The physical configuration of the shoulder anatomy serves to enhance the physiological degenerative process of the shoulder components. This process results in an inevitable development of degenerative changes in the musculotendinous rotator cuff of the shoulder and is typical beyond the age of 40 years. In younger patients, it presents in the form of an impingement syndrome. However, the process is the same in both age groups. With abduction of the arm, repeated impingement of the greater tubercle of the humerus on the acromion takes place. This results in a degenerative change involving inflammation of the supraspinatus tendon with secondary inflammation of the subdeltoid bursa. Abduction of the arm results in pain. In time, the process becomes chronic with the deposition of a calcific deposit in the degenerated tendon with resultant inflammatory edema contributing to the pain cycle. Spontaneous rupture of early calcific deposit results in pain relief; otherwise, the pain persists and although chronic deposits commonly do not rupture, they may be resorbed. Considering this clinical chronology, it is evident that this process is reversible in each phase. Also, if the calcific debris remains contained inside the tendon sheath and is free of tension, the shoulder complex commonly retains its full range of motion without pain.
Conservative care during the acute phase includes moist cryotherapy, with the use of a loose sling. This phase usually lasts about two days. Heat usually aggravates the lesion and is likely due to the fact that this is an acute inflammatory process at this stage. The cryotherapy probably reduces the spasm and pain by reducing the nerve conduction velocity which commonly results when the skin temperature is reduced by 5-10 degrees centigrade. Application should be for at least 20 minutes, but no longer; and in the event of skin cyanosis at the application site, it should be discontinued until local arterial color reappears. Complete immobilization is discouraged due to the possibility of development of local adhesions, as well as local ischemia. Active range of motion exercises should be initiated within the first week with emphasis on the first four days. If pain is produced on performing certain motions, that motion must be avoided.
As the shoulder complex begins to heal, as evidenced by motion without pain, dangling passive pendular exercises should be commenced. Following several days of this regimen without pain, the same exercises may begin in the active mode. As the range of motion exercise become less painful with motion, moist heat may be applied, and this could possibly be by the third day in some cases. Additionally, at such a point in the program, it may be of help to apply lidocaine/cortisone phonophoresis using 0.5 percent hydrocortisone ointment and 2.5 percent lidocaine together as the coupling agent using 0.75 W/cm2 pulsed ultrasonic energy. The sonation beam should be directed into the site of the lesion. In this authors experience, the regimen following the acute phase which is most effective is the use of lidocaine/cortisone phonophoresis, range of motion exercises, and moist heat application.
In the opinion of his author, it is unwise to inject additional fluids into an area already inflamed and containing inflammatory edema (excess fluid). Ultrasonic energy, however, has been shown to dissipate tissue fluid and transudate. At one megacycle, the standard medical ultrasonic wave generates approximately five atmospheres of pressure, which is, of course, about 75 p.s.i. of radial pressure. This is the principle mechanism of medical phonophoresis.
References
Cailliet, R: Shoulder Pain. F.A. Davis Publishers, 1980.
Davis RV: Therapeutic Modalities for the Clinical Health Sciences, ed 1. Copyright -- Library of Congress, TU-389-661, 1983.
Griffin JE, Karselis TC: Physical Agents for Physical Therapists, ed 2. Springfield: Charles C. Thomas, 1982.
Krusen, Kottke, Ellwood: Handbook of Physical Medicine & Rehabilitation, ed 2. Philadelphia: W.B. Saunders Company, 1971.
Netter F: Musculoskeletal Disorders. The Ciba Collection, Part II.
Schriber WA: A Manual of Electrotherapy, ed 4. Philadelphia: Lea & Feibiger, 1975.
R. Vincent Davis, D.C., BSPT, DNBPME
Independence, Missouri
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