Shoulder tendinitis: features, symptoms and treatment

Tendinitis is a disease that causes inflammation in the tendons and connective tissues. Localized in places where the bone and tendon come into contact. May spread along the muscle tissue. Absolutely all individuals are susceptible to pathology. Most often, shoulder tendonitis occurs in the following places:

• Biceps tendons;
• Shoulder joint capsule;
• Supraspinatus muscle.

Patients complain of limited movement, severe pain of unknown etymology.

Description of the disease

Shoulder tendonitis is a pathological condition associated with inflammatory processes in the shoulder. The tendons and soft structures surrounding the shoulder joint are affected. The disease is widespread. Athletes and people who have previously suffered injuries in the shoulder area are susceptible to it. Sometimes it can manifest itself in young people in adolescence or later.

Inflammation of the shoulder joint – tendonitis – more often affects the female body, which is associated with hormonal changes in the body. Men are characterized by a menopausal form of the disease.

Recently, scientists have begun to devote more time to the spread of the disease. This is due to the impact on the patient’s quality of life, the ability to move, and independently care. If the diagnosis is confirmed, long-term treatment with mandatory rehabilitation is required.

Features of the course of the disease

Pathology begins to appear after damage to the capsule of the shoulder joint, which includes five different muscles. Tendon tissue under the influence of prolonged intense stress leads to exhaustion. If the rights of work and rest are respected, the tissue is capable of independent restoration and active cell regeneration. However, in the absence of a break in physical labor, microcracks of the ligamentous apparatus occur, where the inflammatory process gradually develops.

The first signs appear at the site of attachment of the ligaments to the bone tissue, then spread to healthy tissue. In severe cases of tendinitis of the shoulder joint, code according to ICD 10, adhesions occur, and with prolonged intensive work, the tendon ruptures and finally thins. As a result, the muscle capsule ruptures.

Shoulder tendonitis develops in three stages, namely:

• Stage 1 – there is swelling and damage to the bursa and tendon;
• Stage 2 – connective tissue grows with the appearance of scars. Inflammation actively spreads along the bursa and tendon;
• Stage 3 – the patient experiences tendon ruptures and pathological changes in bone matter.

It is impossible to restore the shoulder joint after complete destruction. Pathology leads to loss of ability to work and disability.

Reasons for formation

The shoulder joint consists of the glenoid cavity of the scapula and the head of the humerus. The spherical head is only partially directed into the cavity. It is held in place by tendons and ligaments that make up the rotator cuff. The cuff consists of the tendons of the teres minor, infraspinatus, supraspinatus, and subscapularis muscles. Intense physical activity and injury often cause damage to the rotator cuff and ligaments.

Inflammation forms in the supraspinatus tendon and gradually spreads to healthy tissues: muscles, joint capsule, subacromial bursa. Next comes degeneration and thinning of the tendons. Micro-fractures occur.

Also, one of the main causes of pathology is improper treatment after operations and injuries, the presence of cervical osteochondrosis at any stage.

Other causes that can cause shoulder tendinitis include:

• Infections, especially sexually transmitted diseases;
• Injuries in the area of ​​tendon weaving;
• Diseases that cause metabolic disorders.

At-risk groups

Certain categories of people are more likely to get tendonitis. The following population groups are affected by the disease:

• Persons who regularly perform work with increased load on the shoulder girdle;
• Athletes: tennis players, swimmers, weightlifters;
• Loaders;
• Gardeners;
• Women during menopause, after hormonal changes;
• Men aged 50-60 years

In the older age group, tendinitis of the shoulder joint ICD 10 occurs due to loss of elasticity of the tendons. Regular excessive loads on the shoulder can provoke pathology. No break during intensive work with active work with hands, shoulder movements, frequent lifting of weights. Athletes are susceptible to tendonitis without long-term rehabilitation due to injury. The disease is also provoked by:

• Infections such as gonorrhea;
• Early history of joint diseases;
• Diabetes;
• Allergy to potent drugs;
• Problems with the functioning of the thyroid gland;
• Congenital pathologies and genetic predisposition.

Reasons for the development of pathology

Symptoms of tendinitis identified by an orthopedist during an examination of the patient may indicate the causes of inflammation in the tendon. Often tissue microtraumas result from a high level of human motor activity. The pathology is common among professional tennis players, golfers, javelin throwers and skiers. The monotonous movements typical of gardeners, carpenters or painters often cause inflammation of the tendons.

