Shoulder Capsules

Inflammation of the synovial bag and joint capsule is a capsulitis. The most common lesion is the shoulder and knee. Let's consider the peculiarities of the disease, the methods of its treatment.

Stiffness and soreness in the joint, which lasts for several days can indicate a progressive inflammation. The disease is characterized by the appearance of severe pain and a sharp decrease in the functionality of the affected area. If the pathology proceeds in an easy stage, it is difficult for the patient to perform movements with his hands. Severe forms of the disorder can cause disability.

According to the international classification of diseases ICD-10, capsulitis is included in the category: M00-M99 Diseases of the musculoskeletal system and connective tissue, subcategory M60-M79 Diseases of soft tissues:

M70-M79 Other soft tissue disorders.

• M75 Shoulder Lesions.
  • M75.0 Adhesive shoulder capsulitis.

For the first time a diffuse lesion was described in 1882. In medical practice was introduced such a concept as shoulder-scapular periarthritis. In 1932, the pathology was called "frozen shoulder" because of a pronounced symptom of stiffness and restriction of movements. In 1945, the violation received a modern name - an adhesive capsulitis.

The disease lasts from six months to several years. The affected tissues surrounding the joint become inflamed and stiff. Gradually begin to form spikes, limiting movement and causing acute pain. Most often, pathology is associated with traumatic injuries and autoimmune reactions of the body. Treatment is long, consists of a course of drug therapy and physiotherapy. In especially severe cases, surgical intervention is performed.

[1], [2], [3], [4], [5], [6]

Epidemiology

According to medical statistics, the incidence of capsulitis among adults is 2-3% per year. In most cases, the disease is diagnosed in patients 40-70 years. If pathologies occur in people younger than 40 years, then this is likely a secondary form of diffuse lesion.

However, statistics indicate that women are sick three times more often than men. In 10% of cases after the resolution of the pathological process in one joint, the second lesion develops (the time interval from six months to five years). The development of the pathological process in the second limb does not affect the course of the disease in the first. After complete recovery, recurrences of the capsulitis are unlikely.

[7], [8]

Causes of the capsulitis of the shoulder

The etiology of inflammation of the synovial bag and joint capsule is thoroughly unknown. The causes of the capsulitis are associated with neurotrophic disorders, which lead to morphological changes (fibrosis, reduction of the joint cavity). The disease can develop against the background of other pathologies: diabetes, cancer, myocardial infarction, stroke, hyperthyroidism.

Inflammatory process is most often associated with such causes:

• Prolonged load on the joint due to weight, sport or uncomfortable hand position.
• Professional factor: working specialties, athletes, musicians.
• Injuries and dislocations of bones.
• Diseases of the bone system.
• Secondary pathology on the background of autoimmune, infectious or allergic lesions.

Based on the known reasons, the capsulitis is divided into the following types:

1. Traumatic (post traumatic) - develops after injuries (dislocation, damage, penetrating wounds) and operations on this site.
2. Idiopathic - arises from unknown causes, but most often its appearance contributes to such factors:

• Infectious chronic diseases.
• Oncological diseases.
• Endocrine disorders.
• Mental disorders.
• Disorders from the circulatory and respiratory system.

The disease has a long course, which, with a constant effect of irritant factors, can lead to disability.

[9], [10], [11]

Risk factors

The exact causes of the diffuse lesion of the joints are not established, but doctors identify a number of risk factors for the capsulitis:

• Diseases of the musculoskeletal system.
• Diseases of the spine.
• Age over 40 years.
• Congenital deformities of joints or their underdevelopment.
• Hereditary predisposition.
• Subcooling.
• Frequent colds.
• Disorders of the cardiovascular system.
• Endocrine disorders.
• Mechanical injuries.
• An osteochondrosis in the anamnesis.
• Heart attack, stroke, heart muscle surgery.
• Long stay in a pose with your hands up.

Very often, a painful condition develops against the background of existing pathologies. Thus, the inflammatory process can occur in disorders of the nervous system or disorders of the respiratory system.

[12], [13], [14], [15], [16]

Pathogenesis

Degenerative processes are susceptible both to joints and periarticular tissues. Pathogenesis of the capsulitis is a kind of response of the body to their reactive inflammation. In this case, the most vulnerable places of attachment of tendons, articular bags and ligaments to the joint itself.

The mechanism of the development of the disease is associated with the impact of provoking factors (chronic or infectious diseases, hypothermia, stress, trauma). Failure in the immune system leads to the fact that the leukocytes begin to attack the joints of the body. Against this background, there are inflammatory reactions that cause severe pain and disrupt the mobility of the joints.

Often capsulitis develops against the background of arthritis. Diseases are subject to patients over 40 years of age, professional athletes and people whose work is associated with increased physical exertion.

