**6. Analgesic techniques in treatment of chronic pain**

The term "painful shoulder" encompasses all processes that determine pain in the anatomical region of the shoulder. "Painful shoulder syndrome" is a frequent and incapacitating pathology of diverse etiology and complex diagnosis. The causes of painful shoulder are multiple (**Table 2**). We should always ask if we are facing a disease of the shoulder or if it is a pain referred from another location.


**Table 2.** Etiology of painful shoulder.

alternative in certain groups. To date, there have been no extensive trials comparing the efficacy and safety of the two, which could cause some reluctance to adopt suprascapular block-

**Figure 2.** Ultrasound view of brachial plexus block at interscalene level. ASM, anterior scalene muscle; MSM, medium

Good studies have recently appeared in this line. Dhir et al. [11] carried out a study with 60 patients in which they analyzed the combined blockade of the suprascapular and axillary nerves, comparing it with the interscalene brachial plexus block. They observed that the combined block provides nonequivalent analgesia compared to interscalene block in arthroscopic shoulder surgery. They conclude that while combined blockade provides better quality pain relief at rest and fewer adverse effects at 24 hours, interscalene block provides better postoperative analgesia. Therefore, for arthroscopic shoulder surgery, combined blockade may be a clinically acceptable analgesic option with a different analgesic profile compared to intersca-

However, Wiegel et al. [12] in a very recent study with 329 patients comparing the combined blockade of the suprascapular and axillary nerve with the interscalene blockade as analgesic techniques in arthroscopic shoulder surgery concluded that for outpatients subjected to arthroscopic surgery under general anesthesia, combined blockade seems preferable to interscalene. It provides excellent postoperative analgesia without exposing patients to alterations

In the immediate postoperative period, the patients present a very intense pain during the first hours. It is necessary to apply analgesic guidelines to control it, such as the combination

ade as the regional technique of choice for shoulder surgery [10].

in mobility and the risks of interscalene blockade.

**5. Postoperative analgesic techniques**

of nonsteroidal anti-inflammatory drugs and intravenous opioids.

lene blockade.

scalene muscle; BP, brachial plexus.

160 Advances in Shoulder Surgery

The most common symptom in the shoulder is pain. The patient's age, nature, and evolution of pain often lead to diagnosis. It is important to observe its onset, periodicity, location, character, irradiation, concomitant symptoms, and factors that aggravate or alleviate it. The radicular pain that radiates from the cervical region of the shoulder is almost always lacerating; on the other hand, the pain of tendinitis is diffuse, deaf, and continuous.

than a combined physiotherapeutic approach (mobilization, exercise, and electrotherapy) in improving the main complaint at 3, 7, and 13 weeks, but not later. This benefit was maintained when combined with a second study that evaluated short-term pain and did not demonstrate

Integral Management in Painful Shoulder Treatment: Anesthesiologist's Point of View

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Several studies have evaluated the use of hyaluronic acid in the treatment of shoulder pain. The study by Abellán et al. [13] compared the treatment with subacromial infiltrations with hyaluronic acid and those of corticosteroids, considered as the gold standard, in the treatment of conservative treatment resistant shoulder pain. The results show that subacromial infiltration of hyaluronic acid decreases pain and improves joint function in the same way as corticosteroids. Corticosteroids improve the patients faster, while with hyaluronic acid the

Infiltrations would be indicated in the case of poor recovery 4–8 weeks after conservative treatment and in patients with severe pain limiting rehabilitation treatment. The following are

With corticosteroids, local anesthetic, NSAIDs or combined, it is not recommended to make

**1.** Infiltration of the acromioclavicular joint: with the patient seated and the upper limbs resting on their thighs, the physician should be placed in front, in an anterior position and lateral to the shoulder to infiltrate. To identify the joint, it is useful to palpate the lateral epiphysis of the clavicle in the medial-lateral direction to locate a small depression usually

**2.** Infiltration of the glenohumeral joint: it can be approached by posterior or anterior route, in the latter the anatomical relations are more important. With the patient seated and the upper limbs resting on their thighs we will position laterally to the shoulder to infiltrate, and placed in a plane anterior or posterior to the shoulder according to the way of approach. The poste-

**3.** Infiltration of the subacromial space: it is an efficient and economic technique, which has a double function, on the one hand, clinical confirmation of the diagnosis in the pathology of the rotator cuff and the subacromial syndrome and, on the other hand, its symptomatic treatment in both processes. There are several introduction windows in the subacromial space, but the most recommended and used in the clinic are the following two (**Figure 3**):

**a.** *Lateral path*: The puncture window is located in the space between the acromion and the humeral head, on the lateral side of the shoulder. The patient is placed with the shoulder in neutral position, with the elbow in 90° flexion and the hand on the thigh of the same side.