A quarter of clinically diagnosed cases of tendonitis develop under the influence of other factors: rheumatic pathologies or diseases of the thyroid gland. Inflammation of the tendons can be a consequence of gonorrhea, intoxication of the body or abnormalities of the bone skeleton (different lengths of limbs, etc.).

Symptoms

Patients consult a doctor complaining of severe shoulder pain. Discomfort occurs with certain movements: when reaching out and raising an arm, lifting a light or heavy object. In the case of throwing movements, the pain intensifies and has an acute form. Often patients indicate discomfort at night, for example, when turning towards the affected area during sleep.

As the disease actively spreads, the pain becomes intense and manifests itself even with light movements without the active participation of the shoulder joint. For example, during a handshake, trying to take a small object.

Gradually, stiffness in movement and limited joint mobility appear. Depending on the form of tendinitis of the shoulder joint, the symptom is defined as a crunch.

In the later stages, the patient regularly experiences regular pain, even at rest. Irradiation is observed along the anterior and outer surface of the shoulder. On palpation, pain occurs in the area of ​​the intertubercular groove, the anterior edge of the acromion. Movements are constrained.

Shoulder tendonitis symptoms and treatment are as follows:

1. Localized pain. However, unlike osteochondrosis, it manifests itself when performing certain movements. It can be aching, dull, sharp, depending on the stage of its progression;
2. On palpation, the pain and inflammatory reaction intensify due to the penetration of bacteria. The density of tendon tissue decreases, which is determined by the thickening of the joint capsule;
3. The affected area has swelling with redness of the skin;
4. The presence of purulent masses in severe forms of the disease;
5. Stiffness of movements.

You can suspect problems with the shoulder joint by the presence of a characteristic creaking sound in the shoulder. Gradually, the patient cannot lift even a small load. The arm does not rise above 90 degrees and does not go behind the back. Depending on the form of the disease, symptoms may vary.

Calcific tendonitis of the shoulder joint

Calcific tendinitis of the shoulder is a condition in which calcium deposits in the tendons of the rotator cuff muscles. The muscles along with the tendons of the rotator cuff are responsible for movement in the shoulder joint. With the disease, there is a deposition of calcium salts in the thickness of the tendons of the rotator cuff. The process may be accompanied by severe pain due to the inflammatory process. This form of tendonitis affects people over 40 years of age.

The disease most often affects middle-aged women 30-60 years old. In the process of calcium deposition, pressure on the tendon increases, which causes chemical irritation and inflammation. Pain syndrome also develops in the shoulder joint. The pain gradually increases as the disease worsens.

Sometimes calcific tendinitis is painless. Together with chemical irritation, causing intratendinous pressure, narrowing of the subacromial space, causing pinching of the tendon and disruption of its functions. As a result of such processes, the patient is practically unable to raise his arm.

This form of tendonitis can be identified by the following signs:

1. Pain when moving the arm, especially with vigorous activity in the upper and outer part of the shoulder, may radiate to the forearm;
2. Limited mobility;
3. Frequent night pain due to uncomfortable sleeping position.

There are two types of calcific tendinitis: degenerative and reactive. The first type is typical for older people. This is due to decreased blood flow to the rotator cuff tendons. As a result, the strength of the tendon decreases and fibers rupture during loading. To keep the tendon intact, the body tries to heal the affected parts with scar tissue, which is done by depositing calcium salts.

The exact cause of reactive tendinitis has not been established. This type is divided into three stages. During the first, recalcification, conditions for salt deposition are formed. during the second period, the process of deposition of calcium salt crystals on the tendons begins. Deposition can sharply intensify or slow down. At the last stage of the disease, the tendons are completely exposed to pathology and are replaced by scar tissue.

As soon as the tendons heal, the pain decreases and gradually subsides.

Preventive measures

If you want to eliminate the possibility of tendonitis, you should perform sports exercises only after warming up the tendons and muscles and stretching. In another situation, the occurrence of microcracks and foci of inflammation is an inevitable process.

Also, to prevent the development of the disease, you should adhere to the following recommendations:

• Avoid monotonous shoulder movements;
• Monitor any disruptions in the metabolic system and hormonal imbalances;
• Perform physical therapy exercises regularly if you have already been diagnosed with foci of inflammation in the shoulder joint;
• Take a course of treatment for osteochondrosis;
• Eliminate the possibility of hypothermia;
• Maintain a balanced diet.

Representatives of professional sports activities should periodically visit a specialist in order to undergo the necessary examinations.

