Frozen shoulder BY MIN^ED ACADEMY

1. FROZEN
SHOULDER
PRESENTED BY-
SWARN LATA
MPT (ORTHOPAEDICS)
PAGE 1

2. Course
Outline ANATOMY
DESCRIPTION
CAUSES
SYMPTOMS
EXAMINATION
PAGE 2
MANAGEMENT

3. PAGE 3
• The shoulder girdle is the link
between the upper extremity and
the trunk .
ANATOMY
• Sternum
• Clavicle
• Scapula
• Humerus
The shoulder complex
consists of four bones:-

4. PAGE 4
Sternoclavicular Joint
Glenohumeral Joint
• And 2 functional joints:-
Acromioclavicular Joint
Scapulothoracic Joint
Subacromial/Suprahumeral Joint or
Subacromial Space
• It is composed of 3 independent joints:-

5. GH JOINT
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 About-
 Ball and socket joint
 Tri axial joint
 Lax joint capsule
 The head of the upper arm bone fits into a shallow socket in your shoulder blade.
 Support-
 Tendon of Rotator cuff
 Gleno-humeral (superior, middle, inferior) lig.
 Coracohumeral lig.
 Strong connective tissue, called the shoulder capsule, surrounds the joint.

6.  Stability and congruity (↑)
 Form by fibro cartilaginous lip
 Glenoid labrum (deepens the
fossa)
 To help shoulder move more easily,
synovial fluid lubricates the
shoulder capsule and the joint.
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7. Frozen shoulder
 AKA- Periarthritis shoulder or Adhesive capsulitis
 CHARACTERIZED BY-
Stiff and painful shoulder- due to arthritic change in cartilage and bone.
Dense adhesion, Capsular thickening and capsular restrictions- Significant loss of
AROM and PROM (equal loss)
 Age group- 40 -65 year (F >M)
 Worsen symptoms get better full recovery 3 years
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8. PATHO- ANATOMICAL FEATURES FS
Develop adhesion
Become stiff and tight
Produce collagen fibre proliferation, granulation and contracture of the capsular ligamentous
complex
Angiogenesis into the capsule tissue
Provoke chronic inflammation in musculotendinousor synovial tissue or synovial tissue
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• Many case- less synovial fluid.

9. CAUSES
 Idiopathatic
Risk factors-
Diabetes- greater degree of stiffness that continues for a longer time before
"thawing.“
Other diseases- hypothyroidism, hyperthyroidism, Parkinson's disease, and
cardiac disease.
Immobilization- due to surgery, a fracture, or other injury
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10. This clinical entity progresses through a series of
four stages following a classic continuum:-
Gradual onset of pain that increases with movement and is
present at night
Loss of external rotation motion with intact rotator cuff strength
is common.
The duration of this stage is usually less than 3 months.
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Stage 1

