Peri-arthritis Is A Common Condition Characterised By Pain And Progressive Limitation Of Abduction & External Rotation Movement Of Shoulder Joint

1. PROF. (DR.) NIRAJ KUMAR
PH.D. PHYSIOTHERAPY, MPT, MHA, BPT
SHRI GURU RAM RAI UNIVERSITY
SHRI GURU RAM RAI SCHOOL OF PARAMEDICAL & ALLIED
HEALTH SCIENCES
DEPARTMENT OF PHYSIOTHERAPY
PATEL NAGAR DEHRADUN-248001, UTTRAKHAND
PERIARTHRITIS SHOULDER
&
ADHESIVE CAPSULITIS/FROZEN SHOULDER

2. YOUR SHOULDER IS A BALL-AND-SOCKET JOINT MADE UP OF
THREE BONES: YOUR UPPER ARM BONE (HUMERUS), YOUR
SHOULDER BLADE (SCAPULA), AND YOUR COLLAR BONE
(CLAVICLE).
THE HEAD OF HUMERUS FITS INTO A SHALLOW SOCKET IN
YOUR SHOULDER BLADE (SCAPULA).
STRONG CONNECTIVE TISSUE, CALLED THE CAPSULE, GL,
SURROUNDS THE JOINT.
TO HELP YOUR SHOULDER MOVE MORE EASILY, SYNOVIAL
FLUID LUBRICATES THE SHOULDER CAPSULE AND THE JOINT
Anatomy

3. ANATOMY OF SHOULDER JOINT

4. ANATOMY OF SHOULDER JOINT

5. Introduction:-
In 1872 Dupley 1st Described And Called Humeroscapular
Peri-arthritis .
In 1934 Codman Coined The Term Frozen Shoulder.
In 1945 Neviaser Gave The Term Named Adhesive Capsulitis
.
FROZEN SHOULDER OCCURS IN ABOUT 2% OF THE GENERAL
POPULATION. IT MOST COMMONLY
AFFECTS PEOPLE BETWEEN THE AGES OF 40 AND 60, AND OCCURS
IN WOMEN MORE COMMON THAN MEN.
AGE:- 40 TO 60 YRS OLD AGE.
SEX:- F>M
Peri-arthritis Shoulder / Frozen Shoulder

6. DEFINITION:-
1. Peri-arthritis Is A Common Condition Characterised By Pain And
Progressive Limitation Of Abduction & External Rotation Movement
Of Shoulder Joint
2.FROZEN SHOULDER, ALSO CALLED ADHESIVE CAPSULITIS,
CAUSES PAIN AND STIFFNESS IN THE SHOULDER. OVER TIME,
THE SHOULDER BECOMES VERY HARD TO MOVE.
3. FROZEN SHOULDER OR ADHESIVE CAPSULITIS DESCRIBES
THE COMMON SHOULDER CONDITION CHARACTERIZED BY
PAINFUL AND LIMITED BOTH ACTIVE AND PASSIVE RANGE OF
MOTION IN ALL PLAINS WITH RADIOGRAPHIC APPEARANCE.

7. FIG: FROZEN SHOULDER/PA

8. 1.Immobilisation Dueto Fracture & Dislocation Around
The Shoulder Jt.
2. Bicipital Tendinitis
3. Rotator Cuff Tendinitis
4. Stroke,
5. Lung Disease,
6. RSD
7. Thyroid Disease ---- Hyperthyroidism
8. Heart Disease (CVS) -- Ischemic Heart Diseases
9. Diabetes Mellitus- insulin dependent diabetes
10. Tonic Seizures
11. Strain and Strain and Surgical trauma.
Risk factors for frozen shoulder/PA
include:-

