mechanism and introduction of frozen shoulder

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PROJECT ON FROZEN SHOULDER
PATIENTS
Amity Institute of Physiotherapy
Amity University, Uttar Pradesh
NOIDA
2018

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Introduction
A condition clinically manifested as a stiff shoulder due to the stiffening and tightening of the
shoulder joint capsule, is known as FROZEN SHOULDER. Also known as Adhesive
capsulitis, it’s the inflammation of the capsule of shoulder joint resulting in pain and
stiffness of the shoulder joint. The major functional limitation is that the patient is unable to
move, rotate the arm and perceives stiffness and tightens in the shoulder joint. Women are
more prone to developing a frozen shoulder then men of the same age group. Patients may
find difficulty in movement of the shoulder joint . The treatment of this condition is given by
the situation or the stage of the patients. In this condition there are three stages freezing stage,
frozen stage and thawing stage. The risk factors increasing the proneness to frozen shoulder
are diabeties, surgery, injury and trauma or even an auto-immune disease.
There are three stages of frozen shoulder.
1. In freezing stage, TENS machine can be applied to reduce pain and to
increase range of motion. Gentle passive range of motion exercise, gentle
shoulder mobilization.
2. In frozen stage, mobilization with movement techniques appears to be the
more effective than the stretching exercises.
3. In thawing stage, painful and restrictive symptoms start disappearing and
improvement is seen through mobilization, stretching and range of motion
exercises.

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The strengthening exercises are helpful in maintaining the shoulder range of motion and
physiotherapy is most effective during this phase.
SYMPTOMS
Characteristic symptoms of frozen shoulder are: Pain, Stiffness and difficulty in moving the
shoulder. Also patient feels dull pain in the concerned shoulder.
CAUSES
1. This is caused by an injury and trauma to that area.
2. When the scar tissue formation in the shoulder. This causes the capsule of the
shoulder joint, more thickens and tighten.
3. It is more commonly in the diabetes patients.
4. Most of the people have frozen shoulder because of the recent injury or fracture.
Risk Factors
Common risk factors are :
1. Age : This condition are prone over the 40 years of age.
2. Gender : Females (70%) are having more chances to this condition.

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3. Recent injury or trauma : Any surgery or arm fracture can also lead to immbobility
and causes stiffen or tightensshoulder capsule.
4. Diabeties : Around 10-20% of people develops frozen shoulder.
Diagnosis
Diagnosis of frozen shoulder based on the signs, the symptoms, the physical examination and
the diagnostic imaging oh the concerned shoulder. The condition and stage of the of the
condition is determined by the extent of certain shoulder movements such as internal rotation,
abduction and flexion, in sequence. Structural deviations can be determined using the various
imagings such as X-ray or MRI.. Functional Assessment
Various methods of assessment of the frozen shoulder exist:
a.Observation
Observation is an essential element of the assessment process and depends on the skill and
experience of the clinician. Common clinical manifestations include swelling, muscle
wasting, lack of symmetry and erythma. Patient’s poor posture posture is common since the
soft tissue adapt to the poor posture. Muscle tightness (pectoralis ) can be perceived as
contracture. A protracted posture of the shoulder girdle occurs due to tight pectoralis minor
muscle.
b.Palpation
Examination by palpation helps detect and assess important manifestations such as
temperature changes, tenderness, effusion/ oedema, the tone of the muscles and the feel of
superficial tissues.
c.Active ROM
The active ROM of the concerned joint helps determine various components of the
examination process such as the available range of motion, the quality of allowed movement,
pain, pain arc, available strength of the performing muscles, etc.
d.Passive ROM
Passive assessment of the shoulder complex aids the clinician to determine the available
range of motion beyond the muscle limitation.
e.Accessory joint movement
The movements which are beyond the voluntary control of the patient and can only be
isolated by external intervention are known as the Accessory movements. The examination of
these movements allows the clinician to assess quality and the range of allowed movement
across the joint. An abnormality in the joint capsule can be determined by any palpated