Tendinitis of the supraspinatus muscle of the shoulder joint

Tendonitis of the supraspinatus muscle of the shoulder joint ICD 10 is formed in the tendons of the muscles of the shoulder joint, then affects the supraspinatus muscle fibers. Lack of proper treatment leads to the rapid spread of the disease. Causes of tendonitis of the supraspinatus muscle of the shoulder joint include:

1. Professional sports;
2. Work requiring heavy physical labor;
3. Diseases of the musculoskeletal system;
4. Presence of shoulder dysplasia;
5. Frequent colds;
6. Long-term rehabilitation after suffering fractures of the upper limbs;
7. Endocrine diseases.

With this disease, there is a high risk of further rapid deterioration of the physiological capabilities of the articular complex, the rapid formation of an inflammatory process, and thinning of the tendon. Such pathologies lead to complete degradation of the shoulder joint.

Supraspinatus tendinitis most often develops after injury to the muscle capsule of the acromioclavicular joint, the acromiococlavicular ligament, or the acromion itself. The inflammatory process can be weak, sluggish, asymptomatic, and rapid. Tendinitis of the supraspinatus muscle of the shoulder joint requires long-term treatment with a mandatory long rehabilitation period.

Causes of the disease

Professional sports that require stress on the shoulder joint (tennis, volleyball, basketball, gymnastics, shot throwing and javelin) are the main cause of pathology in young people. Painters, plasterers and masons are also at risk. Contribute to the manifestation of pathology:

• shoulder injuries;
• immobilization for more than 3 weeks;
• bone and joint pathology (arthrosis and osteochondrosis);
• congenital pathology of the shoulder;
• cervical osteochondrosis.

Secondary tendonitis occurs with autoimmune, infectious, parasitic pathologies and endocrine diseases.

Biceps tendonitis

Biceps tendonitis is a type of inflammation that affects the shoulder joint. The disease affects tendons and muscles that connect bones.

This form manifests itself in the form of severe pain and limited hand mobility. If biceps tendonitis is left untreated, a chronic process occurs in which the tendons completely lose functionality. The inflammation primarily affects the upper anterior sections of the shoulder. Actively progresses with physical activity and overexertion. On palpation, pain is felt in the intertubercular groove. The pain can be mild or pronounced. Acute pain occurs at night.

Biceps tendonitis also occurs due to a tear of the rotator cuff. Leads to weakening of the tendon and severe inflammation. Impingement and shoulder instability can cause biceps tendonitis. In the first case, the pathology develops due to pinching of the soft tissue between the head of the humerus and the upper part of the scapula. Such processes occur due to systematic, specific movements.

Shoulder instability occurs due to regular frequent movements of the humeral head, as well as repeated excessive loads, for example, when throwing a ball, swimming. The labrum gradually moves away from the place of attachment to the articular surface and forms a pathology. Such processes also form after dislocation. When the labrum is torn, which causes the head of the humerus to produce sudden excessive movements in the socket. As a result, the tendons are damaged, the injured area becomes inflamed, and tendonitis of the long head of the biceps tendon is formed.

Rotator cuff tendonitis

With tendinitis of the rotator cuff, pain and inflammation develop in the outer upper part of the shoulder joint, which can radiate to the elbow. They arise due to sudden and unusual loads, especially during prolonged work, for example, with arms raised up.

Sometimes the disease affects a specific structure of the rotator cuff. This shape can be determined by pressing the tendon between the head of the humerus and the acromial arch. Pain occurs in the middle of the upper part of the joint. The disease also affects the infraspinatus and teres minor muscles. The patient complains of difficulty raising his arm or doing any work.

Types, stages and forms of shoulder tendonitis

To determine the type of pathology, the localization of the source of inflammation should be taken into account. Most patients are diagnosed with supraspinatus , and treatment in this case should be aimed at strengthening the tendon.

There are also the following types of pathology:

• Tendinitis of the head of the biceps shoulder joint . Localized in the tendon area between the shoulder and biceps muscle;
• Tendinitis of the rotator cuff tendon . Provokes pain and inflammation in the immediate vicinity of the cuff. Usually occurs against the background of increased physical activity.

There is another type of disease - calcific tendinitis of the shoulder joint, which is identified as a separate item, and the treatment of this disease should be selected taking into account its form:

• Reactive. The deposition of calcifications is caused by injury, infections and excessive physical exertion;
• Degenerative. The accumulation of calcium salts is associated with age-related factors and deterioration of blood flow in the joint area.

The above form of the disease is characterized by three stages of development:

1. Precalcification. The conditions for the appearance of calcium deposits are formed under the influence of risk factors.