**b.** *Posterior path*: The puncture window is located just below the acromion on the posterior side of the shoulder. With the patient in the same anterior position, we placed behind this and located the posterolateral edge of the acromion, marking the point of infiltration just below it.

painful under pressure. Injection can be done by superior or anterior approach.

rior route is the safest route and the least technical complication.

improvement is progressive, presenting the same results at 6 months.

significant differences between groups.

the most frequent infiltration techniques:

**6.1. Intra-articular infiltration**

more than three infiltrations.

Subacromial syndrome (SAS), associated or not with rotator cuff tears, is a common cause of shoulder pain, especially in manual workers and athletes involving throwing. The most frequent clinical manifestation of this pathology is through a painful arch pattern between 90 and 120° of abduction. However, SAS can also be presented by a capsular pattern, appearing as a rigid shoulder, or with a pseudoparalytic pattern, in which the main manifestation is impotence for shoulder elevation. This pattern indicates a massive lesion of the rotator cuff with alteration of the kinematic pattern of the shoulder. Finally, a mixed pattern may appear in which several forms of presentation are manifested associated with each other [13].

There is a wide range of painful shoulder treatments beginning with conservative treatment, physical therapies with rest, thermal, physiotherapeutic exercises, drug treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics, and joint blockages. Radiofrequency techniques are proposed as a therapeutic alternative in cases refractory to the treatments described.

We have several therapeutic options. Conservative treatment is the first step among the different nonpharmacological alternatives. Modifying daily activity is a simple treatment to decrease shoulder pain. Specific recommendations based on avoiding or decreasing painful activity are the basis of treatment in rotator cuff pathology, glenohumeral joint arthritis, and adhesive capsulitis. Avoiding movement above the head eludes the painful arch between 60 and 120° [6]. There are therapeutic modalities designed to relieve pain directly: cold and heat, ultrasound, iontophoresis, as well as stretching and strengthening [14] exercises that aim to improve overall shoulder function.

In a systematic review, Camarinos et al. concluded that the benefit of nonpharmacological interventions is based on improving mobility, although improvement in function and quality of life is questionable. Fortunately, we also have a broad pharmacological array, although few medications are specifically approved for the treatment of chronic shoulder pain. Most of these are indicated only for bursitis [15]. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be effective in 50–67% of patients, but have only been evaluated in short periods of time. There are no randomized studies comparing the effectiveness of NSAIDs with other analgesics or with a more conservative approach.

Due to the lack of oral medication and the lack of existing evidence, it is necessary to use different nonsurgical therapeutic alternatives [16]. Among the invasive techniques, intra-articular infiltration is a relatively simple technique that can provide adequate pain control. Intra-articular injection of corticosteroids provides better pain relief than oral NSAIDs in the short term.

A recent Cochrane [15] review comparing intra-articular injection with other nonphysiotherapeutic treatment interventions and including a multiple outcome study evaluated at many time points shows that intra-articular corticosteroid injection is significantly more beneficial than a combined physiotherapeutic approach (mobilization, exercise, and electrotherapy) in improving the main complaint at 3, 7, and 13 weeks, but not later. This benefit was maintained when combined with a second study that evaluated short-term pain and did not demonstrate significant differences between groups.

Several studies have evaluated the use of hyaluronic acid in the treatment of shoulder pain. The study by Abellán et al. [13] compared the treatment with subacromial infiltrations with hyaluronic acid and those of corticosteroids, considered as the gold standard, in the treatment of conservative treatment resistant shoulder pain. The results show that subacromial infiltration of hyaluronic acid decreases pain and improves joint function in the same way as corticosteroids. Corticosteroids improve the patients faster, while with hyaluronic acid the improvement is progressive, presenting the same results at 6 months.

Infiltrations would be indicated in the case of poor recovery 4–8 weeks after conservative treatment and in patients with severe pain limiting rehabilitation treatment. The following are the most frequent infiltration techniques:
