**5. Conservative approach**

and cervical spine alignment that alters the scapula's rest position [82]. Postural abnormalities related to shoulder pain, include extension of the atlanto-occipital joints, reduction of physiological cervical lordosis, increase of dorsal kyphosis, protrusion (abduction) of the scapula with rotation downward and internal rotation of the humerus. All these results in neuro-

A thorough collection of the patient's medical history is used to detect if pain origins really from shoulder whether it is a referred pain from other anatomical structures. It is frequently reported that the pain in the shoulder is actually coming from the cervical spine, in which case the irradiation along the upper limb pain, radicular pathology reaches generally until the hand and the fingers, while the pain that starts from the shoulder radiates up and not past

The shoulder physical examination can be expressed in the following steps: inspection, palpation, mobility and specific functional tests. The inspection is usually negative, while palpation may aid in the diagnosis. Palpation should include all the articulation of the scapular girdle and all the rotator cuff muscles trying to overcome with appropriate maneuvres the deltoid that covers a large part of the rotator cuff. During the palpation, must be taken simultaneously consider several aspects. They are: the tenderness, the swelling, changes in temperature, the deformity, both obvious and hidden, the muscle characteristics and the relations between the various structures. The motion of both shoulders should be assessed actively and passively. Forward elevation and elevation in the scapular plane as well as internal and external rotation

Tests of affected muscles against resistance are imperative to formulate a correct diagnosis.

Neer test: the doctor is placed behind the patient, with one hand passively he raises his arm in internal rotation and abduction, while with the other stabilizes the scapula. If the patient refers pain in an arc of movement between 70° and 120°, the test shows a conflict between the

Hawkins test: it is performed with arm at 90° of flexion front and elbow flexed to 90°; in this position the physician, in front of the patient and imprints an internal rotational movement of the glenohumeral joint. Pain located below the acromioclavicular joint with internal rotation is considered a positive test result and it is indicative of inflammation of the subacromial bursa or of an impingement of all structures that are located between the greater tubercle of

Palm-up test: the examiner contrasts the movement of the patient to elevate the arm with the elbow in extension and palm of the hand facing up. If the test shows pain is positive to a lesion

Jobe test: the examiner stands in front of the patient keeps his arms positioned at 90° of abduction, 30° of anterior flexion and maximum intra-rotation (thumbs pointing to the ground). The examiner lowers arms against the patient's resistance against exerting a downward thrust. The test is positive for the supraspinatus muscle if the affected limb is lowered, regardless of

with the arm at the side and in 90° of abduction should be performed.

greater tuberosity and the humeral the acromion.

the humerus and the coracohumeral ligament.

of the long head of the humeral biceps.

whether or not the presence of pain.

musculoskeletal changes.

220 Advances in Shoulder Surgery

the elbow.

The conservative approach avails of different kind of treatments, whose main purpose is to reduce pain and other signs of inflammation, recover function and prevent further joint damage [85].

A great number of studies support the conservative approach as the main treatment for the mildest forms of shoulder pain due to adhesive capsulitis [86]. The natural course of the frozen shoulder leads to healing in more or less long times. To reduce pain faster and recover the articular functionality, we can intervene with several alone or combinated therapies, such as physical therapy (ultrasound, lasers, hyperthermia, electro-analgesia and shock waves), intra-articular corticosteroid injection, intra-articular saline hydrodilation with distention and eventual rupture of the glenohumeral joint capsule, intra-articular sodium hyaluronate injection into the glenohumeral joint, suprascapular nerve block, shoulder manipulation under anesthesia, oral corticosteroid or NSAIDs (non-steroidal anti-inflammatory drugs) and analgesics. In case of failure of these therapies, the alternative is to proceed with open or arthroscopic synovectomy and glenohumeral capsular releases [87–89].

#### **5.1. Extracorporeal shock wave therapy**

Since 1980, the extracorporeal impact waves have been used in different conditions, initially to destroy kidney stones. Investigating the side effects on the surrounding tissues, it was understood that they could also find use in the treatment of musculoskeletal disorders [90]. The effect on these tissues is dose-dependent: high doses tend to have destructive effects, low doses have regenerative effects [91].

All the principles that led the application of the ESWT since 1995 have been revised in a recent review, that has established new ones. The recommended energy limit should be beneath 0.28 mJ/mmq, above which necrotic effects prevail; ESWT is performed without anesthesia, even on larger areas; their application also on open growth plates seems to be safe [92].

tendinitis, promoting resorption of the calcifications using high energy density (conventional limit set at 0.20 mJ/mmq, less than this intensity was labeled low-energy). Functional outcome (Constant-Murley score) and radiographic resorption (chance of complete resorption) of the deposits after 3 months, showed that high-energy ESWT is more effective than low-energy ESWT [103]. The effect on calcifications is not merely mechanical as in the case of kidney stones, but rather biochemical induces interstitial and extracellular changes, enhancing tissue

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Few studies specifically address the application of ESWT in frozen shoulder. One of the study [105], recruited 36 patients divided into 2 groups: one received shock waves (1200 shocks with energy between 0.1 and 0.3 mJ/mmq) and one sham. Pain and disability score were assessed with the Shoulder Pain and Disability Index (SPADI) questionnaire before and after the therapy, and 2 and 5 months after the treatment. The results show a positive effect on recovery of