2. The appearance of calcifications. Calcium crystals enter the tendon fibers and settle.

3. Postcalcification. Characterized by the replacement of tendon tissue with scar fibers.

Moreover, there is chronic tendinitis of the shoulder joint, and its acute form , which necessitates treatment adjustments.

Diagnostics

In the treatment of tendonitis, it is important to timely and correctly diagnose the pathology. To confirm one form or another, a number of tests are prescribed after examining the patient. The disease can be determined through the following examination options:

• Magnetic resonance imaging;
• Ultrasound of the joint;
• X-rays.

To detect metabolic disorders in the body, as well as determine other negative effects, a biochemical blood test is performed. Such tests are carried out at the Yusupov Hospital clinic. After visiting the consultation, the patient can immediately carry out all the necessary tests on site using the new equipment. Quick diagnosis allows you to immediately apply a treatment method and prevent the spread of pathology throughout the body.

Diagnosis of calcific tendonitis

The diagnosis can be made after a detailed clarification of complaints, collection of anamnesis, examination and physical examination, as well as after analysis of signs of calcification identified by radiography. The diagnosis of calcific tendonitis of the shoulder is confirmed by radiological examination in the presence of calcification of the tendons. This sign is not easy to detect. To detect it, photographs of the shoulder joint both in the direct projection with its neutral position, and in external and internal rotation. In the early stage, deposits can be dense and well defined. An MRI scan can also help in making a diagnosis.

Treatment

Treatment for tendonitis of the shoulder joint is provided in the form of a complex effect on the pathology. In therapy, it is important not only the medicinal effect, but also the patient’s desire to recover quickly and understand the essence of the disease. The following treatment methods are used:

1. Drug therapy;
2. Physiotherapy;
3. The use of therapeutic exercises;
4. Visiting massages;
5. Surgical intervention in late stages of diagnosis.

The method of treating shoulder tendonitis is selected individually for each patient, based on his test results. Great care is taken to ensure that the affected shoulder remains at rest. The factors that provoked inflammation must be eliminated.

Drug therapy

The doctor determines how to treat shoulder tendonitis in each specific case. Medicines are prescribed to eliminate swelling, pain, and relieve muscle tension. In the presence of destructive processes, drugs are prescribed to resume metabolic processes. Conventionally, all medications are divided into the following types:

1. Non-steroidal anti-inflammatory drugs. The most effective include Naklofen, Movalis, Ketorol, Indomethacin, Revmoxib, Ortofen. Used orally with great caution due to the large number of side effects;
2. Additionally, compresses with Dimexide are prescribed. The active components of the drugs quickly relieve the first signs of the disease;
3. Analgesics. Prescribed to relieve pain. Paracetamol, Ibuprofen are suitable;
4. Gels and ointments to normalize blood circulation, accelerate tissue restoration, and improve metabolic processes. These include: Voltaren-Emulgel, Deep Relief, Fastum-gel;
5. Steroid hormones are rarely used. This could be Prednisolone, Hydrocortisone. Assigned in neglected forms.

Treatment is carried out strictly under the supervision of the attending physician.

Physiotherapy

An important criterion for how to treat shoulder tendinitis is the use of physical therapy. It has a good positive effect in rehabilitation therapy. The following procedure options are prescribed:

• Electro- and phonophoresis of novocaine;
• UHF therapy;
• Laser treatment;
• Wave therapy;
• Mud and paraffin therapy;
• Magnetotherapy.

The course consists of 7-10 procedures, which must be carried out strictly as prescribed by the doctor. This way you can get a quick and lasting positive result.

Physiotherapy

Physical therapy is required during the recovery period. With its help, it is possible to restore the functions of the joint to its full extent. Therapeutic exercises contribute to the proper functioning of the muscular-ligamentous system. It is carried out under the supervision of a specialist and only during the absence of acute signs of the disease. It is carried out gradually, without sudden movements. Efficiency depends on the patient’s persistence and desire to get results.

Restorative massage

Used to relieve pain. Leads to muscle relaxation and improved metabolic processes. Conducted in 10-15 sessions.

Surgery

Prescribed in cases where conservative therapy has failed or in case of tendon rupture. Basically, arthroscopic surgery is performed with minimal trauma. With its help, the affected areas of tissue are removed, plastic surgery is performed and the tendon is properly fixed. After surgery, rehabilitation treatment is required.

Before the procedure, it is necessary to determine which area of ​​the shoulder joint is affected. Based on the diagnostic results, a form of therapy is prescribed. Calcific tendinitis of the shoulder joint requires surgical treatment.

Prevention methods

To prevent the development of pathology during training, all muscles must be warmed up. The load increases gradually in accordance with the strengths and capabilities of the person. When pain occurs, it is important to immediately respond by reducing activity and ensuring adequate rest.

