Deforming osteoarthritis of the shoulder joint

Deforming osteoarthritis of the shoulder joint is often diagnosed in patients with metabolic-dystrophic disorders accompanied by cartilage destruction, bone overgrowth and shoulder curvature. Regular mechanical damage to the tissues of the joint causes the development of recurrent inflammatory process - synovitis, which worsens the clinical course of the disease.

This pathology is sometimes called osteoarthritis, or simply deforming arthrosis. Previously, the disease was considered to be age-related, but today there are cases of its development in children. [1], [2]

Epidemiology

Problems with articular cartilage occur in many people. In general, the incidence of deforming osteoarthritis is about 7%, but correlates with age, reaching extremely high rates in patients over 45-50 years of age (about 14% or more).

The prevalence of the disease, depending on the region of residence, ranges from 700-6500 cases per hundred thousand population. According to other data, about 30% of people aged 25 to 70 years have X-ray signs of osteoarthritis in at least one location. The most frequently diagnosed joints are the hands and feet, less frequently gonarthrosis and coxarthrosis, and even more rarely deforming osteoarthritis of the shoulder joint.

It is noticed that the disease more often affects women, which is associated with frequent hormonal changes in the female body.

In childhood, the problem is more likely to be hereditary in nature.

Deforming osteoarthritis of the shoulder joint is predominantly a secondary pathology that starts after serious injuries, joint fractures, chronic diseases, including systemic diseases (rheumatoid arthritis, diabetes, osteoporosis, etc.).

The risks of osteoarthritis are particularly high in athletes and certain professions, such as:

• weightlifters;
• tennis players;
• boxers;
• handball players;
• swimmers;
• miners;
• builders;
• movers, etc.

Causes of the osteoarthritis of the shoulder joint

Deforming osteoarthritis of the shoulder joint can be primary, in which it is not always possible to find out the exact cause of the pathology. In many cases, there is a relationship with age-related changes, hereditary predisposition, overweight, insufficient or excessive physical load on the shoulder joint. Such a primary pathology is prone to gradual but steady progression. [3]

Secondary osteoarthritis occurs as a result of other diseases or traumatic injuries, which can occur at almost any age, even childhood. The main causes of secondary deforming osteoarthritis are considered to be:

• Acute traumatic injuries (joint fractures, contusions, subluxations or dislocations;
• Regular trauma, including repetitive sports micro-injuries;
• congenital dysplasia;
• previously post-trophic destruction of the shoulder joint (Perthes' disease), osteochondropathy;
• metabolic disorders, hypodynamia, obesity, purine pathologies (gout, etc.);
• endocrine pathologies (diabetes, hormonal disorders);
• inflammatory diseases (rheumatoid arthritis, joint psoriasis, etc.);
• impaired blood circulation in the shoulder joint and upper extremity.

Risk factors

• Heavy work associated with carrying and lifting heavy objects, loads.
• Professional sports, especially those involving excessive or regular stress on the shoulder joint.
• Excess body weight.
• Injuries, microtraumas of the shoulder joint.
• Spinal column curvatures, vertebral osteochondrosis of the cervical or thoracic spine.
• Tendency to allergic reactions.
• The presence of foci of chronic infection.
• Female gender (endocrine factor).
• Hereditary predisposition. [4]

Pathogenesis

The shoulder joint is a mobile joint whose surfaces are covered by smooth cartilage tissue. Externally, the joint is enclosed in a capsule held together by a ligamentous apparatus. Inside, the capsular bursa is filled with synovial fluid. The complexity of the design is due to the need for long-term and stable operation of the shoulder even against the background of reglular significant load on the upper limb.

The pathological mechanism of intra-articular disorders in patients with deforming osteoarthritis of the shoulder joint starts with damage to cartilage structures - chondrocytes. Normally, they produce collagen and proteoglycans. As a result of any pathological process or traumatic injury, this production is disturbed: defective collagen and incomplete proteoglycans are produced, which are unable to be retained in the matrix layer and pass into the joint fluid.