9. YOU SHOULD BE ABLE TO MOVE YOUR SHOULDER IN ALL DIRECTIONS
WITHOUT PAIN. TO TEST YOURSELF, DO THESE THINGS:
SHOULDER STIFFNESS
INABILITY TO RAISE ARM
LIMITED SHOULDER MOBILITY
SHOULDER PAIN
SHOULDER IMMOBILITY
RADIATING PAIN DOWN ARM
SHOULDER PAIN; USUALLY A DULL, ACHING PAIN
LIMITED MOVEMENT OF THE SHOULDER
DIFFICULTY WITH ACTIVITIES SUCH AS BRUSHING HAIR, PUTTING ON SHIRTS/BRAS
PAIN WHEN TRYING TO SLEEP ON THE AFFECTED SHOULDER
1. IN PA LIMITATION OF ABD. & ER OF GH JOINT.
2.PAIN FROM FROZEN SHOULDER & PA IS USUALLY DULL OR ACHING. IT IS TYPICALLY WORSE
EARLY IN THE COURSE OF THE DISEASE AND WHEN YOU MOVE YOUR ARM. THE PAIN IS
USUALLY LOCATED OVER THE OUTER SHOULDER AREA AND SOMETIMES THE UPPER ARM.
3. TENDERNESS FRONT OF SH. JT.
Clinical Feature

10. CLASSIFICATION OF F.A/A.C ADHESIVE CAPSULITIS IS CLASSICALLY
CHARACTERISED BY THREE STAGE:-
1) FIRST STAGE (STAGE OF PAIN) ---- ( 3 TO 6 MONTH)
2) SECOND STAGE (STAGE OF STIFFNESS) ---(3 TO 18 MONTH)
3) THIRD STAGE (STAGE OF RECOVERY )-----(6 MONTH TO 2 YRS.)
1) FIRST STAGE (STAGE OF PAIN) – IS THE FREEZING STAGE IS
CHARACTERISED BY—
*ACHING PAIN IN SHOULDER
*PAIN MORE SEVERE AT NIGHT WITH ACTIVITIES.
*PAIN MAY RADIATES DOWN THE ARM
* PATIENTS ADEPT THE ADDUCTION + INTERNAL
ROTATION.
* DISCOMFORT SHOULDER.
NOTE:- (WHEN IT IS TREATED BY MOBILISATION THEN SYMPTOM
BECOME WORSEN THE FREEZING PROCESS).

11. 2) SECOND STAGE (STAGE OF STIFFNESS) – IT IS ALSO CALLED
FROZEN OR PROGRESSIVE STIFFNESS PHASE
* PAIN ↓ DURING REST.
*ADL SEVERELY RESTRICTED.
* SHOULDER MOTION RESTRICTED
IN ALL PLAIN.
*PATIENT COMPLAIN:-
1 INABILITY TO REACH IN TO BACK POCKETS.
2 FASTEN THE BRA.
3 COMB THE HAIR.
4 WASH THE OPPOSIT SHOULDER.
5 PAI AT NIGHT.
STAGE CAN BE LAST FROM 3 TO 18 MONTH
( NOT:- EASILY TREATED WITH MEDICINE AND PHYSICAL
THERAPY.)

12. 3) THIRD STAGE (STAGE OF RECOVERY )----
FINAL STAGE IS THROWING OR RESOLUTION PHASE. IT IS
CHARACTERISED BY NO PAIN WITH SLOW RECOVERY OF
MOTION. LOSS OF EXTERNAL ROTATION WITH ARM AT SIDE OF
THE PT. IS HALLMARK OF THIS CONDITION.
(NOTE:- AGGRESSIVE TREATMENT WITH PHYSICAL THERAPY AS
CLOSE MANIPULATION AS MAITLAND & MULLIGAN ETC. IF
CONSERVATIVE MANAGEMENT IS FAILED THAN SURGICAL
RELEASE IS REQUIRED ).