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resistance . These movements aids the clinician’s knowledge of any soft tissue pliability or a
probable associated muscle spasm
Generally any restriction in the osteokinematic mobility is a result of the accessory ROM
restriction at glenohumeral joint. For instance the inferior glide is the restricted
arthrokinematic movement which limits the shoulder elevation in abduction. Therefore
releasing this interior gliding motion of the humeral head in the glenoid cavity will result in
improved range of motion of the shoulder abduction motion. The techniques of joint
mobilization are primarily used in the same.
f.Muscle testing
An important aspect of the assessment of frozen shoulder is the evaluation of the tone and
elasticity of specific muscle groups of the shoulder girdle. Reduced coordination and
improper and unequal co-contractions of the agonist and antagonist muscle groups for any
movement results in apparently reduced range of motion due to the restriction of the joint.
Prolonged improper contractions of these muscle groups will eventually result in muscle
tightness. Now this may indicate an altered muscle control associated with the pathology,
resulting in deviations of the movements of the shoulder girdle from the normal. A
differentiation can be made between the tissue tightness and the poor motor control by
making adjustments in the position of the patient or/and the position of the arm. Further
deficit proprioception and the patient’s inability to control the movement results in restricted
range of motion of glenohumeral joint. The tightness, spasm or muscle guarding can also be a
manifestation of the pain or apprehension to movement.
Pathology
a.Joint capsule and ligaments
The inflamed and contractured joint capsule is the main source of pain. A similar observation
was made when therapeutic technique of arthroscopic capsular release was introduced to
treatment of frozen shoulder. Researchers like Lundberg concluded from extensive research
that inflammation acts as essential event resulting in pain, stiffness and eventual capsular
fibrosis because this inflammation of the joint capsule is followed by increased deposition of
collagen. Clinical examination of the coracohumeral ligaments in the patients with shoulder
stiffness included fibrinoid degeneration, hyalinization as well as fibrosis. Radiological
examination of anterosuperior capsule revealed the presence of collagen (type-3). Cells with
vimentin were found confirming that fibrotis had started occuring. This fibrosis bestows the
stiffness to the shoulder complex.
b.Synovium
The following findings are seen in frozen shoulder:
• the synovial layers (superficial) loses its ability of multiplication

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• synoviocytes containing IL-1α are absent
• numerous inflammatory cellular factors like TNF-α and Interleukin-1α, 1 β, and 6
were present
• fibrotic growth factors like a and b and several others were present.
• Cellular factors provoking inflammation were detected.
• Lymphocytes-B and T-lymphocytes along with macrophages and mast cells were
detected indicating the involvement of an immunological response.
Diagnostic Imaging
Imaging reports such as x-ray and MRI aid the assessment process.
Arthrographic examination shows represent a decreased joint volume indicating its
shortening along with the erasure of the subcoracoid fat triangle. Axillary thickening of the
capsule and a denser than normal coracohumeral ligament is a common MRI finding.
MRI combined with intravenous administration of gadolinium helped determine that synovial
inflammation increased the perfusion of the gadolinium from blood vessels to capsule. This
perforation seemed to decreased by the administration of corticosteroids intra-articularly.
Treatment
a.Hot packs: Since the disease is chronic in nature, hence the hot pack aids in reduction of
the pain symptom. Hot packs are generally given for (10 – 12) minutes.
b.Cold packs: The inflammation developed can be reduced using cryotherapy. Cold packs
used for 10-15minutes can help resolve the inflammation and hence reduce the other
implications of inflammation such as pain, muscle spasm, etc.
c.Transcutaneous electrical nerve stimulation (TENS): TENS is an electrotherapeutic
intervention which produces a numbing effect on the nerve endings in the spinal cord that
transmit the pain afferents. TENS produces pain relief by two mechanisms: sensory level of
stimulation and the motor level of stimulation. Different patients have different level of
electrical sensitivity nd hence different intensities of rectangular currents relive pain of
different patients. Intensity range of conventional TENS is up to 80milliamperes and time of
application is 10-15 minutes.
d.Shoulder manipulation : The shoulder joint is gently menueverised while patient is under
the effect of general anaesthesia. Certain joint play techniques are applied to the shoulder
joint surfaces in order to reduce the stiffness and tighten around the shoulder joint. These

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joint play techniques are known as glides which are given in superior, inferior, anterior and
posterior planes of the shoulder joint.
e.Physical therapy: Like various exercises to maintain mobility and flexibility of the joint.
Several exercises suggested commonly are Pendulum stretch (8-10) counts,finger ladder,in
)flexion-extention and abduction-adduction) towel stretch (6-8) repitations pulley exercises,
wall push-ups(8-10) counts, circumduction exercises, etc.

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Case study-1
Name : Mrs. Sarla
Age : 40 yrs.
Sex : female
Occupation : Housewife
Address : 1412/4 , sec- 28, Faridabad,Haryana
Marital status : Married
Chief Complaint :
Pain in right shoulder
Not able to perform ADL. Activities
Decreased range of motion
History :
Pain gradually progressive
Pain from last 6 months
Continous pain
Non traumatic
No surgery
Observation :
Shoulder is elevated and protracted
Swelling present around the shoulder joint
No deformity
Examination :
Tenderness present at right deltoid region
Range of motion assessment
Active Movements :
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-180 100 170

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Shoulder extension 45-55 30 42
Shoulder abduction 170-180 95 174
Shoulder external rotation 80-90 60 83
Shoulder internal rotation 80-90 65 83
Elbow flexion 145-155 140 147
Elbow extension 145-155 145 145
Passive Movements :
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-185 105 175
Shoulder extension 45-65 35 47
Shoulder abduction 170-185 99 177
Shoulder external rotation 80-95 63 86
Shoulder internal rotation 80-95 67 86
Elbow flexion 145-160 144 147
Elbow extension 145-160 147 147
Probable Diagnosis : FROZEN SHOULDER
Therapist Goals :
Decrease pain
Increase ROM without pain
Make him able to do ADL. Activities
Decrease stiffness
To correct posture
Treatment :
Modality protocol
Moist hot pack over shoulder region for 15 min.
TENS for 15 min.
Ultrasound over right shoulder tenderness with 1.6w/cm2 for 15 min.
Exercise protocol :

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Shoulder mobilization
Pendular exercise
Finger ladder exercise
Pulley exercise
Wand exercise
Right shoulder muscle strenghtening exercise
Precautions :
Hot formentation
No jerky movement
No weight lifting
Exercise as a advice.

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Case study- 2
Name : Mr. Suresh
Age : 48 yrs.
Sex : male
Occupation : Business man
Address : 214/B , Sec- 16, Faridabad,Haryana
Marital status : Married
Chief Complaint :
Pain in left shoulder
Not able to perform ADL. Activities
Decreased range of motion
History :
Pain gradually progressive
Pain from last 2 months
Continous pain
Non traumatic
No surgery
Observation :
Shoulder is elevated and protracted
Swelling present around the shoulder joint
No deformity
Examination :
Tenderness present at left deltoid region
Range of motion assessment
Active Movements :
Movement Normal- Range Right Left
Shoulder Flexion 170-180 170 100
Shoulder extention 45-55 42 30

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Shoulder abduction 170-180 174 95
Shoulder internal
rotation
80-90 83 65
Shoulder internal
rotation
80-90 83 60
Elbow flexion 145-155 147 140
Elbow extension 145-155 145 145
Passive Movements :
Movement Normal-Range Right Left
Shoulder flexion 170-185 175 105
Shoulder extension 45-65 47 35
Shoulder abduction 170-185 177 95
Shoulder internal
rotation
80-95 86 67
Shoulder internal
rotation
80-95 86 63
Elbow flexion 145-160 144 147
Elbow extension 145-160 142 145
Probable Diagnosis : FROZEN SHOULDER
Therapist Goals :
Decrease pain
Increase ROM without pain
Make him able to do ADL. Activities
Decrease stiffness
To correct posture
Treatment :
Modality protocol
Moist hot pack over shoulder region for 15 min.
TENS for 15 min.