In professional activities, control over overloads is maintained. Work gives way to rest. At the first sign of injury, be sure to consult a doctor. Otherwise, there is a high risk of complete immobilization of the limb.

Possibilities of ultrasound in monitoring conservative treatment of shoulder tendinitis

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Introduction

Ultrasound diagnosis of pathology of soft tissues and the musculoskeletal system is gradually becoming a routine examination in clinical practice. Ultrasound is a reliable, non-invasive and inexpensive method of examination compared to arthroscopy, magnetic resonance and computed tomography. This method allows you to examine the tendons of muscles, nerves and joints in several projections during clinical motor tests [2, 3, 6, 8].

In clinical practice, quite often there are patients with pain syndrome and complaints of limitation and/or impossibility of movements in the shoulder joint. This can be caused by: pathology of the shoulder joint itself, damage to the tendons of the muscles surrounding the joint; pathology in the acromioclavicular joint; diffuse damage to the joint capsule; damage to peripheral nerves; complex involvement of structures located under the acromion; changes in the cervical and thoracic spine.

Tendon pathology is one of the most common indications for ultrasound of the musculoskeletal system [4, 7]. In this case, it is possible to diagnose inflammatory changes in the tendons (acute tendonitis or tenosynovitis and chronic tendinitis), tendinopathies (degenerative changes, calcific tendonitis), damage (partial and complete ruptures) of the tendons. Tendon changes are associated with an increase in the glycoprotein matrix, with the proliferation of tenocytes and fibroblasts with the formation of disorganized collagen fibers. These processes lead to changes in the characteristics described by ultrasound - thickness, structure, echogenicity and vascularization of the tendons.

In our work, we tried to monitor the treatment of shoulder tendinitis using ultrasound.

Materials and methods

We examined 65 patients (age from 31 to 55 years, average age - 42.5±6.2 years) with complaints of pain in one shoulder joint and restrictions of movement. The average duration of pain and limitation of movement was 3.2±1.8 months (from 1.5 to 9.2 months).

According to the anamnesis, clinical examination, and functional movement tests, the possibility of traumatic injury was excluded. All patients underwent ultrasound using devices equipped with color and power Doppler mapping modes, three-dimensional angiography before, after 2 and 4 months of treatment. The tendons (thickness, structure and echogenicity) of the rotator cuff of the affected shoulder joint were assessed in gray scale mode and these characteristics were compared with the contralateral asymptomatic shoulder joint. The tendons assessed included: the supraspinatus tendon, the long head of the biceps, the infraspinatus tendon, and the subscapularis tendon (Fig. 1). In B-mode, tendon thickness was measured (shown by an arrow) in the longitudinal projection (Long Axis), structure and echogenicity were assessed in two projections: longitudinal and transverse (Short Axis). The presence of fluid in the bursa of the shoulder joint was determined: the approximate volume in the bursa of the long head of the biceps - using 2 projections - Long Axis and Short Axis, the thickness of the fluid - in the subacromio-subdeltoid and in the subscapular bursa - in the Long Axis projection. Ultrasound angiography in the mode of energy mapping and three-dimensional reconstruction assessed the degree of vascularization along the tendons. Ultrasound data were compared with data from clinical examination of patients.

Rice. 1.

Assessment of tendons of various muscles in B-mode, Long Axis.

A)

Supraspinatus muscle. The structure is heterogeneous, the echogenicity of the tendon is normal. The subaromyo-subdeltoid bursa is not increased in size (asterisk).

b)

Long head of biceps. The structure is homogeneous, the echogenicity of the tendon is normal. Fluid along the tendon is not detected.

V)

Infraspinatus muscle. The structure is homogeneous, the echogenicity of the tendon is normal.

G)

Subscapularis muscle. The structure is homogeneous, the echogenicity of the tendon is normal. The bag has not been increased in size (asterisk).

d)

Measuring the liquid in the bag.

A set of techniques was used to treat patients: laser therapy, hirudotherapy, manual therapy using acupuncture and massage, automobilization and individual therapeutic exercises. In case of severe pain symptoms, treatment began with the introduction of non-steroidal anti-inflammatory drugs into the joint cavity. The basic method of treatment for bursitis was laser therapy, and for tendonitis - hirudotherapy. Subsequently, treatment was supplemented with another method of conservative treatment, the choice of which depended on clinical symptoms.

results

According to ultrasound, tendonitis of the supraspinatus muscle was detected in 52 (80%) patients, in 74% of cases - a combination of tendonitis of the supraspinatus muscle and tendinitis of the long head of the biceps. In gray scale mode, the supraspinatus tendon was thickened in all patients. The echogenicity of the tendon was reduced in all patients (Fig. 2). The tendon structure was inhomogeneous in all cases, without clear signs of damage (Table 1). When using ultrasound angiography, hypervascularization along the supraspinatus tendon was detected in only 15 (28.9%) patients (Fig. 3); in most patients the tendon remained hypovascular.