[17], [18], [19], [20]

Symptoms of the capsulitis of the shoulder

Capsulitis is characterized by a gradual course, therefore the symptoms of the disease completely depend on the phase of inflammatory pathology.

Allocate such stages of the disease:

• Painful - lasts about 9 months with acute, aching pain with sharp movements.
• Peak - lasts less than a year, characterized by a violation of the functionality of the affected limb.
• Fading - lasts up to 3 years, recurs. The pain subsides temporarily and the mobility is restored, but after a while the pathology again makes itself felt.

Let us consider in more detail the symptoms of each stage of the inflammatory lesion of the synovial pouch and joint capsule:

1. Light pain that occurs after lifting weights and loads. The mobility of the affected limb is preserved, but there is a stiffness that does not make itself felt at rest.
2. Stiffness is accompanied by difficulties in performing normal movements. Painful sensations also make themselves felt at rest. Discomfort increases during the night, increases body temperature and worsens overall well-being.
3. Without proper treatment and in the absence of it, the disease becomes chronic. Pain becomes less pronounced, but sometimes there are sharp lumbago. Local signs of inflammation are almost not noticeable, but overall health worsens: sleep is disturbed and increased nervousness develops.
4. The disease takes an adhesive form, which is the most dangerous complication of the capsule. In the joint capsule, adhesions and adhesions appear. The adhesion process significantly reduces the mobility of the limb and intensifies the painful sensations. In rare cases, ankylosis occurs, which completely fetters movement. With strong adhesion, mobility is restored surgically.

[21], [22], [23]

First signs

In order to diagnose capsulitis, you should pay attention to the first signs of the disease:

• Limited amplitude of joint rotation.
• Painful sensations when moving.
• Deterioration of general well-being.

At the initial stage, there is slight discomfort in the affected limb, which increases after physical activity. The duration of the first signs is about 6 months. It is at this point that you need to seek medical help to prevent further progression of the disease.

Inflammatory disease affecting the synovial membrane of the shoulder joint is a capsulitis.

There are such reasons for diffuse lesion of the shoulder:

• Injuries and mechanical injuries.
• Exchange violations.
• Hormonal disorders.
• Arthritis.
• Osteochondrosis of the spine (thoracic and cervical department).
• Diseases of the cardiovascular system (ischemia, myocardial infarction).
• Hereditary predisposition.
• Prolonged static load on the shoulder.

The disease does not affect the bone base and cartilaginous articular surfaces. The prolonged course of the inflammatory process leads to the formation of dense fibrous scars in the joint. Because of this, the mobility of the shoulder is limited. The initiated stages proceed with adhesions between the articular surfaces of the bones. In this case, the patient is diagnosed with adhesive or adherent humeroscapular periarthritis.

Diagnosis of inflammatory pathology is based on its symptoms. Visual examination and collection of anamnesis allow the doctor to make a preliminary diagnosis. On a mandatory basis, capsulitis is differentiated with similar diseases. The patient is prescribed radiograph of the shoulder joint, MRI, ultrasound, arthrography, as well as a set of laboratory tests.

After the final diagnosis is made, a treatment plan is drawn up. Therapy consists of several stages. First of all, patients are prescribed painkillers (capsules, tablets, ointments, intramuscular injections). To prevent the transition of the disease to severe form and the development of adhesions, intra-articular injection of glucocorticosteroids and other anti-inflammatory drugs is indicated. In the process of rehabilitation, the patient is prescribed a course of physiotherapy and therapeutic gymnastics, a special diet and intake of vitamins.

[24], [25], [26]

Stages

The main difference between the inflammation of the synovial bag and the joint capsule from other joint lesions is that there are no lesions affecting the cartilage and other tissues. That is, all changes occur only in the synovial bag.

As the capsulitis progresses, the following stages of the disease are distinguished:

1. Light - painful sensations are insignificant and make themselves felt after prolonged exertion. In rare cases, slight stiffness occurs during movement.
2. Acute - elevated subfebrile body temperature, swelling of the affected area and pain. It is difficult to make movements, which adversely affects working capacity and overall well-being.
3. Chronic - the discomfort gradually subsides, but with movements appear lumbago. Affected joints wear out, limiting mobility. The patient suffers from sleep disorders and increased nervousness.
4. Complicated - severe damage to the joint capsule leads to disability. Intensive acute pains make themselves felt in any movement and at rest, completely limiting its functionality. On damaged shells spikes are formed, there is a risk of ankylosis.

Treatment of the disease in the early stages has a favorable prognosis. Later stages significantly complicate the treatment process and the recovery forecast.

[27]

Forms

Capsule is classified into several stages and species, which depend on the neglect of the disease and its symptoms.