"Incorrect" proteoglycans cannot retain moisture, and collagen begins to swell due to the excess of this moisture and, over-saturation, disintegrates into separate fibers. The intra-articular fluid becomes cloudy, and the cartilage itself becomes dull and rough. As a result of constant friction, it rapidly thins, the load on the joint increases, and the bony surfaces become thickened. Bony marginal outgrowths occur, which contribute to increased pain and limited mobility.

The function of the shoulder joint gradually deteriorates, which is aggravated by the accession of inflammatory and autoimmune process. The bursa thickens, the corresponding musculature atrophies. In the absence of adequate therapy, the patient can become disabled, and the shoulder completely loses mobility - the articular gap fuses. [5]

Symptoms of the osteoarthritis of the shoulder joint

The basic manifestations of deforming osteoarthritis of the shoulder joint are pain, curvature and functional disorder of the joint. Primary osteoarthritis is characterized by a slower course, and the dynamics of secondary pathology depends on the underlying cause - traumatic or other injury.

The first signs of an incipient problem are not detected immediately: the initial pathological stage does not manifest itself, neither joint distortion, nor impaired function. Pain syndrome is mechanical, with attachment to intense activity of the shoulder joint. At rest, the discomfort quickly passes. In the morning or after prolonged rest, there may be a starting pain, which also disappears quickly.

Clear symptomatology appears somewhat later - after several months or even years. The patient begins to feel prolonged pain after exertion, sometimes even at night (at rest). In moments of movement, typical "clicks" are often heard, indicating the appearance of irregularities on the joint surfaces.

Over time, the pain becomes constant, with rare periods of relief. The shoulder joint changes its shape, function suffers: the patient begins to "take care" of the arm, avoid loads on it, which greatly affects the ability to work.

It is optimal if the patient consults doctors as soon as the first suspicious symptoms appear. Such manifestations require an immediate and obligatory visit to a specialist:

• persistent pain, night pain in the shoulder joint, or involvement of other joints;
• The appearance of swelling and redness in the shoulder area, increasing its volume;
• the appearance of "clicking", sharp pain, difficulties with extension and flexion, lifting the limb and pulling it to the side.

Deforming osteoarthritis of the shoulder joint is a pathology with a high probability of developing serious consequences, so it is important to seek medical help in a timely manner. [6]

Stages

Three degrees of pathology are distinguished:

• Deforming osteoarthritis of the shoulder joint of the 1st degree is often asymptomatic, or reveals itself with a small load pain. Radiographs show no changes or a slight narrowing of the articular gap against the background of the initial signs of osteosclerosis. Patients complain of a slight limitation of motor amplitude.
• Deforming osteoarthritis of the shoulder joint of the 2nd degree has a progressive course, accompanied by the appearance of frequent aching pain, "clicking". X-ray images show a 2-3 times reduction in the joint gap, the presence of marginal bone growths, clear signs of osteosclerosis.
• Grade 3 deforming osteoarthritis is characterized by constant pain (even at rest), the appearance of separate bone segments ("joint mice"). Radiographically, there is a strong narrowing of the articular gap up to its complete absence, pronounced growth of osteophytes, curvature of the shoulder joint. There are clear signs of osteosclerosis, cystic cavities and sequestrations. When examining the patient, the forced position of the limb, ankylosis draws attention.

Complications and consequences

If you do not consult a doctor for a long time, self-medicate and ignore the problem, the risks of complications increase:

• increase in pain syndrome not only in moments of shoulder joint loading, but also at rest;
• of a sustained shoulder curvature;
• loss of function of the affected arm, problems with extension, flexion, extension, elevation of the arm, up to complete ankylosis;
• impairment of the ability to work.

Worsening of pain is most often caused by a recurrence of the inflammatory reaction - synovitis. The synovial membrane is affected, effusion accumulates in the joint cavity, the capsule swells. Symptomatology worsens sharply. To confirm intra-articular synovitis, the doctor performs a puncture with further examination of the effusion.

If ankylosis develops - immobility of the shoulder joint due to fusion of the articular surfaces of the bones - disability occurs.

