The document discusses the investigation and management of frozen shoulder. It begins by describing the typical presentation including severe pain, stiffness, and loss of shoulder range of motion, especially external rotation. It then covers examination findings, differential diagnosis, diagnostic imaging, and stages of management. Management involves a combination of physical therapy techniques like stretching and active range of motion exercises, as well as medications in more severe cases. The goal is to gradually restore range of motion and relieve pain and stiffness of the shoulder joint.

1. INVESTIGATION AND
MANAGEMENT OF FROZEN
SHOULDER
Dr. Taniya verma ( PT)
MPT-Musculoskeletal

2. HISTORY AND EXAMINATION
• AGE: 45+ insidious type;
• 3 hallmarks of frozen shoulder are progressive shoulder stiffness,
severe pain (especially at night) that results in the inability to sleep on
the affected side and a near complete loss of passive and active
external rotation of the shoulder.

3. • Pain:-
• Location- generally located over the upper arm ;predominantly over the lateral
shoulder/deltoid region over the anterior shoulder .
• may be referred distally into the forearm
• Type :- Deep; diffuse or poorly localized ;constant or unrelenting in nature
• intensity =severe .
• AF= marked increase in pain with rapid or unguarded movements
• uncomfortable to lie on the affected shoulder
• Function is limited by increasing stiffness in this stage
Associated factors= diabetes , thyroid.

4. • inspection= mild disuse atrophy of the deltoid and supraspinatus in
longstanding cases .
The arm may be adducted and internally rotated.
• Tenderness = would be positive on palpation of the glenohumeral joint.
• ROM= Both active and passive range of motion are affected, especially that
of abduction and external rotation ;presence of shoulder hiking; pain at
end ranges.
• ROM restrictions in a capsular pattern. ER limitations > ABD limitations >
IR limitations
• RIC= normal when arm by side ; weakness in shoulder ER, IR and ABd
relative to the asymptomatic side
• Sensory function= not affected

5. • Aggravating activities - limited reaching, particularly during overhead
(e.g., hanging clothes) or to-the-side (e.g., fasten one's seat belt)
activities. Patients also suffer from restricted shoulder rotations,
resulting in difficulties in personal hygiene, clothing and brushing
their hair.
• Scapular winging of the involved shoulder may be observed from the
posterior and/or lateral views.
• Yang et al. investigated the reliability of 3 function related tests in
patients with shoulder pathologies via a non-experimental study.

6. • 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 (The Scarf Test -
cross body adduction)

7. • The signs and symptoms of rotator cuff tendinitis overlap with those
of frozen shoulder. However, in contrast to the former, where pain is
the main limiting factor, patients with pure frozen shoulder may
complain of chronic pain; however, symptoms of stiffness
predominate.
• In addition, the signs and symptoms of cervical radiculopathy and
upper limb neurology should be evaluated, as cervical spondylosis or
other cervical disc disease may lead to or coincide with frozen
shoulder.
• On the same note, cardiac conditions, especially coronary artery
disease, may present with shoulder pain (referred pain)

8. Diagnostic imaging
• Radiography- negative ;to rule out other pathology.
• MRI= thickening of the coracohumeral ligament (CHL) and the joint capsule in the
rotator cuff interval, as well as the subcoracoid triangle sign (complete
obliteration of the fat triangle between the CHL and the coracoid process), are
characteristic findings in frozen shoulder; to exclude rotator cuff tears or intra-
articular pathology .
• ultrasonography = recommended only if the physical examination indicates the
possibility of another shoulder pathology such as rotator cuff tears.
• There is a mild elevation of erythrocyte sedimentation rate (ESR) and C-reactive
protein (CRP)
• Blood factors exclude an infective or systemic inflammatory state

9. Differential diagnosis
Possible diagnosis Presentation Special test
Rotator cuff lesions Tenderness of RC
Acromial spurring
Upward displacement of humeral
head
MRI diagnostic
Drop arm test;
Empty can test
Atraumatic instability Normal/excessive AROM/PROM
Pain on activity; slipping/popping
of humerus
Load and shift; relocation test;
apprehension test, sulcus sign
Cervical spondylitis Affected reflexes and dermatomes;
Limited ROM, radiograph:
osteophytes; narrowing of space
Spurling test;distraction test
Shoulder impingement Pain; ROM complete/ slight limited Neers test, Hawkins kennedy
Bone tumor Positive radiographs: defined bone
mass.

10. MANAGEMENT
CONSERVATIVE TREATMENT : STAGE 1
• Combination of hot
and cold pack.
• Gentle stretching in
pain free range.

11. • STAGE 2

12. • STAGE 3

13. • STAGE 4

14. Active assisted end range movements in
flexion, external rotation and extension
Active assisted end-range
movements in internal rotation,
horizontal adduction and flexion
Coracohumeral Ligament Stretch
Active assisted movements in
elevation and external rotation wi
a cane.

15. PHARAMACUTECAL AND SURGICAL
MANAGEMENT