shoulder and slightly rotates his shoulder joint outward.

In this position, the inner edge of the scapula and the lower corner move away from the back surface of the body, allowing the doctor’s other hand to penetrate under the scapula and carry out massaging circular movements. During the appointment, the patient experiences pain, which should not be excessive to enable the mobilization of the scapula and kneading of the subscapularis muscle to be repeated at least 10 times.

4. Post-isometric relaxation (PIR) techniques for the infraspinatus and partially pectoralis minor muscles

The patient sits on a chair or couch. The doctor sits down behind him. On the painful side, the patient places his hand behind his back, resting the back of his hand on the gluteal region or higher, which depends on the possibility of placing the hand. The position of the hand should not cause intense pain. The doctor fixes the patient’s extended hand with one hand, and the back surface of the elbow joint with the other.

Performing PIR: the patient moves the shoulder back, rotating the shoulder outward. The doctor counters this movement with the hand that fixes the patient’s elbow. The resistance of the patient and the doctor should be equal in strength (static hold) and last from 5 to 10 s. After tension, during a pause of 5–10 s, the doctor slightly moves the patient’s elbow away from himself, after which the counteraction is repeated. This isometric tension is repeated 3–6 times.

Repeated isometric tension during this technique can be carried out by changing the position of the patient’s hand behind the back, by moving the hand to a higher position.

5. PIR on the subscapularis muscle

Initial position of the patient: lying on his back. The doctor sits on a chair on the side of the patient, facing the sore shoulder. The exercises are reminiscent of arm wrestling. The patient's shoulder lies on the couch and is brought to the body, the forearm is bent at the elbow joint at an angle of 90°.

The doctor takes the patient’s hand with his hand and rotates his forearm outward (the patient’s shoulder is supinated) until pain is felt in order to determine the limit of pain. Having returned the forearm back to the border of the pre-pain threshold, the doctor gives the command to the patient to rotate the forearm inward, and he himself puts pressure on the patient’s hand in the other direction. The mechanism of repetition of isometric tension is the same as with PIR on the infraspinatus muscle.

There is a simple and visual way to assess positive dynamics. Before treatment, the patient stands with his back to a free surface (wall, door). The doctor fixes the patient's shoulder girdle with his hand. The patient moves his arm away from his body to the maximum possible level. This place, on top of his brush, is marked with a marker. After 2–3 sessions, the arm abduction assessment is repeated. On average, an increase in arm abduction by 10 cm is considered a good result. The combination of corticosteroids, NSAIDs and mobilization techniques is a fairly effective method of treating PLP and can be performed by one doctor.

Benefits of Arthroscopy

less blood loss;
smaller incisions and better aesthetic effect;
patient recovery takes less time;
less postoperative pain;
the duration of the operation is reduced;
its labor intensity has been reduced.

As a rule, pain caused by compression of the supraspinatus tendon goes away immediately after decompression.

Old partial damage

Long-term partial damage to the tendon of the supraspinatus muscle of the shoulder can lead to a long-term limitation of the range of motion in the shoulder joint and the inability to perform full abduction of the upper limb. Treatment requires surgery.

Partial damage to the rotator cuff results in an increase in the length of the supraspinatus tendon over time. As a result, it becomes functionally inferior. The person cannot actively abduct the shoulder, although the amount of passive movement (performed by the therapist's hands) is usually maintained. The more the tendon is changed, the more pronounced the limitation in abduction of the limb.

If the tendon of the supraspinatus muscle of the shoulder is damaged, treatment is carried out using different methods:

medial movement of the muscle to eliminate functional deficiency;
osteotomy of the greater tuberosity and distal movement until physiological tension of the supraspinatus muscle is created in the state of shoulder abduction;
lower wedge-shaped resection of the acromial process of the scapula, excision of the acromiocoracoid ligament to increase the subacromial space and eliminate pain (the ability to actively abduct the shoulder is not restored).

If a tear of the supraspinatus muscle of the shoulder occurs, treatment should be carried out as early as possible. It will be much more effective if, by the time of the operation, significant degenerative changes in the tissues and lengthening of the tendon have not yet occurred.

Recovery after surgery

complete restoration of function of the shoulder joint;
reduction of periods of incapacity for work;
elimination of pain syndrome;
eliminating muscle spasms;
increasing muscle strength;
eliminating stiffness.

After surgery, external immobilization of the shoulder is indicated. For different surgical interventions, the timing of immobilization is different. They can be from 2 days to 1 month. During this period the following are shown:

isometric muscle tension of the forearm and shoulder;
movements in the elbow and wrist joint.

Exercises are needed primarily to normalize blood circulation in the limb, which ensures full regenerative processes and helps eliminate swelling. Exercises are performed an average of 10 times during the day, 10 repetitions each.

Almost all patients experience impaired active shoulder abduction after removal of the immobilizing bandage. It is due to a number of factors, primarily:

long-term lack of stress on the muscles;
decrease in their tone and contractility;
hypotrophy (decrease in volume) of muscles.

Further rehabilitation procedures are aimed at strengthening the muscles of the shoulder girdle and normalizing the function of the joint. For this purpose, physical therapy and physiotherapy are carried out.

External rotation

Stand with your extended arm away from the door. Attach the end of the expander to the door at waist level, and take the other end of the expander with your developing hand. Bend your elbow 90 degrees and place it on your stomach. Keeping your elbow tucked in, rotate your forearm away from the door—outward. Then slowly return your hand to the starting position. It is important to keep your forearm parallel to the floor. 2 sets of 15 reps.

Is treatment possible without surgery?

It has been established that injuries to the supraspinatus tendon practically do not regenerate. Therefore, most patients require surgical treatment. It is successful in 85% of cases. However, quite often relapses occur, limiting the patient’s ability to work and requiring repeated operations.

If the supraspinatus muscle of the shoulder joint is damaged, treatment can be conservative if we are talking about stage 1 of the pathological process. Functional rest, physical therapy, and physiotherapy are indicated.

Platelet-rich plasma is used to repair the tendon. Platelets secrete several anabolic and trophic factors that promote damage healing. These cells contain growth factors:

Description of the disease

Rotator cuff

– anterior outer part of the capsule of the shoulder joint. It combines the tendons of the supraspinatus, infraspinatus, and teres minor muscles. Despite the difference in the functions they perform, such an anatomically close location of fixation of the muscles allowed traumatologists to identify them in a common group (the rotator cuff).

Damage to the rotator cuff can be considered a rupture of one or a group of tendons that make up its composition. Most often this is caused by injury, dislocation or previous chronic inflammatory process.