Diagnostics of the osteoarthritis of the shoulder joint

The diagnostic process begins with a survey and examination of the patient: the doctor listens to complaints, descriptions of the main symptoms, obtains information about the period of the start of the first signs of the disorder.

During the visual examination, the doctor can detect swelling, swelling, redness of the shoulder joint, its curvature. Next, he assesses the motor capabilities: for example, he asks the patient to take the affected arm to the side, raise it up, join both hands behind the back. There is a high probability that it is at this stage that the doctor can suspect deforming osteoarthritis of the shoulder joint.

Blood tests most often have no deviations in the indicators, sometimes signs of inflammation are detected: increased leukocyte count, accelerated COE. [7]

Instrumental diagnosis includes three main types of investigations:

• radiographs;
• CT scan;
• MRI.

Often only one of the suggested methods will suffice.

Arthroscopy - endoscopic diagnostics using a flexible probe - is prescribed for therapeutic and diagnostic purposes. The doctor can examine the shoulder joint cavity, take biomaterial (synovial fluid) for analysis, perform minimally invasive surgery (for example, remove a "joint mouse"). [8]

Differential diagnosis

In occupationally caused deforming osteoarthritis, anamnesis collection reveals the presence of significant work experience in conditions of shoulder joint overload. The disease develops mainly gradually, characterized by a chronic and steadily increasing course.

Deforming osteoarthritis, which is not professionally related, is most often associated with general systemic pathology - for example, metabolic, endocrine, congenital or acquired disorders of the musculoskeletal system.

In all cases of diagnosis, it is necessary to rule out secondary joint damage, i.e. To find out the true underlying cause of the pathology, which is not related to the occupational conditions. Diseases such as Perthes disease, joint hypermobility, ochronosis, hemochromatosis, Wilson's disease, etc. Should be differentiated. It is important to carry out diagnostic measures aimed at excluding endocrinopathies: hyperparathyroidism, hypothyroidism, diabetes, acromegaly.

Treatment of the osteoarthritis of the shoulder joint

The treatment regimen for deforming osteoarthritis of the shoulder joint usually consists of a set of measures:

• non-medication (weight normalization, physical unloading of the shoulder, physical therapy, physiotherapy, spa treatment, orthopedic correction);
• medications (analgesics and myorelaxants, glucocorticosteroids, structural modifiers, etc.);
• surgical prosthetics.

The most common medications prescribed to patients with deforming osteoarthritis of the shoulder joint:

• Acetaminophen (Paracetamol);
• opioid analgesics;
• topical and systemic non-steroidal anti-inflammatory drugs;
• coxibs;
• glucosamine, chondroitin;
• Diacerein;
• intra-articular injection of corticosteroids, hyaluronic acid;
• multivitamin, vitamin and mineral complex preparations;
• herbal remedies.

Analgesics are the key symptomatic drugs, as pain syndrome is the leading clinical picture of deforming osteoarthritis of the shoulder joint. Analgesics of choice are most often non-steroidal anti-inflammatory drugs, Paracetamol or narcotic drugs (Tramadol). The dose of Paracetamol must be relatively high to achieve the necessary effect, so many specialists trust non-steroidal anti-inflammatory drugs more. Thus, doctors give preference to low doses of acetylsalicylic acid, Ibuprofen or Ketoprofen, Nimesulide or Meloxicam, as well as Celecoxib and Lycophelone. [9] Chondroblastic medications that are used in low dosages are especially recommended:

• propionic acid preparations (Ibuprofen 1200-1800 mg per day, Ketoprofen 100 mg per day, Dexketoprofen 75 mg per day);
• preparations of arylacetic acid (Diclofenac 50-100 mg per day, Aceclofenac 100-200 mg per day, Ketorolac 30-60 mg per day);
• selective COX-2 inhibitors (celecoxib 100-200 mg daily, Nimesulide 200 mg daily, Meloxicam 7.5-15 mg daily).

Medications such as Indomethacin and Methindol are not recommended due to their adverse effects on cartilage tissue.