Another research [106] compare ESWT (1000 shock waves, with energy between 0.01 and 0.16 mJ/mmq) with conservative physical therapy, both group treated twice a week for six weeks. Pain and function were assessed, respectively, with visual analogue scale (VAS) and patient-specific functional scales (PSFS). Both group showed significant decreases in VAS

ESWT is therefore a possible way to treat the frozen shoulder, especially if we consider the

Intra-articular drug administration offers several advantages: increased bioavailability, reduced systemic effects and fewer side effects. Moreover, most joints can be accessed accu-

Intra-articular injections into the glenohumeral joint are commonly performed to treat different conditions affecting this articulation, such as osteoarthritis, adhesive capsulitis and rheumatoid arthritis. Despite the widespread use of this treatment, there are no standard criteria

With regard to this type of therapy applied to the treatment of shoulder pain, two substances are used: corticosteroids and hyaluronic acid [108]. The pharmacological properties of corticosteroids are well known, in accordance with them, this procedure is recommended in the acute phase. The risks associated with corticosteroid injection are limited if performed by experienced hands and in patients eligible for such procedure. Injection should be avoided in

The main purpose in treating the frozen shoulder is to reduce the loss of function and to give relief to pain that significantly limits movement. In the case of adhesive capsulitis, intraarticular administration of corticosteroids is generally associated with conventional physical therapy. A systematic review of 25 studies from 1947 to present, compares infiltrations with manipulation under anesthesia, physical therapy and distension of the joint capsule. In all

patients with septic arthritis, bacteremia and in immunocompromised patients [109].

and PSFS, the ESWT group reported lower score then the control group.

regeneration [104].

frozen shoulder that was faster than sham group.

fact that it is a safe, non-invasive and low cost procedure.

rately, especially under ultrasound guidance [107].

**5.2. Intra-articular injections**

for their performance [26].

The regenerative effect of ESWT is the consequence of the activation of gene expression for growth factors or cytokines and fibroblast proliferation. Mechanical stimulation is converted by tendon tissue in enhancement of TGF-β1 gene expression and increase of collagen I and collagen III [93].

The phenomenon of mechanosensing is particularly clear in bone tissue, due to its structure and physiology: it acts like a piezoelectric. After ESWT exposure, bone shows: osteogenic differentiation of mesenchymal stem cells [94]; expression of nitric oxide synthase (eNOS), vascular endothelial growth factor (VEGF) that lead to neoangiogenesis and accelerate tissue regeneration and healing [95]; bone regeneration, starting from periosteum stimulation [96]; direct stimulation of osteoblasts and indirect reduction of osteoclasts activity [97].

In addition, the increase in NOS appears to be involved in another signaling pathway leading to the reduction of pro-inflammatory factors. It has been seen that NOS exerts an inhibitory action on nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), hence the role in production of proinflammatory cytokine and leukocytes recruitment, generating pain and phlogosis, are blocked [98].

Other mechanism is the production of NO and VEGF resulting in neoangiogenesis (**Figure 6**) that improves blood supply promoting tissue repairing and wash-out of algogenic and noxious substances [99].

ESWT intervene in pain modulation also by release of endogenous analgesic sustances P and calcitonine gene-related peptide (CGRP) and according to the gate control [100]. About the gate control, Saggini et al. [101], claim that a hyperstimulation-like shock waves, activate the descending inhibitory system, blocking following nociceptive stimuli in the posterior column of the spinal cord. In addition, ESWT modify substances P and CGRP levels, damaging peripheral small unmyelinated fibers, responsible of immediate release of the algogenic peptide. All these mechanisms make ESWT suitable to treat various musculoskeletal disorders, such as calcific tendonitis, epicondylitis, osteoarthritis and long bone fracture [102].

ESWT has proved to be a valid option in the treatment of calcifying tendinitis of the shoulder. A study based on a meta-analysis showed the power of ESWT to intervene in case of calcific

**Figure 6.** Coronary neovascularization after 4 weeks of shock wave therapy.

tendinitis, promoting resorption of the calcifications using high energy density (conventional limit set at 0.20 mJ/mmq, less than this intensity was labeled low-energy). Functional outcome (Constant-Murley score) and radiographic resorption (chance of complete resorption) of the deposits after 3 months, showed that high-energy ESWT is more effective than low-energy ESWT [103]. The effect on calcifications is not merely mechanical as in the case of kidney stones, but rather biochemical induces interstitial and extracellular changes, enhancing tissue regeneration [104].

Few studies specifically address the application of ESWT in frozen shoulder. One of the study [105], recruited 36 patients divided into 2 groups: one received shock waves (1200 shocks with energy between 0.1 and 0.3 mJ/mmq) and one sham. Pain and disability score were assessed with the Shoulder Pain and Disability Index (SPADI) questionnaire before and after the therapy, and 2 and 5 months after the treatment. The results show a positive effect on recovery of frozen shoulder that was faster than sham group.

Another research [106] compare ESWT (1000 shock waves, with energy between 0.01 and 0.16 mJ/mmq) with conservative physical therapy, both group treated twice a week for six weeks. Pain and function were assessed, respectively, with visual analogue scale (VAS) and patient-specific functional scales (PSFS). Both group showed significant decreases in VAS and PSFS, the ESWT group reported lower score then the control group.

ESWT is therefore a possible way to treat the frozen shoulder, especially if we consider the fact that it is a safe, non-invasive and low cost procedure.