11. Stage 2- “Freezing” Stage
Characterized by persistent and more intense pain
even at rest.
Motion is limited in all directions and cannot be fully
restored with an intra-articular injection
This stage istypically between 3 and 9 months after onset.
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12. Stage 3- “Frozen” Stage
Characterized by pain only with movement,
significant adhesions, and limited GH motions
Excessive scapulothoracic movement is a typical
compensation.
Atrophy of the deltoid, rotator cuff, biceps, and triceps
brachii muscles may be noted
This stage occurs between 9 and 15 months after onset.
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13. Stage 4- “Thawing” Stage
Characterized by minimal pain and no synovitis but
significant capsular restrictions from adhesions.
Motion may gradually improve during this
stage.
This stage lasts from 15 to 24 months after onset,although some
patients never regain normal ROM.
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14. Symptoms
 Pain from frozen shoulder is usually
dull or aching.
 worse early in the course of the
disease.
 The pain is usually located over the
outer shoulder area and sometimes
the upper arm.
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15. Examination
 1: History-sign/symptoms, mechanism of injury.
 2. examination, assessment, special test
 People with frozen shoulder have limited range of motion both actively and
passively.
 Palpation-
Soft tissue: tenderness may be present over insertion of rotator cuff at greater
tuberosity, long head of biceps at bicipital groove
 Rom : Active/passive/overpressure
Cervical, thoracic, shoulder ROMs as well as rib mobility should be performed.
Scapular substitution frequently accompanies active shoulder motion.
Capsular pattern is seen in the movements, where scaption is mainly seen.
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16. Examination
 Resisted muscle tests
 Shoulder external rotation (ER)/ Internal rotation (IR)/abduction (ABd) (seated) should be performed.
 Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the
asymptomatic side.[
 Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern. A capsular
pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint
 The shoulder joint has a capsular pattern where external rotation is more limited than abduction which is
more limited than internal rotation (ER limitations > ABD limitations > IR limitations)
 In the case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD, while ABD and
IR were not seen to be different.
 Joint play:
 Posterior to Anterior gliding of head of humerus is restricted more limiting the external rotation most
 Inferior gliding restricted limiting abduction
 Posterior gliding restricting limiting internal rotation.
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17. Examination
Imaging Tests
 1.X-rays.
 2. Magnetic resonance imaging (MRI) and ultrasound.
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X-rays of shoulder joint
MRI of shoulder joint
Ultrasound of shoulder joint

18. Differential Diagnosis:
 1.Osteoarthritis (OA). Both may have limited abduction and external rotation
AROM but with OA, PROM will not be limited. OA will also present with the most
limitations with flexion whereas this is the least affected motion with adhesive
capsulitis. Radiography can be used to rule out pathology of osseous structures.
 2. Bursitis. Bursitis presents very similarly to adhesive capsulitis, especially
compared to the early phases. Patients with bursitis will present with a non-
traumatic onset of severe pain with most motions being painful. A main difference
will be the amount of PROM achieved. Adhesive capsulitis will be extremely
limited and painful whilst patients with bursitis, although painful, will have a larger
PROM.
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19. Differential Diagnosis:
 Rotator Cuff (RC) Pathologies. The primary way to distinguish RC pathologies
from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive
capsulitis presents with restrictions in the capsular pattern while RC involvement
typically does not. RC tendinopathy may present similarly to the first stage of
adhesive capsulitis because there is limited loss of external rotation and strength
tests may be normal. MRI and ultrasonography can be used to identify soft tissue
abnormalities of the soft tissue and labrum.
 Posterior Dislocation. A posteriorly dislocated shoulder can present with
shoulder pain and limited ROM, but, unlike adhesive capsulitis, it is related to a
specific traumatic event. If the patient is unable to fully supinate the arm while
flexing the shoulder, the clinician should suspect a posterior dislocation.
 Cervical spondolosis
 PIVD at Cervical level
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20. Special test
 Shoulder Shrug Sign
 Hand to neck (Figure 1A)
 Shoulder flexion + abduction + ER
 Similar to ADLs such as combing hair, putting on a necklace
 Hand to scapula (Figure 1B)
 Shoulder extension + adduction + IR
 Similar to ADLs such fitting a bra, putting on a jacket, getting into back
pocket
 Hand to opposite scapula (Figure 1C)
 Shoulder flexion + horizontal adduction
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21. Outcome measures
 The following outcome measures have been used in studies researching adhesive
capsulitis.
 Disability of the Arm, Shoulder and Hand scale (DASH)
 VAS
 Scapulohumeral rhythm.
 Scapular winging of the involved shoulder may be observed from the
posterior and/or lateral views.
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22. Management
 Medical management
 Treatment for pain, loss of motion, and limited function
 1.Various interventions have been researched that address the treatment of the synovitis and
inflammation and modify the capsular contractions such as oral medications, corticosteroid
injections, distension, manipulation, and surgery.
 2. Manipulation under anesthesia
 Surgical treatment
 Arthroscopic capsular release
 It has been found to be a reliable and effective method for restoring range of motion and is
especially recommended for diabetics and in post-operative or post-fracture adhesive capsulitis
patients.
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23. PT treatment
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 Modalities
 a) Moist heat used in conjunction with stretching can help to improve muscle extensibility
and range of motion by reducing muscle viscosity and neuromuscular mediated relaxation.
 b) Ultrasound, massage, iontophoresis, IFT and phonophoresis reduced the chances of
positive outcomes.

