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.
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R. Vincent Davis, D.C., BSPT, DNBPME