Rice. 2.

Supraspinatus tendon in B-mode, Long Axis.

A)

Before treatment. The tendon is thickened (up to 0.8 cm), has a moderately heterogeneous structure, and reduced echogenicity.

b)

After 2 months of treatment. There is a decrease in the thickness of the tendon (up to 0.6 cm), the structure is the same, the echogenicity is moderately increased.

V)

After 4 months of treatment. The tendon is not thickened (up to 0.47 cm), its structure is somewhat heterogeneous, and its echogenicity is normal.

Table 1

. Characteristics of the supraspinatus tendon, quantity (%).

Rice. 3.

The supraspinatus tendon in various modes and projections.

A)

B-mode, before treatment, Short Axis. The tendon is thickened, has a moderately heterogeneous structure, and reduced echogenicity.

b)

Energy mapping and 3D reconstruction respectively, before treatment, Short Axis. Along the course of the tendon, closer to the place of attachment to the greater tubercle, hypervascularization is determined.

V)

Energy mapping and 3D reconstruction respectively, before treatment, Short Axis. Along the course of the tendon, closer to the place of attachment to the greater tubercle, hypervascularization is determined.

G)

B-mode, after 4 months of treatment, Short Axis. Reduced tendon thickness, increased echogenicity. The tendon structure is more homogeneous.

After 2 months of treatment, positive dynamics were noted: a decrease in tendon thickness, an increase in echogenicity in 75% of cases and a change in the structure of the tendon in 67% of cases, a decrease in the degree of vascularization.

Positive dynamics after 4 months of treatment were observed in 46 patients. At the same time, the average thickness of the tendon decreased, and the echogenicity of the tendon increased. The tendon structure remained heterogeneous in 13.5% of cases. The absence of positive dynamics was noted in 6 patients: according to the gray scale, in all patients the decrease in tendon echogenicity remained; Ultrasound angiography showed moderate enrichment of the vascular pattern in 3 patients.

When assessing the long head of biceps tendon, tendinitis was identified in all 65 patients (Fig. 4). Before treatment, the average thickness of the tendon was 0.38 cm, the echogenicity of the tendons was reduced in most cases, and the structure was heterogeneous (Table 2). According to ultrasound angiography, hypervascularization was detected in 15 (31.9%) patients. During treatment, positive dynamics were observed in the form of a decrease in tendon thickness, normalization of the tendon structure (in 35.4% of cases - after 2 months and in 83.1% - after 4 months) and an increase in the echogenicity of the tendon (in 56.9% - after 2 months and in 91% - after 4 months).

Rice. 4.

The tendon of the long head of the biceps in various modes and projections.

A)

B-mode, before treatment, Long Axis. The tendon is moderately thickened, has a somewhat heterogeneous structure, and reduced echogenicity. Along the tendon there is a small amount of fluid.

b)

B-mode, after treatment for 2 and 4 months, respectively. There is a decrease in tendon thickness and increased echogenicity. The structure of the tendon after 4 months of treatment is homogeneous. Fluid along the tendon is not visualized.

V)

B-mode, after treatment for 2 and 4 months, respectively. There is a decrease in tendon thickness and increased echogenicity. The structure of the tendon after 4 months of treatment is homogeneous. Fluid along the tendon is not visualized.

G)

Energy mapping and 3D reconstruction respectively, lo treatment, Long Axis. Along the course of the tendon, pronounced hypervascularization is determined.

d)

Energy mapping and 3D reconstruction respectively, lo treatment, Long Axis. Along the course of the tendon, pronounced hypervascularization is determined.

table 2

. Characteristics of the tendon of the long head of the biceps, quantity (%).

During treatment, the degree of vascularization in patients decreased. In cases where there was no positive effect, in 9% of cases the tendon of the long head of the biceps remained hypoechoic and hypervascular (see Table 2).

