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Conservative treatment

1. Adhesive capsulitis

This is perhaps the most common shoulder disorder occurring also after a mild trauma . Sometimes it appears spontaneously and occurs frequently in women between 45 and 60 years of age , in diabetic subjects but all age groups and men can be affected.

The intial symptom is generally shoulder pain worse at night. In the following weeks considerable difficulty raising and rotating the arm is the hallmark of this disorder.

Shortly adhesive capsulitis is the severe inflammation of the capsule, first inflamed (pain) and then made unelastic (less elastic) due to adherences and capsular thickenings, the end result of the inflammation.

Capsule may be completely (frozen shoulder) or partially (localized capsulitis) damaged.

Unfortunately due to the symptoms overlapping those of subacromial impingement or cuff tendonosis the localized condition might be treated with physiotherapy not aimed at solving the capsular problem or even worse surgically.

Patients with capsulitis generally tend to heal spontaneously in a 7/8 month period. But a proper injection treatment and phyiokinesitherapy make it easier and faster to heal from this discomfortablel but not life-threatening disorder.

Adhesive capsulitis may also fall into the complex series of symptoms of a clinical picture defined "reflex sympathetic distrophy" (RSD).

Generally this disorder affects young or relatively young women, in particular astenic subjects under emotional stress. The very long- term healing is spontaneous.


2. Rotator cuff lesion

Rotator cuff is made up of four tendons wrapping around the humeral head and allowing its movement. Cuff lesion is the tear of one or more cuff tendons commonly due to degenerative causes.

Tendon lesions of the rotator cuff may not be necessarily treated surgically and most patients can move their arm with little or even no pain.

Lesions to be treated are those allowing to move the arm completely and painfully or those causing difficult and painful shoulder movement.

MRI of complete supraspinatus lesion MRI of complete supraspinatus lesion

Radiography and MRI scan allow the specialist to integrate the images with the patient’s history and the objective examination. This integration will allow to select between rehabilitation or surgery.

The influencing factors are the following:
  • quantity of pain and of limited range of motion
  • age
  • job and sports type
  • dominant or nondominant limb
  • lesion features (information resulting from the correct X-ray and MRI interpretation)
  • patient expectations
  • rehabilitation possibilities
  • patient’s compliance to heal and family support


3. Instability

As we have observed instabilities may be caused by constitutional factors (ligament laxity) or traumas.

The shoulder specialist has the task to opt for the conservative or surgical treatment.

After a first case of traumatic or atraumatic glenohumeral dislocation patients are generally not operated but they are recommended to follow a rehabilitation treatment well described in the next paragraphs. But some exceptions are represented by young throwing athletes or cases where the shoulder may be subject to further severe traumas, or where the ligament injury is associated with bone and cartilage fractures.

Generally after the first case of dislocation the arm must be immobilized with a brace for 20-25 days at neutral rotation, despite improved results in the recent literature( decreased relapses ) in case of immobilization in slight extra rotation. This treatment is often not well tolerated by patients despite the theoretically better clinical results.

The conservative treatment aims at rebalancing the posture , reinforcing the scapulothoracic muscles and progressively regaining the range of motion first passively then actively always under the threshold of the pain.


4. Arthrosis

Glenohumeral arthrosis
Glenohumeral arthrosisThe joint pain (knee, hip, shoulder etc) can be caused by a disorder referred to as "arthrosis"

A tissue named cartilage covers the extremities of the bone surfaces,. It is smooth and very delicate (similar to a billiard ball) allowing the bone extremities to slip over one another thanks also to the synovial liquid.

The cartilage is responsible for the joint movement together with muscles and tendons.

Anteroposterior X-ray in
normal shoulder

Anteroposterior X-ray in normal shoulderCartilage is a "noble" tissue: it does not regenerate on its own once worn out due to traumatic or degenerative causes.

A genetic clock regulates every organism dictating the "aging" times of the different tissues including the cartilage.

Arthrosis is caused by a progressive cartilage degradation (depletion of the lining of bone extremities) and a decreased synovial liquid, the physiological lubricant of joints. The symptoms are pain and limited range of motion.

A specialist visit and specific instrumental investigations are necessary to plan a conservative treatment (not surgical) that may include:

Specific joint treatment (possible weight loss, reduced physical acitivity)
Rehabilitative-physiotherapeutic treatment
Injection treatment (ialuronic acid)


5. Fractures

Possible arm traumas can cause lesions in the bone segments.

The clavicle, the humeral head and more rarely the scapula can be damaged as a result of low and high-energy traumas. A correct radiographic test and the opinion of a specialist may discriminate between fractures requiring a conservative treatment, that is a 30-day immobilization followed by a specific rehabilitative treatment, and those requiring a surgical treatment. Generally surgery is the treatment of choice in case of severe displaced fracture (meaning displacement of two or more bone fragments)

As for the rehabilitative treatment the rationale is to immobilize the patient with a brace or appropriate bendings, to check him/her every 15 days to verify the status of the healing process (bone callus of the injured structures); and when the orthopedician deeems necessary to start a conservative treatment very similar and overlapping that adopted in case of instability: lumbopelvic muscle strengthening, neuromuscular control of the scapulothoracic joint, careful and progressive recovery of active and then passive range of motion.


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