The main types of pathology, depending on its causes:

• Post-traumatic - the disease develops after trauma: fractures, tendon ruptures, inflammatory and infectious processes.
• Idiopathic - this species is most often diagnosed in women aged 40 to 60 years. The main factor of the disease are violations of the circulatory and respiratory organs.

Most often, under the capsulitis is meant the defeat of the shoulder, but the pathological process can also capture other areas:

• Shoulder (shoulder) - the most common form of the disease. May occur due to metabolic disorders, shoulder or neck injuries, cervical osteochondrosis.
• Capsules of the elbow joint (the arm of a tennis player) - the most affected people are those whose work is associated with regular microscopic traumatism. At the initial stages of pain appear at elevated loads, and subsequently assume a chronic character.
• The defeat of the fingers - the pain and hyperemia of the periarticular tissues and their puffiness. Factors causing the disease are frequent hypothermia of the hands and increased pressure on the upper limbs.
• Knee - this type of inflammation is characterized by severe pain when flexing joints. Diseases are most affected by women after 40 years.
• Capsulitis of the ankle is a rare disease that occurs due to increased loads on the lower limbs.
• Defeat of the hip joint - another rather rare form of violation, is typical for people of advanced age. Patients complain of pain in the thigh area, giving to the knees and the shin. Discomfort occurs with physical activity and any movements.

All types of capsulitis have similar symptoms, treatment tactics and diagnostic methods.

[28]

Adhesive capsulitis

The total defeat of the joint capsule with severe pain and impaired mobility is an adhesive capsulitis. Chronic fibrosis is about 2-5% of all cases of the disease. The peculiarity of this form is that it can last for many years and have two outcomes: the functions of the affected joint are completely restored or irreversible complications develop.

Reasons for the adhesive form of periarthritis:

• Traumatic injuries.
• Postponed operations on the joints.
• Decreased physical activity.
• Excessive strain on the joints.
• Infectious and inflammatory diseases of the body in chronic form.
• Metabolic disorders, endocrine and hormonal disorders.

All of the above factors lead to the fact that the joint capsule loses its elasticity and hardens, disrupting mobility.

Symptoms of the adhesive form are characterized by long pain and limited mobility of the affected limb. It is chronic pain that causes the patient to seek medical help. But the complicated form of the disorder is difficult to treat.

To eliminate adhesion, drug therapy is indicated, and in particularly severe cases, surgical intervention is also indicated. The patient also has a long rehabilitation period. In especially neglected cases, the pathological condition leads to disability, that is, the loss of functionality of the affected limb.

[29], [30], [31]

Complications and consequences

Without timely diagnosis and treatment, capsulitis can lead to serious problems. The consequences and complications of the disease are most often manifested by such pathologies:

• Calcification of the joint.
• Transition of the disease into a chronic form.
• Limitation of mobility.
• Fibrous tissue fusion.
• Atrophy of the affected limb.
• Cyanosis and swelling.
• Ankylosis (partial or complete fusion of articular surfaces).

A prolonged course of the disease leads to sleep disorders due to persistent pain. The patient faces difficulties in performing movements and self-service. Against this background, the psychoasthenic syndrome develops and the loss of working capacity.

To avoid the development of consequences, the first painful symptoms should be consulted by a doctor and passed a set of diagnostic examinations. Treatment of inflammation in the early stages facilitates the recovery process and minimizes the risk of complications.

[32], [33], [34], [35]

Diagnostics of the capsulitis of the shoulder

In order to accurately establish the presence of inflammation of the synovial bag and joint capsule, it is necessary to undergo a series of examinations. Diagnosis begins by contacting a surgeon or orthopedic trauma specialist. The doctor collects an anamnesis and questions about when the painful symptoms first appeared, whether the injuries, operations or diseases of the musculoskeletal system preceded it.

At the next stage, the patient is examined and the stage of the disease is established:

• A simple form - pain in the joint with the removal of the affected limb, painful sensations during palpation, limited movements.
• Acute form - irradiating pain, severe limitation of movement, tenderness and swelling.
• Chronic - moderate pain, progressive limitation of movements, signs of mechanical blockade.

After the examination, the patient is prescribed a set of instrumental diagnostic methods: MRI, ultrasound, arthrography and radiography of the affected joint. It is also necessary to pass tests to identify signs of inflammation and assess the general condition of the body. If the results of the surveys do not give a clear picture, then differential diagnosis is carried out.

[36]

Analyzes

Diagnosis of any disease includes laboratory studies. Analyzes are necessary for an estimation of the general condition of an organism and revealing of features of a current of diagnosed illness.