Ultrasound of the infraspinatus tendon revealed tendonitis in only 16 (24%) patients. The average tendon thickness before treatment was 0.61 cm (range 0.52-0.75); during treatment after 2 and 4 months, it was 0.54 and 0.48 cm, respectively (Fig. 5). Just as with tendinitis of the supraspinatus muscle, the echogenicity of the tendon of the infraspinatus muscle with tendinitis was reduced in most cases, the structure was heterogeneous. During treatment, there was an increase in echogenicity and a change in the structure of the infraspinatus tendon (Table 3).

Rice. 5.

Infraspinatus tendon in B-mode, Long Axis.

A)

Before treatment. The tendon is thickened, has a moderately heterogeneous structure, and reduced echogenicity.

b)

After 4 months of treatment. Decreased tendon thickness, moderate increase in echogenicity. The structure of the tendon is the same.

Table 3

. Characteristics of the infraspinatus tendon, quantity (%).

Ultrasound angiography revealed an increase in the degree of vascularization before treatment in only 4 patients; during treatment, the degree of vascularization decreased.

Subscapularis tendinitis (Fig. 6) was detected in 47 (72%) patients. Moreover, before treatment, the tendon was thickened on average to 0.7 cm, in all patients the echogenicity was reduced, the structure was heterogeneous. Hypervascularization before treatment was detected in 10 patients. A decrease in the average thickness to 0.64 cm after 2 months and to 0.52 cm after 4 months, as well as an increase in echogenicity and a change in structure were regarded as positive dynamics during treatment (Table 4).

Rice. 6.

Subscapularis tendon in B-mode, Long Axis.

A)

Before treatment. The tendon is thickened, has a moderately heterogeneous structure, and moderately reduced echogenicity. Fluid in the subscapular bursa is not detected.

b)

After 4 months of treatment. Decreased tendon thickness, moderate increase in echogenicity. The structure of the tendon is the same.

Table 4

. Characteristics of the subscapularis tendon, quantity (%).

The absence of positive dynamics during treatment was noted in 4 patients, while the echogenicity of the tendon did not change significantly, hypervascularization remained in 1 patient.

Ultrasound revealed fluid in the joint capsules in most cases (Table 5).

Table 5

. Characteristics of shoulder joint bursae during B-mode ultrasound, number (%).

As can be seen from table. 5, before treatment, in most cases (62 patients), fluid was detected in the bursa of the long head of the biceps (Fig. 7). After 2 months of treatment, with changes in tendon characteristics, the amount of fluid decreased, and tenosynovitis was detected in 40% of cases. The lack of positive dynamics in the treatment of tenosynovitis of the long head of the biceps was accompanied by the persistence of a small amount of fluid in its bursa.

Rice. 7.

Determination of fluid in the bursa of the long head of the biceps in B-mode.

A)

Before treatment. The bag contains about 1.21 ml of liquid.

b)

After 4 months of treatment. Reducing the volume of liquid to 0.01 ml.

The amount of fluid in the subacromio-subdeltoid and subscapularis bursae was measured by the thickness of the corresponding bursae. According to the above data, a decrease in fluid is visible after 2 months of treatment and its absence after 4 months. The results obtained completely coincided with the clinical data.

Discussion

The term "tendinitis" means inflammatory changes in the tendon. In reality, this term is not always used correctly. Taking into account histomorphological data, tendinitis shows signs of degenerative rather than inflammatory changes. In such cases, it is more correct to call this process “tendinosis.” However, these changes in etiology are inflammatory, so distinguishing tendonitis from simple tendinosis is important, since the treatment tactics for these diseases are different [4, 5]. Although both processes can be treated conservatively (rest and anti-inflammatory therapy), inflammatory processes that do not respond to treatment require the use of corticosteroids or surgery.

The range of ultrasound findings depends on the type of tendon affected and changes in the adjacent synovial bursa. The tendon is a dense specialized connective tissue consisting of a matrix (type 1 collagen fibrils, elastin, proteoglycans) and fibrocytes [1]. It is surrounded either by connective tissue (epitenon) or by a tendon sheath - a sheath covered from the inside with synovial tissue [1, 3, 5]. On ultrasound, the epitenon looks like an ultrasound line; in tendons with a synovial membrane, a thin hypoechoic strip of fluid can be detected along the tendon.

In tendons with the presence of peritenon, the inflammatory process leads to the development of peritendinitis - thickening of the paratenon, uneven contour of the tendon, the appearance of fluid in the paratenon and in the peritendinous tissues.

