TCM Acupuncture and Massage

Chapter 64 Bone and Joint Diseases (2)
7. Postural disorders. Occupations with bad posture, such as manual work and sitting at a desk for a long time, due to long-term bad posture or posture disorder, the scapula tilts, and the position of the acromion and humerus also changes due to abnormal stress, resulting in rotator cuff injuries. lead to frozen shoulder.

In addition, psychological factors such as depression, apathy and emotional repression also have a certain relationship with the occurrence of frozen shoulder.These numerous causes collectively cause mild non-specific inflammatory changes in the soft tissue of the shoulder joint.

The pathological changes of frozen shoulder mainly occur in the subacromial bursa, the subscapularis bursa, the synovial sheath of the long head of the biceps brachii, and the synovial cavity of the scapulohumeral joint. Edema, hyperemia, villous hypertrophy with exudation.The later pathological changes are synovial cavity adhesion atresia, fibrinoid substance deposition, etc., and the soft tissue becomes fragile and easy to tear.All these pathological changes are clinically manifested as local pain and joint mobility disturbance.In addition, there are similar pathological changes in the hip, ankle, wrist and other joints of the human body, but there is no obvious joint movement disorder like the shoulder joint.Frozen shoulder is a self-limiting disease with a tendency of self-healing. When the symptoms of pain and movement limitation increase to a certain extent, the pain can gradually disappear and the activity function can gradually recover.As some patients said: I don’t know how I got sick when I got sick, and I don’t know how to get better when I got better.The natural recovery time is difficult to estimate, and it may take several months to two years, generally about half a year.

([-]) Clinical manifestations

Pain is the most prominent symptom of frozen shoulder.The initial pain symptoms are often mild and paroxysmal, often caused by weather changes or fatigue.With the passage of time, it gradually develops into persistent pain, especially when the shoulder joint is internally rotated, extended, raised, and abducted, it is more obvious, and even the pain is unbearable.At this time, patients often use the method of restricting upper limb movement to relieve pain.In addition to the aggravation of the pain symptoms during shoulder joint movement, the pain symptoms will also aggravate during rest, especially during nighttime sleep. In severe cases, you may not be able to sleep at night, and you cannot lie on the side with the affected shoulder. Sometimes, any posture may not relieve the pain. .Insomnia can further produce depression and irritability and aggravate the condition.The painful area of ​​frozen shoulder is generally limited to the deltoid muscle and adjacent areas.But once the pain induces a muscle spasm, the pain can be widespread and sometimes radiate along the back of the upper arm to the elbow.In addition, patients can experience pain in adjacent areas such as the upper back and neck due to excessive compensation by adjacent muscles.The nature of pain is generally unclear, and some patients may be very sensitive to pain.

Limitation of shoulder joint function is another feature of frozen shoulder.Generally, the limitation of shoulder joint movement occurs 3 to 4 weeks after the pain symptoms are obvious.Early limiting factors for functional mobility of the shoulder may be pain, muscle spasm, etc.The limited movement of the shoulder joint in the late stage is due to factors such as adhesion and contracture of soft tissues such as joint capsules and ligaments. The shoulder joint is obviously stiff, and the full range of joint functional activities is limited, including passive movement.As the course of the disease progresses, the pain gradually decreases, and the degree of limitation of joint mobility becomes more and more severe.The limitation of shoulder joint activity in abduction and internal and external rotation is more obvious and occurs earlier.Once the joint capsule is adhered and contracted, the patient may experience a typical "shoulder-carrying" phenomenon when the shoulder joint is abducted, that is, when the chest and back are moved, the scapula produces compensation in order to expand the degree of shoulder joint abduction.This is often easy to mask some of the symptoms.When the "shoulder-carrying" phenomenon occurs, daily activities such as dressing, tying a belt, combing hair, touching the back, wiping the anus, and drying clothes will have difficulties.In severe cases, it may even involve the elbow joint, and the hands cannot touch the back when the elbow is bent. On the one hand, the phenomenon of "shoulder carrying" is to complete the compensatory movement function by elevating the scapula, rotating it back and abducting it, and on the other hand, it is also changing the position to protect the scapulohumeral joint with existing lesions.For example, when resting, the upper arm on the affected side is usually placed in adduction and internal rotation, and the swing range of the arm is significantly reduced when walking.These protective manifestations are common in patients with frozen shoulder.Due to pain and shoulder joint mobility impairment, the shoulder joint activity of frozen shoulder patients has been reduced for a long time, and atrophy of shoulder muscles such as the deltoid muscle may occur in various degrees in the late stage.In particular, the atrophy of the lateral deltoid muscle of the shoulder can not only make the affected shoulder lose its original plump appearance, but also cause acromion protrusion, and it can also aggravate the degree of movement disorder of the shoulder joint.

