Periarthritis scapulohumeraris (Frozen shoulder)

Japanese: 肩関節周囲炎（五十肩） - けんかんせつしゅういえん（ごじゅうかた）（英語表記）Periarthritis scapulohumeraris (Frozen shoulder)

What is the disease?

Shoulder pain that occurs after middle age (especially in people in their 50s) pain ( To ) ) and movement restriction ( Contracture ( Education ) It is a general term for diseases accompanied by inflammation of the shoulder joint and surrounding tissues, causing various symptoms depending on the area and level of inflammation.

There has been much discussion about the definition of frozen shoulder, but currently there are two common definitions: broad and narrow. In the broad definition, it is the same as periarthritis of the shoulder, but in the narrow definition, it is a shoulder joint injury accompanied by pain and contracture ( Frozen Shoulder ( Receiving ) ) refers to

What is the cause?

The bones and cartilage that make up the joints ligament ( Constitution ) or tendon ( sword ) The main cause is thought to be inflammation of the tissues surrounding the shoulder joint caused by aging (degeneration) of the shoulder joint. The area where this inflammation occurs is the sac ( Subacromial bursa ( Health and Welfare Law ) ), the sac that surrounds the joint (joint capsule), and the shoulder muscles Humeral head ( Senior citizen ) where the arm muscles attach to the shoulder blade (rotator cuff) Long head of biceps ( The Jowan Tokincho Token ) ) (Figure 62). The subacromial bursa and joint capsule adhesion ( Yuchaku ) This can then lead to further loss of shoulder movement (contracture or frozen shoulder).

How symptoms manifest

It is characterized by pain in the shoulder or from the shoulder to the upper arm and reduced joint movement. Depending on the symptoms and timing, it is classified into three stages: acute (pain is at its strongest), chronic (pain is relieved but movement restriction (contracture) remains), and recovery (joint contracture improves).

In the acute phase, pain is mainly felt in the inflamed rotator cuff and subacromial bursa, but inflammation may also spread to the surrounding tissues, causing pain over a fairly wide area around the shoulder. The pain is intense even when at rest (rest pain) and is particularly severe at night. The pain is not only felt in the shoulder, but sometimes radiates from the shoulder to the upper arm.

The pain worsens at night when the shoulder gets cold or when the humerus is pulled while sleeping. Subacromial sliding mechanism ( Health and Sports Examination ) It is believed that prolonged pressure on the joints is the cause. In such cases, getting up and sitting with your arms down may help relieve the pain.

In addition, in daily life, putting on and taking off clothes, tying an obi, bathing (washing the body and hair), using the toilet, and using the arms ( Upper limbs ( Victory ) Pain occurs or worsens when trying to lift the shoulder (pain during movement). Therefore, shoulder joint movement is significantly restricted.

When the acute phase passes and the condition becomes chronic, the pain at rest disappears. However, pain is felt when raising the arm (upper limb), and the movement of the shoulder joint is restricted. In particular, the internal and external rotation of the shoulder joint is often restricted.

During the recovery period, restrictions on movement will gradually improve and pain during movement will disappear.

Testing and diagnosis

In addition to periarthritis, shoulder pain can occur due to shoulder tendon injury, shoulder rotator cuff injury, and calcific tendonitis.

These are differentiated (differential diagnosis) by X-rays, arthrography, MRI, ultrasound, etc. X-rays do not show abnormal findings specific to shoulder periarthritis, so they are performed to exclude the diseases mentioned above.

Treatment methods

During the acute phase when the pain is severe, resting with a sling or arm bandage (it is important to position the limb so that it is not painful) and taking anti-inflammatory analgesics orally or by injection are effective. Once the acute phase has passed, physical therapy such as heat therapy (hot packs, baths, etc.) and exercise therapy (to prevent contractures and strengthen muscles) are performed. As a rule, physical therapy should be performed after the inflammation has subsided.

If these methods do not improve the condition, intra-articular pumping under fluoroscopic guidance, in which saline containing a local anesthetic is repeatedly injected to expand the joint capsule, or surgery may be recommended. Surgery involves inserting an arthroscope under anesthesia to remove adhesions. Peeling ( Peeling ) Methods such as arthroscopic passive joint manipulation are currently being performed.

What to do if you notice an illness

It may heal naturally, but if left untreated, not only will it impair daily life, but the joints may become adhered and unable to move.

The rule of thumb is to rest during the acute phase, but some people may endure the pain and try to move. If you force yourself to move, the tissue (edema) caused by inflammation around the shoulder will be damaged by strong friction, and if it gets worse, the rotator cuff may be damaged. In order to avoid this condition, we recommend that you visit an orthopedic surgeon.