14. DIAGNOSING OSTEOARTHRITIS:-
1. X – RAY AP & LATERAL VIEW SHOULDER .
2. MRI SHOULDER
3. ORTHROSCOPY OF SHOULDER
4.ELEVATED ERYTHROCYTE SEDIMENTATION RATE [ESR]
5. C-REACTIVE PROTEIN [CRP] LEVEL) – INCREASE
6. ANTI–CYCLIC CITRULLINATED PEPTIDE [ANTI-CCP]
7. INFLAMMATORY JOINT FLUID WITH A PREDOMINANCE OF
....POLYMORPHONUCLEAR LEUKOCYTES (PMNS)
8. TLC & DLC , ELEVATED WHITE BLOOD CELL (WBC) COUNT

15. MANAGEMENT OF PA/FS
DRUG MANAGEMENT
1.NSAID:-
ASPIRIN, CELECOXIB (CELEBREX), DICLOFENAC POTASSIUM
(CATAFLAM), DICLOFENAC SODIUM (VOLTAREN, VOLTAREN XR),
DICLOFENAC SODIUM WITH MISOPROSTOL (ARTHROTEC),
IBUPROFEN, INDOMETHACIN (INDOCIN, INDOCIN SR),
OXAPROZIN (DAYPRO), PIROXICAM (FELDENE), ROFECOXIB
(VIOXX)
MEFENAMIC ACID (PONSTEL), MELOXICAM (MOBIC),
NABUMETONE (RELAFEN), NAPROXEN (NAPROSYN,
NAPRELAN), NAPROXEN SODIUM, KETOPROFEN

17. NSAID

18. 2. ANTACIDS:-
PANTOPRAZOLE AND RABEPRAZOLE TABLE ALAMAG,
ALAMAG SUSPENSION, ALUMINUM AND MAGNESIUM
HYDROXIDE ORAL SUSPENSION (ALAMAG
SUSPENSION, MAALOX SUSPENSION, MAGNALOX
SUSPENSION, MAGNOX SUSPENSION, MINTOX
SUSPENSION), ALUMINUM AND MAGNESIUM HYDROXIDE
(ALAMAG, ALUDROXGEL, MAALOX, MAGNALOX, MYLANTA, RUL
OX), ALUMINUM HYDROXIDE ORAL LIQUID (ALTERNAGEL
LIQUID, AMPHOJEL SUSPENSION), ALUMINUM HYDROXIDE
(ALTERNAGEL, ALU-CAP, ALU-TAB, AMPHOJEL, DIALUME),
CALCIUM CARBONATE TABLETS (AMITONE, CALTRATE 600,
DICARBOSIL, EQUILET, MALLAMINT, TITRALAC, TUMS),
LANSOPRAZOLE, MAGNESIUM HYDROXIDE, OMEPRAZOLE,
PREVACID, PRILOSEC, RANITIDINE, ZANTAC, ZOTON

19. ANTACID
S:-

20. ANTACIDS

21. 3. CALCIUM THERAPY WITH VITAMIN D3

22. MANAGEMENT :-
THE BASIC AIM OF FROZEN SHOULDER EXERCISES ARE:
TO REDUCE PAIN.
TO INCREASE EXTENSIBILITY OF THE THICKENED AND
CONTRACTED CAPSULE OF THE JOINT.
TO IMPROVE MOBILITY OF THE SHOULDER.
TO IMPROVE STRENGTH OF THE MUSCLE. HOWEVER IT
MAY BE REMEMBERED THAT STRENGTHENING OF
MUSCLE IS SECONDARY TO MOBILIZATION.

23. MANAGEMENT OF PA/F. S. CLASSIFIED INTO
THREE STAGE :-
1) FIRST STAGE (STAGE OF PAIN) ---- ( 3 TO 6 MONTH)
2) SECOND STAGE (STAGE OF STIFFNESS) ---(3 TO 18 MONTH)
3) THIRD STAGE (STAGE OF RECOVERY )-----(6 MONTH TO 2 YRS.)
1) FIRST STAGE (STAGE OF PAIN) ---- ( 3 TO 6 MONTH):-
1. NSAIDS- FIRST LINE MEDICATION FOR PAIN CONTROL ASSOCIATED
WITH ANTACID.
2. GH JOINT INJECTION: CORTICOSTEROID/LOCAL ANESTHETIC
COMBINATION.
3. ORAL STEROID TAPER- FOR PATIENTS WITH REFRACTIVE OR
SYMPTOMATIC FROZEN SHOULDER.
4. THERAPEUTIC MODALITIES ICE FOR 20 MIN, ULTRASOUND 0.8 TO
1.2 WTTS. FOR 5 TO 7 MINS, HVGS FOR 25 MINS.
APPLY MOIST HEAT BEFORE THERAPY AND ICE PACK AT THE END OF
SESSION.

24. 5. INITIALLY FOCUS ON FORWARD FLEXION AND INTERNAL AND
EXTERNAL ROTATION WITH THE ARM AT THE SIDE, AND THE ELBOW
AT 90 DEGREES.
6. ACTIVE ROM EXERCISES.
7. ACTIVE ASSISTED ROM EXERCISES.
8. PASSIVE ROM EXERCISES.
9. A SUSTAINED STRETCH, OF 15-30 SECONDS, AT THE END ROMS
SHOULD BE PART OF ALL ROM ROUTINES.
10. IN HOME THESE FROZEN SHOULDER EXERCISES SHOULD BE
PERFORMED 3-5 TIMES PER DAY.
2) SECOND & THIRD STAGE (STAGE OF STIFFNESS & STAGE OF
RECOVERY ) ---
CRITERIA FOR PROGRESSION TO STAGE - 2
IMPROVEMENT IN SHOULDER DISCOMFORT.
IMPROVEMENT IN SHOULDER MOTION.
SATISFACTORY PHYSICAL EXAMINATION.

25. GOALS
* PAIN CONTROL BY SAME MEANS AS USED IN 1ST 8 WEEKS.
* IMPROVE SHOULDER MOTION IN ALL PLANE
* IMPROVE STRENGTH AND ENDURANCE OF ROTATOR CUFF AND SCAPULAR
STABILIZERS.
MOTION: FROZEN SHOULDER EXERCISES
* ACTIVE ASSISTED EXERCISES.
* PASSIVE RANGE OF MOTION EXERCISES TO OBTAIN AROUND 140 DEGREE OF
FORWARD FLEXION, 45 DEGREE OF EXTERNAL ROTATION AND INTERNAL
ROTATION.

26. 1. THERMOTHERAPY
DEEP HEATING MODALITIES SUCH AS SWD, UST, LWD ETC.
USING BEFORE PASSIVE MOBILIZATION FOR PROPER
RELAXATION OF MUSCLE & LIGAMENT.
2. GENERAL MOBILIZATION TECHNIQUE:-
*PASSIVE GLIDING WITH LONGITUDINAL TRACTION :- SUPINE,
FULL ABDUCTION AND NEUTRAL ROT. WITH ELBOW IN 90°FL.
THERAPIST APPLY LONGITUDINAL TRACTION ALONG THE AXIS
OF THE HUMERUS, HE CARRIES OUT AP GLIDE & ABD.& ADD
GLIDE IN A SLOW RHYTHMIC MANNER. )
* FORWARD STOOPING POSITING:- STABILIZED THE SH. JT. BY
ONE HAND & OTHER GRASP THE WRIST THEN SLOW
CURCUMDUCTION MOVEMENT IS CARRIED OUT UP TO LIMIT OF
PAIN.

27. PASSIVE GLIDING WITH LONGITUDINAL
TRACTION :-

28. PASSIVE MOBILIZATION OF SH. IN A FORWARD
STOOPING POSITING

29. MUSCLE STRENGTHENING
1. START WITH ROTATOR CUFF STRENGTHENING EXERCISES 3
TIMES/ WEEK, 8-12 REPETITIONS FOR THREE SETS.
2. CLOSED CHAIN ISOMETRIC STRENGTHENING WITH THE
ELBOW FLEXED TO 90 DEGREES AND THE ARM AT THE SIDE.
PERFORM INTERNAL ROTATION, EXTERNAL ROTATION,
ABDUCTION AND FORWARD FLEXION.
3. PROGRESS TO OPEN CHAIN STRENGTHENING EXERCISES
WITH THERABAND FOR SAME GROUP OF MUSCLES.
4. PROGRESS TO LIGHT WEIGHT DUMBBELL EXERCISES FOR
INTERNAL ROTATORS, EXTERNAL
ROTATORS, ABDUCTORS AND
FORWARD FLEXORS.
5. STRENGTHENING OF SCAPULAR
STABILIZERS.
6. DELTOID STRENGTHENING.

30. 1. LYING DUMBBELL PRESSES
PT. LIE ON SUPINE LYING HOLDING A LIGHT DUMBBELL IN EACH HAND.
EXTEND YOUR ARMS VERTICALLY WITH PALMS FACING INWARDS.
NEXT, PUSH YOUR ARMS FURTHER UPWARDS KEEPING THEM PARALLEL TO
EACH OTHER SUCH THAT YOUR SHOULDERS BLADES SEPARATE.
PERFORM BETWEEN 10 AND 20 REPETITIONS OF THE EXERCISE. INCREASE
THE NUMBER OF REPETITIONS WITH PRACTICE.

31. 2. PUSH-UP PLUS
HOLD YOURSELF IN A PUSH-UP POSITION: HERE, YOUR BODY IS HORIZONTAL,
FACING DOWNWARDS, ARMS EXTENDED WITH YOUR SHOULDERS WIDE
APART. KEEP YOUR HEAD IN A STRAIGHT LINE WITH YOUR SPINE.
EXTEND YOUR SHOULDERS TO THE FRONT AND SQUEEZE YOUR SHOULDER
BLADES TO BRING YOURSELF UP. KEEPING YOUR ARMS EXTENDED, LET
GRAVITY BRING YOU BACK TO THE ORIGINAL POSITION. REPEAT THE
WORKOUT 10-20 TIMES DAILY.

32. 3. RHOMBOIDS STRETCH
RHOMBOIDEUS MAJOR AND MINOR ARE TWO IMPORTANT MUSCLES TO KEEP
THE SHOULDER GIRDLE IN A FUNCTIONAL STATE.
FIRST PLACE YOUR RIGHT ARM UNDER YOUR LEFT SHOULDER AND THEN
PLACE YOUR LEFT ARM OVER YOUR RIGHT SHOULDER AND FEEL THE
STRETCH.
HOLD THIS POSITION IN 10 SECONDS AND THEN RELAX. PERFORM 10
REPETITIONS FOR EACH ARM TWICE EACH DAY.

33. 7. PENDULUM EXERCISE
THE PENDULUM EXERCISE IS A PART OF SCAPULAR STABILIZATION EXERCISEIS
GREAT FOR WORKING A LARGE NUMBER OF MUSCLES LIKE THE DELTOIDS,
SUBSCAPULARIS, ROTATOR CUFFS AND SUPRASPINATUS AND INFRASPINATUS
MUSCLES.
LEAN ON A TABLE PLACING ONE OF YOUR HANDS ON THE TABLE FOR SUPPORT.
SWING THE OTHER HAND 10-12 TIMES BOTH IN THE BACKWARD-FORWARDS
DIRECTION AND LATERALLY. ALSO SWING THE ARM CLOCKWISE AND ANTI-
CLOCKWISE.

34. POSTERIOR CAPSULE STRETCHING

35. ANTERIOR CAPSULE STRETCHING

37. HAND TO BACK POSITION:
TO DECREASE SHOULDER STIFFNESS:-
GRAB YOUR AFFECTED HAND BEHIND YOUR BACK AS FAR AS
POSSIBLE. PUSH THE HAND DOWNWARDS INTO THE OPPOSITE
HAND AND HOLD FOR 6 SECONDS. RELAX AND SLOWLY BRING
THE HAND BACK UP. REPEAT 2 TO 3 TIMES.
Hand to back
Sh. Exe.

38. OTHER EXERCISES :
1. WALL & LADDER EXERCISES EXERCISE.
2. SHOULDER & WHEEL EXERCISE
3. FINGER LADDER EXERCISE.
Wall &
ladder exe.

39. THANK YOU