**The Role of Physical Medicine and Rehabilitation in Shoulder Disorders Shoulder Disorders**

**The Role of Physical Medicine and Rehabilitation in** 

10.5772/intechopen.70344

Raoul Saggini, Simona Maria Carmignano, Lucia Cosenza, Tommaso Palermo and Rosa Grazia Bellomo Lucia Cosenza, Tommaso Palermo and Rosa Grazia Bellomo Additional information is available at the end of the chapter

Raoul Saggini, Simona Maria Carmignano,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70344

#### **Abstract**

Shoulder pain is a common problem and it is responsible for a high proportion of patients presenting to general practice, causing work absenteeism and claims for sickness. A lot of factors and conditions can contribute to shoulder pain. The most prevalent cause is rotator cuff tendinitis; its relevance is correlated not only to its high prevalence rate but also to the fact that is disabling, causing high direct and indirect cost in industrialized country. Other causes of shoulder pain are shoulder impingement syndrome, calcific tendonitis, frozen shoulder, etc. In this context, physical medicine and rehabilitation plays a fundamental role. The conservative approach consists of several interventions. The aim is to decrease shoulder pain and to regain shoulder function, with the goal to reduce the degree of impingement, decreasing swelling and inflammation, and to minimize the risk of further injuries. The purpose of this chapter is to give an overview about shoulder disorders and their conservative treatment by means of physical therapy.

**Keywords:** shoulder disorders, physical therapy, rehabilitation, rotator cuff, frozen shoulder, ESWT

#### **1. Introduction**

Shoulder pain is a widespread problem and is responsible for a high percentage of patients presenting to general practice, causing absenteeism and labor complaints for sickness [1].

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

A lot of factors and conditions may contribute to shoulder pain. The most common cause is rotator cuff tendinopathy; its importance is linked not only to its high prevalence rate, but also because it is a disabling condition, causing high costs for health service [2].

reaches maximum abduction and extrarotation [14, 17, 18]. When shoulder joint is in neutral position, rotator cuff muscles contribute equally in providing anterior stability [19]. However, with glenohumeral joint in end-range abduction, subscapularis is a less effective stabilizer

The Role of Physical Medicine and Rehabilitation in Shoulder Disorders

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The "concavity compression" is an important stability mechanism. The compression of the humeral head (convex), exercised by muscles of the rotator cuff, on the glenoid cavity (concave), maintains stable humeral epiphysis, in relation to translational forces. Resistance to joint subluxation is directly proportional to the depth of the articular concavity and to the compression force exerted by the muscles of the rotator cuff [15]. Concavity compression, providing stability of glenohumeral joint, also depends on the extension of glenoid's articular

Stabilization function is made evident when the disease is established; in fact, a rotator cuff tear results in the inefficiency of this mechanism with the consequent sliding of the humeral head upward. This is due to the action of the upper fibers of the deltoid muscle, resulting in a

The action of the rotator cuff muscles must be highly coordinated to be able to perform a specific movement. The muscles must work in coordination, as the rotation of the glen humeral

Tension loads acting on rotator cuff tendons can be divided into two types: concentric and eccentric. Concentric ones are generated when humerus has the same direction of cuff muscle, as it happens during abduction against resistance. These loads are better tolerated by the cuff insertion, which clears the acromion at low angles of elevation, protecting it from impingement by the coracoacromial arch. Eccentric tension loads are produced when the arm movement is opposed to the direction of cuff muscles direction. This occurs in example during active resistance to a downward force applied on the humerus. In fact, when the humeral head rotates with respect of the scapula, bending loads stress cuff tendons; cuff elasticity permits to resist these loads. Rotator cuff tendons are also subjected to compressive loads; an upwardly load presses the cuff between the humeral head and the coracoacromial arch [24]. Furthermore, it has demonstrated a morphologic adaptation of the supraspinatus tendon

with fibrocartilaginous areas in regions of compression, due to mechanical forces [25].

Every rotator cuff muscle origins on the scapula, which therefore influences the activity of these muscles. Therefore, rotator cuff performance is strictly related to the functional state of the scapula. When this bone is well stabilized, thus presenting the proper position in both static and dynamic tasks, it permits rotator cuff to work at an optimal level. However, alterations in scapular kinematics produce an unstable support to rotator cuff and consequently it affects the biomechanics of the shoulder. Scapular dysfunctions may be causative in rotator cuff disorders or may be the result of rotator cuff injuries, increasing the alteration [26].

Many authors have studied scapula kinematics in patients with rotator cuff diseases; alterations in scapular function have been found in most studies. In subjects with clinical symptoms or imaging demonstrating rotator cuff disorders, studies have demonstrated biomechanics alterations, especially scapular dyskinesia [27]. Possible alterations are not consistent, with

than other muscles, while the biceps brachii starts to play a role in joint stability [20].

surface (glenoid arc) available to accommodate humeral head [21].

subacromial impingement [22].

joint does not have a fixed axis [23].

As mentioned, rotator cuff injury is one of the most common shoulder disorders. Among these, the most common are tendinosis, partial thickness tear, and complete rupture. The incidence of the cuff injuries varies from 5 to 39%; it increases in the elderly population, being approximately 6 and 30%, respectively in patients aged below and above 60 years [3].

In this context, physical medicine and rehabilitation plays a fundamental role. The conservative approach consists of several interventions. The aim of these is to decrease shoulder pain and to regain shoulder function, with the goal to reduce the degree of impingement, decreasing swelling and inflammation, and minimizing the risk of further injuries. Many studies have shown that conservative therapy is the first-line treatment for shoulder disorders, in fact rehabilitative approach allows a reduction in pain feeling and symptoms within few weeks [4].

In literature, several studies have proposed conservative treatment for shoulder diseases, such as non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, stretching and strengthening exercises, manual therapy, and physical energies (cryotherapy, extracorporeal shock wave therapy (ESWT), laser therapy, ultrasounds, etc.) to reduce pain feeling and restore shoulder range of motion (ROM) and function.

The purpose of this chapter is to give an overview about shoulder disorders and their conservative treatment by means of physical therapy, reviewing scientific researches, and merging it with our experience in this field. Rehabilitation of shoulder disorders is not easy, because its complex function, which involves not only local structures integrity, but also biomechanics contribution, form other body subsystems. For this reason, it is important to highlight the need of establish a global rehabilitative approach.