Hiroyasu Ikegami

Figure 62. Tissues around the shoulder joint
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Figure 62. Tissues around the shoulder joint

Source: Houken “Sixth Edition Family Medicine Encyclopedia” Information about the Sixth Edition Family Medicine Encyclopedia

Japanese:

どんな病気か

　中年以降（とくに50代に多い）に発生する、肩関節の痛み（疼痛(とうつう)）と動きの制限（拘縮(こうしゅく)）を伴う病気の総称です。肩関節とその周辺組織に炎症を来すため、炎症を起こしている部位、炎症の程度によりさまざまな症状を起こします。

　五十肩の定義についてはいろいろな議論がありましたが、現在では広義と狭義の2つのとらえ方が一般的です。広義の定義では肩関節周囲炎と同じですが、狭義では疼痛と拘縮を伴う肩関節（凍結肩(とうけつかた)）のことをいいます。

原因は何か

　関節を構成する骨、軟骨、靱帯(じんたい)や腱(けん)などが老化（変性）して肩関節の周囲組織に炎症が起きることが、主な原因と考えられています。この炎症が起こる部位は、肩関節の動きをよくする袋（肩峰下滑液包(けんぽうかかつえきほう)）、関節を包む袋（関節包）、肩の筋肉が上腕骨頭(じょうわんこつとう)に付くところ（腱板）、腕の筋肉が肩甲骨に付くところ（上腕二頭筋長頭腱(じょうわんにとうきんちょうとうけん)）などがあります（図62）。肩峰下滑液包や関節包が癒着(ゆちゃく)すると、さらに肩の動きが悪くなります（拘縮または凍結肩）。

症状の現れ方

　肩あるいは肩から上腕への疼痛と関節の動きが悪くなることです。症状と時期によって急性期（疼痛が最も強く現れる）、慢性期（疼痛は軽快しているが運動制限（拘縮）が残っている）、回復期（関節拘縮が改善する）の3段階に分類されます。

　急性期では、炎症を起こした腱板や肩峰下滑液包の痛みが主ですが、周辺組織に炎症が広がる場合もあり、肩周辺のかなり広い範囲に疼痛を感じます。安静にしていても痛みは強く（安静時痛）、夜間に激しいのが特徴です。その痛みは肩だけでなく、時に肩から上腕にも放散します。

　夜間に痛みが強くなるのは、肩が冷えることや、寝ている時に上腕骨の肩峰下滑動機構(けんぽうかかつどうきこう)に長時間圧力が加わることが原因と考えられています。このような場合、起き上がって座位で腕を下げておくと、痛みが軽減することもあります。

　また、日常生活で衣服の着脱、帯を結ぶ動作、入浴時（体や髪を洗う動作）、トイレや、腕（上肢(じょうし)）を上に挙げようとする動きによって痛みが出たり、強くなったりします（運動時痛）。そのため、肩関節の動きはかなり制限されます。

　急性期が過ぎて慢性期になると、安静時痛は消失します。しかし、腕（上肢）を挙げていく途中で痛みを感じ、肩関節の動きが制限されています。とくに肩関節の内旋・外旋制限が残ることが多いです。

　回復期になると運動制限も徐々に改善して、運動時痛も消失します。

検査と診断

　肩関節に起こる痛みには、肩関節周囲炎のほかに、肩腱板損傷(けんけんばんそんしょう)、肩石灰沈着性腱炎(けんせっかいちんちゃくせいけんえん)などがあります。

　これらは、X線撮影、関節造影検査、MRI、超音波検査などで区別（鑑別診断）します。X線像では肩関節周囲炎に特異的な異常所見はないので、前記した疾患を除外するために行われます。

治療の方法

　痛みが強い急性期には、三角巾・アームスリングなどで安静を図り（痛みを感じない肢位をとることが大切）、消炎鎮痛薬の内服、注射などが有効です。急性期を過ぎたら、温熱療法（ホットパック、入浴など）や運動療法（拘縮予防や筋肉の強化）などの理学療法を行います。理学療法は炎症症状が治まってから行うのが原則です。

　これらの方法で改善しない場合は、局所麻酔薬入りの生理食塩水で関節包を広げるように注入を繰り返す透視下関節内パンピングや、手術をすすめることもあります。手術は麻酔下に関節鏡を挿入して癒着を剥離(はくり)する方法（関節鏡視下関節受動術）などが行われています。