The most common side effects of the above drugs (NSAIDs):

Digestive organs: gastropathies, enteropathies, hepatopathies, functional dyspepsia.

Cardiovascular system: hypertension, aggravation of chronic heart failure, peripheral edema.

Kidneys: development of interstitial nephritis, decreased glomerular filtration.

Blood picture: platelet aggregation disorder, risk of bleeding.

Respiratory system: development of aspirin-induced bronchial asthma.

Bone and joint system: aggravation of osteoporosis.

Nervous system: disorder of central nervous system functionality, memory and concentration disorders, insomnia, depressive states.

For acute shoulder pain, fast-acting agents such as Dexketoprofen (Dexalgin), Ketorolac, Diclofenac, Meloxicam (Movalis) are used.

As a supplement, external dosage forms are used - in particular, ointments or gels for rubbing, applicator applications, phonophoresis. Especially common are products with diclofenac (1% Diclovit), ketoprofen (2.5% Fastum gel), brufen (1% Dolgit cream, 10% Ibuprofen gel). Any of the selected external preparations are applied to the affected shoulder from 4 to 6 times a day, a strip of about 5-6 cm, after which it is well rubbed in, using massage movements.

The presence of synovitis is an indication for intra-articular administration of glucocorticoids such as methylprednisolone acetate, hydrocortisone, triamcinolone acetonide, dipropionate, betamethasone phosphate. Hormonal agents are administered after aspiration of joint fluid, which allows you to suppress the inflammatory response and prevent the recurrence of synovitis. Corticosteroid is combined with a local anesthetic (Novocaine, Lidocaine) or isotonic sodium chloride solution. The injection course includes one to three injections with an interval between them of 4-5 days. A repeated course is allowed not earlier than in 3 months. [10]

Physiotherapy treatment

In deforming osteoarthritis of the shoulder joint actively use methods of physiotherapy - in particular, magnetotherapy, shock wave therapy, ultraphonophoresis with drugs, mud treatment, massage and other manual procedures.

Magnetotherapy is popular due to its anti-inflammatory and analgesic effect, which manifests itself after the first procedures. Upon completion of the treatment course, there is a significant improvement in blood circulation, reduction of pain syndrome, inhibition of cartilage destruction processes, improvement of trophism of the shoulder joint.

Ultraphonophoresis involves the introduction of certain medications using ultrasonic vibrations. After the session, the permeability of the skin and blood vessels increases, which favors the penetration of the drug into the tissues.

Shockwave treatment consists of acoustic impact, providing improved blood circulation in the shoulder area, reducing pain, increasing the amplitude of movement in the shoulder joint.

Therapeutic muds and baths are used mainly as part of spa treatment, in combination with other procedures such as massage, LFK, kinesiotherapy. [11]

Herbal treatment

Thanks to natural herbal remedies of folk medicine, it is often possible to successfully complement the main treatment and achieve a steady improvement in the condition. Especially effective is the use of herbs in the early stages of the development of deforming osteoarthritis of the shoulder joint.

You can use any of the suggested recipes:

• Take in equal parts calendula, wort, elderberry, juniper, nettle, horsetail, birch and willow leaves. Raw materials are well dried and crushed, mixed. Pour 2 tbsp. Of the collection of 1 liter of boiling water, steamed in a thermos, kept for 8-9 hours. Then strain the infusion and drink 100 ml up to five times a day for 8-12 weeks.
• Collect in equal amounts of lingonberry leaves, bogulnik, melon, poplar buds, flax seeds, St. John's wort, nettle leaf and mint, succession. Plants are crushed and thoroughly mixed. Pour 1 liter of boiling water in a thermos 2 tbsp. Liters of the mixture, kept overnight, the morning filtered and take 100-150 ml up to five times a day. Duration of the treatment course - up to three months.
• Prepare an equivalent mixture based on the rhizome of aira and calganum, hawthorn fruit, as well as thyme, St. John's wort, mint, violet, pine buds, eucalyptus. Plants are crushed, mixed, in an amount of 2 tbsp. Pour boiling water and insist for 10 hours. Filter, drink 150 ml four times a day for at least 2 months.
• Prepare an ointment based on the color of St. John's wort and St. John's wort, hop cones. Take 2 tbsp. Of each crushed plant (grinded into powder), mixed with 50 g of soft butter or fat, well kneaded. The resulting mass is applied to a piece of gauze, apply to the affected shoulder joint, cover with cellophane and fix a warm scarf or scarf. Hold about an hour and a half. The procedures are repeated daily until a steady improvement in the condition.
• Take 2 tbsp. Pine needles, pour 150 ml of water, bring to a boil and boil over low heat for about half an hour. Filter, wet a piece of gauze or cotton cloth in the decoction, apply to the painful shoulder. Over fix cellophane and a warm scarf. Remove after 1-1.5 hours. Repeat daily.