(1) Clinical stages Frozen shoulder can be divided into pain period, freezing period and recovery period clinically. 1. Painful period The painful period is also called the early stage, the acute stage or the freezing stage, which lasts for about 6 to [-] months.The main clinical manifestation of this stage is pain around the shoulder joint.The pain is severe, aggravated at night, and even affects sleep.The range of tenderness is relatively wide, and tenderness can be manifested in the coracohumeral ligament, subacromial, supraspinatus, long head tendon of biceps brachii, quadrilateral foramen, etc., accompanied by muscle spasm and limited shoulder joint movement.However, it is mainly local sudden and severe pain that reflexively causes muscle spasms, and the shoulder joint itself still has a certain range of motion.

2. The freezing period is also called the intermediate period, the chronic period or the rigid period.The duration is 4 to 12 months.During this period, the patient's pain symptoms were relieved, but the range of tenderness was still relatively extensive.The joint function limitation caused by the protective muscle spasm in the pain stage has developed into joint contracture dysfunction, the functional activities of the shoulder joint are severely limited, and the soft tissues around the shoulder joint are widely adhered and contracted, showing a "frozen" state.The range of activities in all directions is obviously reduced, and abduction, external rotation, lifting, and extension are the most significant, which affects daily life, such as combing hair, putting on and taking off clothes, and raising arms and lifting objects.When performing abduction and forward flexion exercises, the scapula will swing accordingly, resulting in a "shoulder-carrying" phenomenon. In severe cases, the deltoid, supraspinatus, infraspinatus and other shoulder girdle muscles, especially the disuse atrophy of the deltoid muscle, can be seen.

3. The recovery period is also called the terminal period, the thawing period or the functional recovery period.The duration is 5 to 26 months.During this period, not only the pain gradually subsided, but also with daily life, labor and various treatment measures, the range of motion of the shoulder joint gradually increased, and the contracture and adhesion of soft tissues such as the joint capsule around the shoulder joint gradually eliminated. Function returns to normal or close to normal, and muscle atrophy gradually returns to normal.

Frozen shoulder is a self-limiting disease, and the total duration of symptoms can reach 12 to 42 months.The length of the pain period is related to the length of the recovery period, that is, those with a short pain period will have a relatively short recovery; otherwise, it will be longer.There is no correlation between the severity of symptoms and the length of the recovery period, that is, those with severe symptoms may not necessarily have a long recovery period, and those with mild symptoms may not necessarily have a short recovery period.The recovery process does not develop in a straight line, and the improvement of shoulder joint function sometimes has ups and downs. About 10% of patients still have limited motor function after the recovery period.

([-]) Diagnosis

The main points of diagnosis of frozen shoulder are as follows:

1. Middle-aged and elderly people, especially those around 50 years old, often have unilateral disease, and sometimes both sides can occur simultaneously.

2. There may be a history of shoulder or upper limb trauma, chronic strain, metabolic disorder, endocrine disorder, cold, or immobilization. 3. Mainly manifested as persistent shoulder pain, aggravated at night and during shoulder joint activities.

4. The main sign is that when the shoulder is palpated, there may be one to several clear tenderness points in the deltoid bursa and subacromial bursa.

5. It can be seen that the functional activities of the shoulder joint in all directions are restricted to varying degrees, and the restrictions on abduction, lifting, external rotation, and internal rotation are the most serious.Passive movement examination during the painful period can feel that the movement is limited due to the patient's pain and muscle spasm.There is a characteristic sign in the passive movement examination during the freezing period, that is, at the end of the passive movement examination, the examiner can feel a leathery hard resistance.When examining the range of motion of the shoulder joint, factors such as the patient's age, gender, course of disease, and severity of the disease should also be taken into consideration, so as to better evaluate the patient's shoulder joint motion accurately.

