1. DR M S GOUD PROFESSOR OF ORTHOPAEDICS GANDHI MEDICAL COLLEGE SECUNDERABAD

2. DEFINITION:it is a syndrome defined in its purest sense as an idiopathic pain ful restriction of shoulder movements resulting in global restriction of gleno humeral joint. CODMAN in 1934 coined the term frozen shoulder and described as difficult to define,difficult to treat,difficult to explain. 3. CLINICAL FEATURES Slow onset of pain near the insertion of the deltoid. Inability to sleep on the affected side. Pain relatively more in the night. Restriction of abduction and external rotation followed by global restriction. Normal radiological appearance. 4. CLINICAL COURSE Runs for 1 to 3 years. Usually selflimiting It is divided in to three phases a)freezing phase (2-6 months) b)frozen phase (4 -12 months) c)thawing phase (4 -18 months) If not treated will end up in permanent restriction of some movement. 5. EPIDEMIOLOGY Not common before 4th decade. More common in women. Non dominant extremity. Bilateral 34%. More common in hyper anxiety personalities with low pain tolerence. 6. CAUSATIVE FACTORS Primary : idiopathic. Secondary contributing factors 1)injury not treated properly 2)after shoulder surgery 3)diabetes 4)autoimmune disorders. 5)poor posture-specially when recovering from chronic illnesses like CVA,MI etc 7. DIFFERENTIAL DIAGNOSIS IT HAS TO BE DIFFERENTIATED FROM OTHER PAIN FUL SYNDROMES. 1)tuberculosis 2) osteo arthritis. 3)rheumatoid arthritis 4)painful arc syndrome. 5) rotator cuff injuries 8. CONSERVATIVE MANAGEMENT: 1)physical therapy. 2)drug therapy 3)intra articular steroid(methyl prednisolone) 4)intra articular saline injection with breakage of the capsule fibres and adhesions(brisement) 5)closed manipulation under G.A. 9. PHYSICAL THERAPY 1)Electro therapy (ultrasound,IFT). 2)Hydro therapy. 3)exercises to improve flexibility and strength. 4)ice and heat treatment. 5)soft tissue massage. 6)dry needling 7)postural correction. Councelling and motivation. 10. ELECTRO THERAPY Interferential therapy:it is a current used for thereupetic purposes obtained by passing two medium frequency currents where the currents intersect with tissue to produce a new current. 11. PHYSIOLOGICAL EFFECTS OF IFT: Relieves pain Promotes healing. Stimulates muscles. Promotes relaxation. Improves circulation. 12. ULTRA SOUND THERAPY: Mechanical vibrations of sound waves of frequency ranging from 0.5 to 5 MHZ. The theurepetic ultra sound works on reverse piezo electric effect. THERMAL EFFECTS: are useful for treatment. a)increased extensibility of connective tissue. b)decreased joint stiffness and muscle spasm. c)relieves pain d)promotes healing of tissues. 13. ULTRA SOUND THERAPY 14. DRUG THERAPY Anlgesics Muscle relaxants Sedatives Tranquilisers Medicated patches (diclofenac sodium,fentanyl,lidocaine) 15. MANAGEMENT OF FREEZING STAGE( STAGE 1) Gentle physiotherapy (mostly pendular exercises) Intra articular methyl prednisolone 16. MANAGEMENT OF FROZEN AND THAWING STAGE Ideal for active and passive physiotherapy Distension of the shoulder joint with 50 -100 ml of saline will break some fibres of the adhesions(brisement force). MANIPULATION :if there is no response with above treatment. 17. PHYSIOTHERAPY:short period for 5 to 10 min per hour around 10 cycles per day is better than a continuous physiotherapy for long time. Application of heat before physiotherapy( ultrasound and IFT ) will cause vasodilatation that helps in muscle relaxation. Application of ice after physiotherapy (vasoconstriction) reduces the inflammation. 18. INTRA ARTICULAR INJECTIONS Methyl prednisolone saline 19. CLOSED MANIPULATION-GA(MUA) INDICATION:adhesive stage. Patient needs absolute relaxation under GA. 20. BETTER AVOID- MUA Grossly osteoporotic Rotator cuff tear. Arthritis involving gleno humeral joint(RA,OA) Sympathetic osteodystrophy 21. POST MANIPULATION MANAGEMENT Patients limb should be kept in 160 degrees of abduction and 90 degrees of external rotation for 48 hours(ROBERT ET AL). Patient should have an inter scalene block catheter insitu for 48 hours. 22. COMPLICATIONS OF MUA: Fracture surgical neck of humerus. Rupture of sub scapularis. Rupture of long head of biceps. Nerve injury FACTORS THAT MAY INCREASE RISK OF COMPLICATIONS: Recent chronic illness Chronic smokers and alcoholics Previous shoulder surgery. 23. SUMMARY Its a vascular based inflammatory pathology with formation of adhesions. Unknown etiology. Natural history-variable duration. chronic pain with stiff shoulder with restriction of daily living activities NO SINGLE TREATMENT REGIME HAS BEEN PROVED TO BE THE BEST SOLUTION. What ever regime we adopt PHYSIOTHERAPY IS THE MAIN STAY OF THE TREATMENT. 24. There is a role for surgical release (arthroscopy) for chronic and resistant cases.