If such treatment does not lead to improvement of well-being, or on the contrary, the patient gets worse, then it is necessary to urgently stop using herbs and consult doctors. Do not self-medicate deforming osteoarthritis.

Surgical treatment

If conservative treatment is ineffective, surgical techniques are used - this approach is most relevant to patients under 45 years of age, or in patients with initial degenerative changes of the shoulder joint.

The extent of surgery should be appropriate to the clinical manifestations or the degree of limitation of joint function. Arthroscopy, capsular release, corrective osteotomy or interposition arthroplasty may be performed, depending on the indication.

Arthroscopy with capsular release is used most often and demonstrates an effect in patients under 55 years of age, with moderate pain syndrome and limited passive motor skills. During the intervention, the surgeon eliminates osteophytes and "joint mice", as well as unstable cartilage segments. In case of inflammation in the synovial membrane, synovectomy is performed, and in case of thickening of the articular bursa, capsular release is performed.

Arthrodesis brachial fixation is performed in patients younger than 45 years of age, or in cases where there are contraindications to full articular prosthesis. This operation contributes to the elimination of pain, since the head of the humerus is fixed to the glenoid, disarming the painful motor interface.

Shoulder arthroplasty is indicated for patients with severe osteoarthritis:

• in case of severe pain, loss of limb function and ineffectiveness of conservative methods;
• in the terminal stage of rotator cuff lesions of the shoulder joint;
• with necrosis;
• for previously failed joint-sparing surgery.

The main contraindications to endoprosthetics:

• an infectious process in the active phase, or a recent acute infectious disease;
• brachial neuropathy;
• absolute paralysis of the deltoid or rotator cuff muscles;
• severe somatic diseases;
• Instability of the joint that cannot be corrected.

The patient's recovery after surgery starts with motor development. During the first month and a half, stretching exercises are performed to improve joint flexibility. Then gymnastics are included to strengthen the shoulder musculature. Habitual daily practice becomes possible after about 3-4 months. Full recovery takes 1 to 2 years. [12]

Prevention

You can prevent the development of deforming osteoarthritis of the shoulder joint if you faithfully follow the following recommendations:

• do regular exercises, avoiding injuries and overloading;
• control body weight by keeping it within normal limits;
• avoid sudden "jerks" and hand movements, do not start physical activity without prior preparation ("warming up");
• evenly distribute the load on the upper limbs and shoulder girdle (especially when lifting and carrying heavy objects;
• avoid hypothermia.

To improve blood circulation in the articulation area, it is recommended to strengthen the muscles and develop the shoulder girdle. Shoulder massage is also useful and should be entrusted to a professional. Massage begins with stroking, then use kneading, tapping, vibration. The procedure is also completed by stroking. The movements should be as gentle as possible, so as not to harm the shoulder joint.

Forecast

Deforming osteoarthritis of the shoulder joint is a complex pathology, but with timely medical care, the prognosis can be considered favorable.

Specialists strongly recommend to contact doctors at the first detection of pathological symptoms. Postponing treatment until later means complicating the treatment process and worsening the prognosis.

It is optimal to contact qualified therapists and orthopedists who have experience in the treatment of such diseases. The doctor will determine the most effective individual therapy regimen, which will help to overcome deforming osteoatrosis of the shoulder joint and prevent further recurrences.