24. PT treatment
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 c) Pulley may be used to assist range of motion and stretch, depending on the patient’s ability
to tolerate the exercise. Pendulum exercises(codman exercises), passive supine forward
elevation, passive external rotation with the arm in approximately 40 degrees of abduction in
the plane of the scapula, and active assisted range of motion in extension, horizontal
adduction, and internal rotation.
 d) Mobilisation
 2 to 3 , 30 second sets of low velocity, oscillatory mobilisations (Maitland Grade IV-IV+) are
performed initially (anteriorly, posteriorly, and inferiorly).

25. PT treatment
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 e) Self stretches/home programme.
 External rotation — passive stretch. Stand in a doorway and
bend your affected arm's elbow to 90 degrees to reach the
doorjamb. Keep your hand in place and rotate your body as
shown in the illustration. Hold for 30 seconds. Relax and repeat.
 Forward flexion — supine position. Lie on your back with your
legs straight. Use your unaffected arm to lift your affected arm
overhead until you feel a gentle stretch. Hold for 15 seconds and
slowly lower to start position. Relax and repeat.
 Crossover arm stretch. Gently pull one arm across your chest just
below your chin as far as possible without causing pain. Hold for
30 seconds. Relax and repeat.

26. PT MANAGMENT
 Rehabilitation Protocol
 Frozen Shoulder (Adhesive Capsulitis)
 Bach, Cohen, and Romeon
 Phase 1: Weeks 0-8
 Goals
 • Relieve pain.
 • Restore motion.
 Restrictions
 • None.
 Immobilization
 • None.
Pain Control
• Reduction of pain and discomfort is essential for recovery
• Medications
• NSAIDs-hrst-line medications for pain control.
• GH joint injection: corticosteroid/local anesthetic
combination.
• Oral steroid taper-for patients with refractive or
symptomatic frozen shoulder (Pearsall and Speer,
1998)
Because of potential side effects of oral steroids,
patients must be thoroughly questioned about
their past medical history.
• Therapeutic modalities
• Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of
session

27. Phase 2: Weeks 8-16
Criteria for Progression to Phase 2
• Improvement in shoulder discomfort.
• Improvement of shoulder motion.
• Satisfactory physical examination.
Goals
• Improve shoulder motion in all planes.
• Improve strength and endurance of rotator cuff and scapular stabilizers.
Pain Control
Motion: Shoulder Goals
• 140 degrees of forward flexion.
• 45 degrees of external rotation.
• Internal rotation to twelfth thoracic spinous process.
Phase 3: Months 4 and Beyond
Criteria for Progression to Phase 4
• Significant functional recovery of shoulder motion
• Successful participation in activities of daily living.
• Resolution of painful shoulder.
• Satisfactory physical examination.
Goals
• Home maintenance exercise program
• ROM exercises two times a day.
• Rotator cuff strengthening three times a week.
• Scapular stabilizer strengthening three times a week.
 . Motion: Shoulder
 Goals
 • Controlled, aggressive ROM exercises.
 • Focus is on stretching at ROM limits.
 • No restrictions on range, but therapist and patient have
 to communicate to avoid injuries.
 Exercises
 • Initially focus on forward flexion and external and internal
 rotation with the arm at the side, and the elbow at
 90 degrees.

28. REFERENCES
1. Essential of orthopaedic and applied physiotherapy; second edition
Jayant Joshi,Prakash Kotwal
2. S. Brent Brotzman; Clinical Orthopaedic Rehabilitiation; 2nd edition
3. Rehabilitation of the hand and upper extremity, sixth edition
4. Physiopedia.com/ Adhesive capsulitis
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