If you suspect a capsulitis, the patient is prescribed such tests:

• The general analysis of blood - allows you to evaluate the stage of the inflammatory process, leukocytosis, ESR, erythrocytosis, the amount of C-reactive protein.
• The general analysis of urine - is spent for an exception of a gout, that is an acute inflammatory arthritis.
• Blood chemistry.
• A blood test for rheumatoid factor - allows to exclude rheumatoid arthritis.

According to the results, the doctor can make a final diagnosis or assign additional studies.

[37], [38], [39], [40], [41]

Instrumental diagnostics

Another important stage of the examination with suspicion of capsulitis is instrumental diagnostics. With the help of special equipment, the condition of the damaged joint and surrounding tissues is evaluated.

Most often, patients are assigned such a complex of instrumental examinations:

• Radiography - this method is the most informative in the late stages of the disease, as it allows you to see degenerative changes and calcification sites. In the early stages of inflammation, the X-ray makes it possible to differentiate the pathology from arthritis.
• Magnetic resonance and computed tomography - the data of the study give a detailed layered image of soft tissues and bones. Thanks to this, the doctor can draw conclusions about the stage of the disease and prescribe effective methods for its treatment.
• Arthroscopy is one of the most informative surveys. Using an endoscope, a visual assessment of the internal cavity of the synovial bag and other anatomical structures is performed. A sharp decrease in the volume of the joint cavity and the absence of an axillary pocket make it possible to confirm the capsulitis.
• Ultrasound examination of the joint - this method is considered to be of little informative, since its low resolution does not fix the diffuse fibrous changes in the thin tissues of the capsule. During the diagnosis, edema of the adjacent tendons can be detected, which occurs in tendinitis and other injuries of the musculoskeletal system.

The above studies are carried out not only at the stage of diagnosis, but also in the treatment process to determine the dynamics of the disease and the effect of the therapy.

Differential diagnosis

As a rule, the diagnosis of the capsulitis is not difficult. But in the early stages of the disease the disease needs differentiation, since its symptoms are smeared and similar to other pathologies of the musculoskeletal system.

Differential diagnosis is performed by the method of elimination and is compared with arthritis and arthrosis, lesions of the cervical spine, degenerative processes in the joints and periarticular tissues.

Comparison of the capsulitis is most often performed with such diseases:

Symptoms / Disease	Capsule	Arthritis	Osteoarthritis
Pain, swelling and local fever	Pain occurs during movement, there is a small puffiness. Painful points are palpable. The temperature in the affected area is increased.	The pain is spontaneous and increases with any movement. The joint is edematous and painful, the local temperature is increased. When palpation there are sharp lumbago.	With any movements, pain occurs, there is no swelling, as well as a rise in temperature at the site of the lesion. With palpation, slight discomfort can occur.
Changes in joints and surrounding tissues	Deformation is absent.	There is deformation of the joints and changes in soft tissues.	Expressed degenerative changes due to bone growths in the joints.
Movement in the joint	Partially limited	The joint is immobilized	Saved
Movement of the limb	Not violated	There are restrictions	Slightly limited
Laboratory research	The picture of the blood is normal. In the acute phase there is an increase in ESR.	In the blood, C-reactive protein, increased ROE, seromucoid and fibrinogen.	Without changes
Radiography	At the last stages of the disease, calcifications and periostitis are revealed.	The joint gap is narrowed, there is osteoporosis of the epiphyses, on the joint surfaces of erosion.	Articular fissures are narrowed, there are osteophytes and a subchondral form of osteosclerosis.

Differential diagnostics deals with a number of specialists: therapist, surgeon, orthopedist, neurologist, rheumatologist. For research use a full range of diagnostic procedures, that is, both laboratory and instrumental methods.

Treatment of the capsulitis of the shoulder

Medicamentous treatment of the capsulitis is carried out at the first stages of the disease to stop the inflammatory process and reduce pain. Medicines are chosen by the doctor, individually for each patient.

Prevention

For the prevention of neurodystrophic diseases and minimizing the risk of developing a capsulitis, one should adhere to such recommendations:

• Exercise regularly with moderate exercise.
• With prolonged exertion on one joint, observe the rest regime and do massages.
• In time, treat infectious and inflammatory diseases of the body.
• Avoid injuring joint situations. Danger is not only a macro, but also micro-trauma.
• Take vitamins and adhere to a balanced diet.

The above preventive measures help to protect the body from injuries of the musculoskeletal system and the transition of degenerative diseases to a chronic form.

[42], [43], [44]

Forecast

Capsulitis has a favorable prognosis provided that the disease was diagnosed at an early stage and effective treatment was prescribed. In this case, the patient has a high chance of full recovery within a short period of time. If the periarthritis has passed into a chronic form, then the treatment may take more than one year. Lack of medical care leads to a complete loss of mobility of the joint, disability of the patient and loss of ability to work.

[45], [46]