6. The test of activities of daily living showed that daily activities such as combing hair, putting on clothes, touching pockets, back touching, and anus wiping of the affected upper limb were obviously restricted.

7. In the late stage, due to pain and disuse atrophy, the shoulder muscles may atrophy, especially the deltoid muscle.It is manifested by the disappearance of the plump appearance of the outer shoulder and the protrusion of the acromion. Manual muscle strength examination can find that the flexion, extension, and abduction of the affected shoulder joint have different degrees of muscle strength reduction.

8. The X-ray film examination is generally normal, only degenerative changes such as osteoporosis, calcification of ligaments or bursa, and no other bone diseases of the shoulder joint.

9. Relevant laboratory tests are basically within the normal range.

([-]) Treatment

Since the etiology and pathology of frozen shoulder are not completely clear, there is no specific method for clinical treatment of frozen shoulder. The principle of treatment is symptomatic treatment, combined with active exercise, to relieve pain and reduce pain.Frozen shoulder in a narrow sense is a typical self-limiting disease, and there is often a phenomenon of "the time is not enough, the treatment is not good; the time is up, it is not curable". Objectively aiming at the particularity of frozen shoulder, the patients are treated in different periods. , or take corresponding treatment and rehabilitation measures according to the severity of different symptoms.The treatment of frozen shoulder is mainly conservative treatment. If the diagnosis is timely and the treatment is appropriate, the course of the disease can be shortened and motor function can be recovered early.

1. In the early stage of frozen shoulder, that is, the pain stage, the patient's pain symptoms are severe, and the dysfunction is only caused by muscle spasms caused by pain. The main purpose of treatment is to relieve pain and prevent joint dysfunction.To relieve pain, you can use sling braking method to make the shoulder joint fully rest; or use closed therapy, inject prednisolone, etc. at the most obvious local tenderness; or use physical therapy methods such as electrokinetic therapy and warm compress To relieve pain, anti-inflammatory and analgesic drugs can be taken orally, and antispasmodic and analgesic tinctures or external ointments and other external drugs can be applied externally if necessary.In the acute stage, it is generally not advisable to use massage methods prematurely to prevent the aggravation of pain symptoms and prolong the course of the disease.You can take some active exercise exercises by yourself to maintain the range of motion of the shoulder joint.After the acute phase, massage and massage can be used to achieve the purpose of improving blood circulation and promoting the subsidence of local inflammation.

2. During the frozen period of frozen shoulder, the main symptom is joint movement dysfunction, and the pain is often caused by joint movement disorder.The purpose of treatment is to relieve muscle adhesions and restore joint movement function.The treatment methods used can be various measures such as physical therapy, western manipulation, massage, medical sports, etc., in order to achieve the purpose of releasing adhesions, expanding the range of motion of the shoulder joint, and restoring normal joint function.For frozen shoulder patients with severe functional impairment, it is not advisable to take for granted the method of forced passive movement under anesthesia to tear the adhesions, because even if the adhesions are temporarily torn, the body's repair function to the laceration will cause adhesions again.At this stage, the functional exercise of the shoulder joint should be adhered to.In addition to passive exercise, patients should cooperate actively and carry out functional training of active exercise. Active exercise is an extremely important part of the whole treatment process.

3. The recovery period is mainly to eliminate residual symptoms and restore function. The principle is to continue to strengthen functional exercises to enhance muscle strength, restore the shoulder girdle muscles that have been disused and atrophied in the early stage, and restore the normal elasticity and contraction of deltoid muscles and other muscles. Function, in order to achieve the purpose of comprehensive rehabilitation and prevention of recurrence.

