**4. Clinical presentation**

Histological findings attribute to neoangiogenesis the growth of new nerves in the capsuloligamentous complex of these patients and this may be the explanation of the pain associated with

Extrinsic

• Cardiac or breast surgery • Cerebrovascular accident • Cervical radiculopathy

Intrinsic

• Impingement • Tendinopathy • Osteoarthritis • Dislocation or shoulder trauma

Immunocytochemical analysis on arthroscope biopsy material revealed the presence of chronic inflammatory cells predominantly made up of mast cells, T cells, B cells and macrophages, as well as the presence of fibrosis that results from mast cell infiltrate, which typically

Frozen shoulder seems to be the result of failure of the healing process after an initial inflammatory phase, characterized by an excess of cytokines and growth factors with fibroblasts

capsulitis.

**Primary adhesive capsulitis**

**Stage Muscle description** 0 Completely normal muscle

218 Advances in Shoulder Surgery

I Some fatty streaks

Idiopathic (of unknown etiology or condition)

regulate the proliferation of fibroblasts [78].

**Secondary adhesive capsulitis**

**Table 3.** Goutallier classification: by extent of fatty muscle degeneration.

• Chronic obstructive pulmonary

• Osteopenia/reduced bone min-

Systematic

• Thyroid disease • Hyperlipidemia • Hypoadrenalism

II Amount of muscle is greater than fatty infiltration III Amount of muscle is equal to fatty infiltration IV Amount of fatty infiltration is greater than muscle

Stage 1 Proximal stump lies close to its bony insertion Stage 2 Proximal stump retracted at level of humeral head

Stage 3 Proximal stump retracted at glenoid level

**Table 2.** Patte classification (by cuff tears retraction).

disease (COPD)

eral density • Duputreyn's disease • Ischemic heart conditions • Diabetes mellitus

**Table 4.** Frozen shoulder classification.

The diagnosis is based essentially on clinical examination, exclusion of other pathologies and normal glenohumeral radiographs. Initial evaluation of global postural assessment should be perform before focusing on the shoulder, because shoulder pain is often associated with thoracic 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 neuromusculoskeletal changes.

Other tests can be used, such as Yocum test, the horizontal adduction test, the painful arc sign, the empty can test, the drop arm test, the Speed test, the Yergason test and the Pattes test.

The Role of Physical Medicine and Rehabilitation in Shoulder Disorders

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

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Clinical evaluation can completed with assessment scales like Constant-Murley scale [83, 84]

The Constant-Murley score is an ordinal scale used in all pathologies of shoulder (not only for the instability), with a score ranging from 0 to 100 (100 = normal shoulder). The scale investigates four areas through the pain (15 points), activities of daily living (20 points), strength (25 points) and the range of motion (40 points). In this way it achieved a full assessment of the level of pain

The "simple shoulder test" (SST) is a binary scale used for all shoulder pathologies that involves the administration of 12 questions to the patient (normal score = 12). The questions are used to assess the perceived pain and the ability to perform certain activities of daily living. The DASH is halfway between a generic test (as the Short Form) and a specific test for the

Imaging studies are commonly used to identify and differentiate the source of the injury.

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 dam-

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

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

arthroscopic synovectomy and glenohumeral capsular releases [87–89].

or simple shoulder test (SST).

**5. Conservative approach**

**5.1. Extracorporeal shock wave therapy**

doses have regenerative effects [91].

age [85].

and disability related to the activities of daily living.

shoulder, it can use to complete the assessment.

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 elbow.

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

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 greater tuberosity and the humeral the acromion.

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 the humerus and the coracohumeral ligament.

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 of the long head of the humeral biceps.

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 whether or not the presence of pain.

Other tests can be used, such as Yocum test, the horizontal adduction test, the painful arc sign, the empty can test, the drop arm test, the Speed test, the Yergason test and the Pattes test.

Clinical evaluation can completed with assessment scales like Constant-Murley scale [83, 84] or simple shoulder test (SST).

The Constant-Murley score is an ordinal scale used in all pathologies of shoulder (not only for the instability), with a score ranging from 0 to 100 (100 = normal shoulder). The scale investigates four areas through the pain (15 points), activities of daily living (20 points), strength (25 points) and the range of motion (40 points). In this way it achieved a full assessment of the level of pain and disability related to the activities of daily living.

The "simple shoulder test" (SST) is a binary scale used for all shoulder pathologies that involves the administration of 12 questions to the patient (normal score = 12). The questions are used to assess the perceived pain and the ability to perform certain activities of daily living. The DASH is halfway between a generic test (as the Short Form) and a specific test for the shoulder, it can use to complete the assessment.

Imaging studies are commonly used to identify and differentiate the source of the injury.
