**6.1. Intra-articular infiltration**

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 lacerat-

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].

treatments described.

162 Advances in Shoulder Surgery

improve overall shoulder function.

sics or with a more conservative approach.

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

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

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 analge-

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

ing; on the other hand, the pain of tendinitis is diffuse, deaf, and continuous.

With corticosteroids, local anesthetic, NSAIDs or combined, it is not recommended to make more than three infiltrations.


**Figure 3.** Infiltration of the subacromial space.

#### **6.2. Suprascapular nerve block**

Suprascapular nerve block appears to be effective in the treatment of chronic shoulder pain secondary to degenerative diseases and inflammatory diseases using injections of local anesthetic and corticosteroids. It also allows an early rehabilitation with adequate range of movements after reconstruction of shoulder or joint prosthesis. The development of ultrasound and the availability of echographs in the pain units have made it possible to use this technology to perform the blockade in a quick, simple, and practically free of complications.

anterior joint capsule, and innervates the humeral head and upper humeral neck. It has a cutaneous branch, which contributes sensitivity of the skin on the deltoids. To achieve more complete analgesic control of the shoulder joint, including the anterior region, we can perform a combined treatment of the suprascapular nerve and the axillary nerve. Therefore, axillary nerve block is performed as a complement to suprascapular nerve block to improve analgesic quality. In order to perform this ultrasound-guided block, we place the patient in a sitting or lateral position with the affected shoulder above. We will use a linear high frequency transducer (6–13 MHz). We performed an initial scan at the posterior border of the arm at the deltoid level and identified the humeral head and the deltoid muscle. Between both the axillary

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Radiofrequency was first used in the early 1950s. Cosman and Cosman [17, 18] described the use of high frequency currents (in the radiofrequency range) to produce lesions. A few years later, Sweet and Wepsic [19] made a second breakthrough in this field when he developed the first temperature-controlled radiofrequency system to produce lesions for the treatment of

Currently, the use of electric currents by radiofrequency is a widely used clinical technique in the field of chronic pain treatment. It is a minimally invasive, percutaneous access technique in most cases, consisting of the application of a radiofrequency electric field (around 500 kHz)

nerves appear as a rounded and hyperechoic image (**Figure 5**).

**6.4. Radiofrequency techniques**

**Figure 4.** Ultrasound view suprascapular nerve.

trigeminal neuralgia.

In order to perform this ultrasound-guided block, we place the patient in a sitting or lateral position with the affected shoulder above. We will use a linear high frequency transducer (6–13 MHz). We performed an initial scan in sagittal orientation at the medial border of the scapula to identify the pleura. Later, we scan laterally with this orientation and move the transducer to visualize the spine of the scapula. If we move it cephalically, we will find the suprascapular fossa. If we move the transducer laterally, maintaining a transverse orientation, to identify the supraspinatus muscle and the suprascapular fossa, we will find the nerve as a round, hyperechoic image below the transverse scapular ligament in the scapular notch (**Figure 4**).

#### **6.3. Axillary nerve block**

As we have discussed at the beginning of the chapter, this nerve provides motor innervation mainly to deltoids and teres minor, provides sensitive innervation to the lower, lateral, and Integral Management in Painful Shoulder Treatment: Anesthesiologist's Point of View http://dx.doi.org/10.5772/intechopen.69914 165

**Figure 4.** Ultrasound view suprascapular nerve.

**6.2. Suprascapular nerve block**

164 Advances in Shoulder Surgery

**Figure 3.** Infiltration of the subacromial space.

scapular notch (**Figure 4**).

**6.3. Axillary nerve block**

Suprascapular nerve block appears to be effective in the treatment of chronic shoulder pain secondary to degenerative diseases and inflammatory diseases using injections of local anesthetic and corticosteroids. It also allows an early rehabilitation with adequate range of movements after reconstruction of shoulder or joint prosthesis. The development of ultrasound and the availability of echographs in the pain units have made it possible to use this technology to

In order to perform this ultrasound-guided block, we place the patient in a sitting or lateral position with the affected shoulder above. We will use a linear high frequency transducer (6–13 MHz). We performed an initial scan in sagittal orientation at the medial border of the scapula to identify the pleura. Later, we scan laterally with this orientation and move the transducer to visualize the spine of the scapula. If we move it cephalically, we will find the suprascapular fossa. If we move the transducer laterally, maintaining a transverse orientation, to identify the supraspinatus muscle and the suprascapular fossa, we will find the nerve as a round, hyperechoic image below the transverse scapular ligament in the

As we have discussed at the beginning of the chapter, this nerve provides motor innervation mainly to deltoids and teres minor, provides sensitive innervation to the lower, lateral, and

perform the blockade in a quick, simple, and practically free of complications.

anterior joint capsule, and innervates the humeral head and upper humeral neck. It has a cutaneous branch, which contributes sensitivity of the skin on the deltoids. To achieve more complete analgesic control of the shoulder joint, including the anterior region, we can perform a combined treatment of the suprascapular nerve and the axillary nerve. Therefore, axillary nerve block is performed as a complement to suprascapular nerve block to improve analgesic quality.