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Ultrasound over right shoulder tenderness with 1.6w/cm2 for 15 min.
Exercise protocol :
Shoulder mobilization
Pendular exercise
Finger ladder exercise
Pulley exercise
Wand exercise
Right shoulder muscle strenghtening exercise
Precautions:
Hot formentation
No jerky movement
No weight lifting
Exercise as a advice.

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Case study-3
Name : Mrs. Upasna
Age : 35 yrs.
Sex : female
Occupation : Housewife
Address : 365/1 , Sec- 17 A , Faridabad,Haryana
Marital status : Married
Chief complaint :
Pain in right shoulder
Not able to perform ADL. Activities
Decreased range of motion
History :
Pain gradually progressive
Pain from last 4 months
Continous pain
Non traumatic
No surgery
Observation :
Swelling present around the shoulder joint
No deformity
Examination :
Tenderness present at right deltoid region
Range of motion assessment
Active Movements
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-180 100 170
Shoulder extension 45-55 30 42

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Shoulder abduction 170-180 95 174
Shoulder external rotation 80-90 60 83
Shoulder internal rotation 80-90 65 83
Elbow flexion 145-155 140 147
Elbow extension 145-155 145 145
Passive Movements
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-185 105 175
Shoulder extension 45-65 35 47
Shoulder abduction 170-185 99 177
Shoulder external rotation 80-95 63 86
Shoulder internal rotation 80-95 67 86
Elbow flexion 145-160 144 147
Elbow extension 145-160 147 147
Probable Diagnosis : FROZEN SHOULDER
Therapist Goals :
Decrease pain
Increase ROM without pain
Make him able to do ADL. Activities
Decrease stiffness
TREATMENT
Modality protocol
Moist hot pack over shoulder region for 15 min.
TENS for 15 min.
Ultrasound over right shoulder tenderness with 1.6w/cm2 for 15 min.
Exercise protocol
Shoulder mobilization

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Pendular exercise
Finger ladder exercise
Pulley exercise
Wand exercise
Right shoulder muscle strenghtening exercise
PRECAUTION/HOME ADVICE
Hot formentation
No jerky movement
No weight lifting
Exercise as a advice.

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Case study-4
Name : Mrs. sofia
Age : 36 yrs.
Sex : female
Occupation : Housewife
Address : 669/2, street No.2, Srinagar, Delhi
Marital status : Married
Chief complaint :
Pain in right shoulder
Not able to perform ADL. Activities
Decreased range of motion
History :
Pain gradually progressive
Pain from last 2 months
Continous pain
Non traumatic
No surgery
Observation :
Shoulder is elevated and protracted
Swelling present around the shoulder joint
No deformity
Examination :
Tenderness present at right deltoid region
Range of motion assessment
Active Movements
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-180 100 170
Shoulder extension 45-55 30 42

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Shoulder abduction 170-180 95 174
Shoulder external rotation 80-90 60 83
Shoulder internal rotation 80-90 65 83
Elbow flexion 145-155 140 147
Elbow extension 145-155 145 145
Passive Movements
MOVEMENT NORMAL RANGE RIGHT LEFT
Shoulder flexion 170-185 105 175
Shoulder extension 45-65 35 47
Shoulder abduction 170-185 99 177
Shoulder external rotation 80-95 63 86
Shoulder internal rotation 80-95 67 86
Elbow flexion 145-160 144 147
Elbow extension 145-160 147 147
Probable Diagnosis : FROZEN SHOULDER
Therapist Goals
Decrease pain
Increase ROM without pain
Make him able to do ADL. Activities
Decrease stiffness
To correct posture
TREATMENT
Modality protocol
Moist hot pack over shoulder region for 15 min.
TENS for 15 min.
Ultrasound over right shoulder tenderness with 1.6w/cm2 for 15 min.
Exercise protocol
Shoulder mobilization
Pendular exercise

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Finger ladder exercise
Pulley exercise
Wand exercise
Right shoulder muscle strenghtening exercise
PRECAUTION/HOME ADVICE
Hot formentation
No jerky movement
No weight lifting
Exercise as a advice.