([-]) Medical sports therapy

Medical physical therapy plays a very important role in the rehabilitation of frozen shoulder patients.On the basis of whole-body exercise, by purposefully and selectively increasing the functional exercise of each axis of movement of the shoulder joint on the affected side, especially the exercise of the axis of movement where the movement disorder is more obvious, it can not only improve the patient's condition to a large extent The blood circulation in and around the shoulder joint can promote the absorption of focal non-bacterial inflammatory exudate, reduce and eliminate pain symptoms, and can also eliminate movement disorders and restore the shoulder joint by stretching and softening the adhesion of soft tissue around the shoulder joint normal physiological function.In addition, for patients with atrophy of the shoulder girdle muscles (such as the deltoid muscle), medical sports exercises for the shoulder joint can enhance the strength of the muscles and restore the normal elasticity and contraction function of the muscles, thereby gradually eliminating the pain symptoms of the patients and improving shoulder joint health. It restores the patient's ability to live, work and produce labor.

In the early stage of frozen shoulder, patients often have pain symptoms, which limit the activities of the shoulder joint.Therefore, some light-intensity medical sports activities, such as some shoulder joint exercises, can be performed at the same time as certain treatment methods.After the patient gradually adapts, gradually increase the amount of exercise to achieve the purpose of dredging the meridians, eliminating pain, and preventing motor dysfunction.In the late stage of periarthritis of the shoulder, the main symptom of the patient is limited movement of the joint.Therefore, medical sports should choose high-intensity training to loosen adhesions, develop shoulder muscle strength, enhance the elasticity of tendons and ligaments around the shoulder joint, and restore the range of motion of the shoulder joint.Especially the movement axis with obvious movement disorder should be trained more emphatically.

1. Manual gymnastics exercise. Manual gymnastics is easy to learn and does not require any equipment. It is more suitable for patients with frozen shoulder to carry out at home or in their spare time.Here is a set of more practical calisthenics for patients with frozen shoulder.

(1) Back and forth arm swing movement: in the preparatory position, the patient stands with legs apart, with the distance slightly wider than the shoulders, the upper body is bent forward, the head is slightly raised, and the arms are naturally drooping while looking ahead.Action: Relax the right arm and swing it up as far as possible, while relaxing the left arm and swing it back as much as possible, then exchange the swing direction of the left and right arms.Action repeated 10 to 20 times.

(2) Left and right arm swing movement: the preparation posture is the same as the previous section.Action: Relax your arms, swing them up to the side as much as possible, then swing your arms back and cross them in front of your chest.Action repeated 10 to 20 times.

(3) Circular shoulder movement: in the preparatory position, the patient's legs are upright, both elbows are flexed, and the hands are placed on the shoulders.Action: Take the shoulders as the axis, circle the shoulders from front to back 10 to 15 times, and then use the same movement to circle from back to front and down 10 to 15 times.

(4) Stretch shoulder exercise: In the preparatory posture, the patient stands upright with both legs, bends the elbow joints, and crosses the hands and ten fingers on the occiput.Action: After supporting the head with both hands, clamp the arms inward, and then spread them as far as possible from the inside to the outside.Action repeated 10 to 20 times.

(5) Supporting the sky exercise: in the preparation position, the patient stands upright with his legs apart, and his arms hang down naturally.Action: bend both arms to the chest, palms up, cross the fingers of both hands, lift up to the front of the forehead, take the wrist joint as the axis, turn the hands outwards, palms up, push the hands up as much as possible, then, drop the arms from the sides according to the situation Return to the ready position.Action repeated 10 to 20 times.

(6) Forward punch movement: In the preparatory posture, the patient’s knee joints are slightly bent, and the patient stands with legs apart, shoulder-width apart, with both hands clenched at the waist, with the center of the fist facing upward.Action: The right hand punches hard and forward, the heart of the fist turns downward, the right fist is forcefully retracted to the waist, and then the left hand is forcefully punched forward, the heart of the fist turns downward, and the left fist is forcefully retracted to the waist.Action repeated 10 to 20 times.

(7) Side punch movement: preparation posture, same as the previous section.Action: The right hand punches forcefully to the side, the center of the fist turns downward, the right fist is forcefully retracted to the waist, and then the left hand is forcefully punched to the side, the center of the fist turns downward, and the left fist is forcefully retracted to the waist.Action repeated 10 to 20 times.When completing this set of gymnastics, the movements are required to be rhythmic, slightly slow, and the range of motion is as large as possible.This set of gymnastics is more suitable for patients with less severe shoulder joint mobility impairment.Patients with severe movement disorders can appropriately reduce the amount and range of exercise.

(End of this chapter)