In order to perform this ultrasound-guided block, we place the patient in a sitting or lateral position with the affected shoulder above. We will use a linear high frequency transducer (6–13 MHz). We performed an initial scan at the posterior border of the arm at the deltoid level and identified the humeral head and the deltoid muscle. Between both the axillary nerves appear as a rounded and hyperechoic image (**Figure 5**).

#### **6.4. Radiofrequency techniques**

Radiofrequency was first used in the early 1950s. Cosman and Cosman [17, 18] described the use of high frequency currents (in the radiofrequency range) to produce lesions. A few years later, Sweet and Wepsic [19] made a second breakthrough in this field when he developed the first temperature-controlled radiofrequency system to produce lesions for the treatment of trigeminal neuralgia.

Currently, the use of electric currents by radiofrequency is a widely used clinical technique in the field of chronic pain treatment. It is a minimally invasive, percutaneous access technique in most cases, consisting of the application of a radiofrequency electric field (around 500 kHz)

**Author details**

José Miguel Esparza Miñana

Manises, Valencia, Spain

2012;**38**(1):40-43

2008;**10**:547-553

2009;**17**:206-215

Diseases. 1995;**5**(4):959-964

**References**

Address all correspondence to: miespmi@gmail.com

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plexus bloc. Anesthesia and Analgesia. 2004;**99**:589-592

Hombro. Médica Panamericana; 2011. pp. 141-149

Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Hospital de

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167

[1] Esparza Miñana JM, Londoño Parra M, Villanueva Pérez VL, De Andrés Ibáñez J. Nuevas alternativas en el tratamiento del síndrome de hombro Doloroso. Semergen.

[2] Dias D, Matos M, Daltro C, Guimarães A. Clinical and functional profile of patients with the painful shoulder syndrome (PSS). Ortopedia Traumatologia Rehabilitacja.

[3] Benítez Pareja D, Trinidad Martín-Arroyo JM, Benítez Pareja P, Torres Morera LM. Estudio e intervencionismo ecoguiado de la articulación del hombro. Revista de la

[4] Camarinos J, Marinko L. Effectiveness of manual physical therapy for painful shoulder conditions: A systematic review. Journal of Manual and Manipulative Therapy.

[5] Van der Windt DA, Koes BW, De Jong BA, Bouter LM. Shoulder disorders in general practice: Incidence, patient characteristics, and management. Annals of Rheumatic

[6] Burbank KM, Stevenson JH, Czarnecki GR, Forfman J. Chronic shoulder pain: Part II.

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[8] Van Zundert J, de Louw A, Joosten E, Kesseles AG, Honig W, Federen PJ, et al. Pulsed and continuous radiofrequency current adjacent to the cervical dorsal root ganglion of the rat induces late cellular activity in the dorsal horn. Anaesthesiology. 2005;**102**:125-131

[9] Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopy shoulder surgery: A comparison of intraarticular analgesia, suprascapular nerve block and interscalene brachial

[10] Heron M, Dattani R, Smith R. Interscalene vs suprascapular nerve block for shoulder

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**Figure 5.** Ultrasound view axillary nerve.

around a tissue, through an applicator, that produces a modification in the treated target tissue, and consequently an alteration in the transmission of the painful stimulus.

The pulsed radiofrequency method (RFp) was initially used by Sluijter et al. [20]. To date, it has been used for the treatment of peripheral nerves and the dorsal root ganglion. It has been commonly applied for the treatment of low back pain, neck pain, and neuropathies with very good results. An advantage of RFp over conventional radiofrequency (RF) is that it generates very little discomfort and can be performed with very little or no pain on the patient while the technique is being performed.

The application of pulsed radiofrequency on the suprascapular nerve has proven to be an effective method in the treatment of shoulder pain, with a decrease in pain that allows the rehabilitation of patients [21]. On the other hand, it prevents repetitive infiltrations with local anesthetics and corticosteroids, which are not without undesirable effects [8, 22]. In order to achieve more complete analgesic control of the shoulder joint, including the anterior region, we can perform a combined treatment of the suprascapular nerve and the circumflex nerve.

In an observational study involving 16 patients with painful shoulder (13 patients with rheumatoid arthritis and 3 with osteoarthritis) and limited active movement of the joint, a combined block of the suprascapular nerve and the articular branches of the circumflex were performed. A mean reduction in pain intensity of 69% was observed with an improvement in ranges of motion (abduction, adduction, and flexion) that increased from 36 to 67% over a 13-week follow-up period [23].

The combined pulsed radiofrequency on the suprascapular nerve and on the axillary or circumflex nerve has been scarcely studied with very few references in the literature. Since the innervation of the shoulder joint is largely collected by these two nerves, the treatment by pulsed radiofrequency technique on suprascapular nerve and axillary or circumflex nerve can provide a complete and lasting relief of this pathology. In any case, more well-designed studies are needed to define the role of the combined technique in the treatment of the painful shoulder.