According to the authors [2, 5, 8], in the case of tendinitis of a tendon without a synovium (tendon of the supraspinatus, infraspinatus and subscapularis muscles), ultrasound reveals focal expansion of the tendon, an increase in the distance between longitudinally located fibers (a consequence of microtrauma), and the presence of focal hypoechoic areas ( area of ​​inflammation). In most cases, there is a thickening and change in the structure of the tendon along its entire length, which is clearly visible when comparing the tendon with the contralateral side. The decrease in echogenicity of the tendon is due to edema, myxoid degeneration and the presence of vascular proliferation. With long-standing inflammation of the tendon, unevenness of the cortical layer is noted.

With inflammatory changes in the tendon with the presence of a synovial membrane (the tendon of the long head of the biceps), an increase in the amount of fluid is observed around the tendon - tenosynovitis develops. The thickness of the fluid strip may exceed the thickness of the tendon. Synovial fluid may have a heterogeneous structure due to the presence of fibrin, cholesterol, uric acid crystals, calcium pyrophosphate, etc. [5]. There is an increase in the thickness of the synovial membrane and a decrease in its echogenicity. Vascularization in it is not enriched. Acute serous tenosynovitis is diagnosed based on an increased amount of fluid along the tendon sheath, often combined with hyperemia, regardless of the severity of tenosynovitis [4, 5]. With chronic tendinitis, the amount of synovial fluid may not increase. In this case, thickening of the tendon is most often observed. Differential diagnosis is carried out with rheumatoid diseases, in which there is uneven pronounced thickening of the synovial membrane with signs of hypervascularization [2].

In our study, we performed an ultrasound analysis of the thickness, structure, echogenicity and vascularization of the tendons of the rotator cuff muscles before treatment and after 2 and 4 months of conservative treatment. The ultrasound results showed the possibility of monitoring conservative treatment, as well as positive dynamics during the treatment of shoulder tendinitis.

The use of laser therapy as a basic method in patients with bursitis significantly reduced the volume of effusion along the tendon of the long head of the biceps, in the subacromial-subdeltoid and subscapularis bursae, which was reliably confirmed by ultrasound data. The use of hirudotherapy for tendonitis led to a decrease in the inflammatory vascular reaction along the tendons.

Limitations of the study were the inability to compare ultrasound results with MRI and arthroscopy data, as well as the lack of statistical results.

Conclusion

Ultrasound allows non-invasive assessment of the condition of the tendons of the rotator cuff muscles, the severity of inflammatory changes before and during conservative treatment and can serve as an additional method for diagnosing diseases of the shoulder joint.

Literature

1. Belenky A.G. Pathology of the periarticular soft tissues of the shoulder joint. diagnosis and treatment//Uch. village Russian Medical Academy of Postgraduate Education. - M., 2005.- 62 p.
2. Bouffard JA, Sung-Moon Lee, Dhanju J. Ultrasonography of the Shoulder // Seminars in Ultrasound, CT and MRI. Musculoskeletal Ultrasound - 2000. - June. -Vol. 21(3).- P.164.91.
3. Chhem R., Cardinal E. Guidelines and Gamuts in Musculoskeletal Ultrasound // Wiley.Liss-1999. — P. 39.63.
4. O`Connor PJ, Grainger AJ, Morgan SR, Smith KL, Waterton JC, Nash AF Ultrasound assessment of tendons in asymptomatic volunteers: a study of reproducibility// Eur. Radiol. — 2004.- Vol. 14. - P. 1968.73.
5. Martinoli C., Bianchi S., Dahmane M`H., Pugliese F., Bianchi?Zamorani MP, Valle M. Ultrasound of tendons and nerves // Syllabus Ultrasound-2002. — Mar. — P. 44.55.
6. Teefey SA, Middleton WD, Payne WT, Yamaguchi K. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors // AJR-2005. - Vol. 184.- P. 1768.73.
7. Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears. Comparison of Ultrasonographic, Magnetic Resonance Imaging and Arthroscopic findings in seventy.one consecutive cases // The Journal of Bone and Joint Surgery (American). — 2004.- Vol. 86. - P.708.716.
8. van Holsbeeck MT, Introcaso JH Musculoskeletal Ultrasound // Mosby - 2001.- P. 82.129, 463.477, 492.504.

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Treatment in Moscow

Specialists at the Yusupov Hospital clinic specialize in determining tendonitis and establishing the form of the disease. Treatment of joint and tendon diseases is one of the main specialties of the hospital. Diagnosis is carried out by specialists of the highest category. With the help of new equipment it is possible to accurately diagnose the disease and its stage. The clinic also offers the opportunity to undergo a rehabilitation period.

If an operation is necessary, the patient stays on the territory of the institution in a comfortable patient ward, where there are all conditions for a quick and calm recovery. You can make an appointment with a doctor online or by phone.