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PERIARTHRITIS SHOULDER 2012

PERIARTHRITIS SHOULDER
Periarthritis is a term used to indicate a clinical syndrome where glenohumeral motion has a restricted range of active & passive motion for which no other cause can be identified. All patients with idiopathic loss of shoulder range of motion complain of decreased motion. Additional complaints include disturbed sleep and difficulty accomplishing personal hygiene, donning and doffing clothing and overhead movement, reaching or rotation activities. Codman initially coined the term Frozen Shoulder in 1934 Terminology has been based on assumed etiology. Terms based on Inflammation include adhesive capsulitis, Adhesive subacramial bursitis Biceps Tenosynovitis Scapulo humeral periarthritis subdeltoid bursitis

Obliterative bursitis and tendinitis of the short rotators. Non inflammation based terms include stiff and painful shoulder calcification of Supraspinatus tendon particular adhesions Duply Disease An Alogodys Trophic process and checkrein shoulder

PERIARTHRITIS SHOULDER 2012


Gleno humeral motion was chosen for this investigation as a more accurate representation of the actual joint where the idiopathic motion loss is believed to orginate, rather than humerus to trunk motion, which is a function of multiple joints. In this various etiological factors are described, different pathological changes are explained numerous tests and investigation are put in regarding periathritis shoulder. Physiotherapy plays a vital role in maintaining the patients shoulder mobility and with the effective use of various modalities that presents the progression of the degenerative changes of the shoulder. Early diagnosis is very important in periarthritis shoulder patients otherwise it may leads to adverse effects. For the creating awareness in the patients about this condition is very necessary. The main aim in treating the periarthritis patients is to improve the range of motion and to make the person functionally independent and lost but not the least to minimize the discomfort to the patient.

PERIARTHRITIS SHOULDER 2012


Incidence
Usually it effects unilaterally but on occasion becomes bilateral Incidence of periarthritis is not precisely known however if estimated that 3% of people develop the disease over their life time.

The incidence of shoulder complaints in general practice is 15-25 per 1000 patients per year. A higher incidence of periarthritis shoulder exists among patients with diabetics (10-20%) compare to the general population (2-5%). Incidence among patients with insulin dependent diabetes is even higher (36%) with an increased frequency of bilateral shoulder involvement. Bridgman reported that up to 7% of outpatients seen at a community hospital had symptoms of periarthritis and Bunder and Anthony reported that more than 5% of all patients in their study who were seen at shoulder clinics were diagnosed with frozen shoulder. Age and sex distributions reported in the literature have been widely variable with ages ranging from 22 yrs to 85 yrs and with percentage of female subjects ranging from 48% to 84%.
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Codman concluded that symptoms resolved and full movement returned in 21 of 22 patients within 2 years. This tends to effect women than men. Menopause often is cited as a cause of periarthritis shoulder in female.

PERIARTHRITIS SHOULDER 2012

ANATOMY
The shoulder girdle
The shoulder girdle connects the upper limb to the axial Skelton. The shoulder complex is composed of the scapula, clavicle, humerus and the joints that links these bones into a functional entity. The 3 segments (scapula, clavicle and humerus) are controlled by 4 inter dependent linkages. They are : 1. 2. 3. 4. Scapulothoracic Joint (ST) Functional Articulation Sternoclavicular (SC) Joint Acromio Clavicular (AC) Joint Gleno Humeral (GH) Joint

A 5th functional articulation is commonly described as part of the complex and is formed by the Coraco Acromial arch and the head of the humerus 1. Scapulo Thoracic Joint: ST joint is formed by the articulation of the scapula with the thorax on which it sits.
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Joint union is by fibrous, cartilaginous, or synovial tisues The SC and AC joints are inter dependent with the ST joint because scapula is attached by its acromion process to the lateral end of the clavicle via the AC joint. The clavicle, inturn is attached to the axial skelton at the manubrium sterni via SC joint. The functional ST joint is part of a true closed chain with the AC and sc joint.

The Motions of the Scapula are:


i) ii) iii) iv) v) vi) Elevation Depression Protraction (Abduction) Retraction (Adduction) Upward rotation (Lateral rotation) Downward rotation (Medial rotation)

Elevation and Depression of the scapula are trnslatory motions in which the scapula moves upwards (Cephalad) or downwards (Caudally) along the rib cage from its resting position.

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Protraction and retration of the scapula retranslatory motions of the scapula away from or towards the vertebral column respectively. Upward rotation is the movement of inferior angle of scapula away from the vertebral column and downward rotation is movement of inferior angle forwards the vertebral column other movements of scapula:

Anterior Tipping Posteriror Tipping

2. Sterno Clavicular (SC) Joint:


Type: i) ii) iii) iv) v) It is a plane synovial joint. It is a compound joint as there as 3 elements taking part in it, namely Medial end of the clavicle Clavicular notch of the Manubrium Sterni Upper surface of the first costal cartilage It is a complex joint as its cavity is sub divided into two parts by an intra articular disc.

Articular surfaces:
Clavicular :
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Articular surface of the clavicle is covered with fibro cartilage. The surface is convex from above downwards and slightly concave from front to back. Sternal :

Sternal articular surface is smaller than the clavicular surface. It has a reciprocal convexity and concavity. Because of the concavo convex shape of the articular surfaces. The joint can be classified as a Saddle Joint.

SC joint has :
i) ii) iii) A Joint Capsule Articular disc or joint disc Three major ligaments

1. Capsular ligament It is attached Laterally To the margins of the Clavicular Articular surface Medially : To the margins of the articular areas on the sternum and on the first costal cortilage.

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2. Articular Disc: It is attached Laterally:

To the clavicle on a rough area above and posterior to the articular area for the sternum. Inferiorly: To the sternum and to the first costal cartilage at their junction. Anteriorly and posteriorly the disc fuses with the capsule. Ligaments: a) b) Steno Clavicular Ligament Costo Clavicular Ligament

Attached above to the rough area on the inferior aspect of the medial end of the Clavical. Inferiorly, it is attached to the first costal cartilage and to the first rib. c) Interclavicular ligament

Passes between the sternal ends of the right and left clavicles.
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Some of its fibres being attached to the upper border of the manubrium stern

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Blood supply 1. 2. Internal thoracic artery Supra scapular artery.

Nerve supply Medial supraclavicular nerve Movements: 1. 2. 3. Elevation and depression of the clavicle. Protraction and retration of the clavicle. Anterior and posterior rotations of the clavicle.

3. Acromioclavicular (AC) joint: Type: AC joint is a plane synovial joint. Articular surfaces: AC joint is formed by articulation of small facets present. i) At the lateral end of the clavicle and

ii) On the medial margin of the acromion process of the scapula. It has a Joint Capsule, two major ligaments and a joint disc may or may not be present.

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Capsular ligament: Completely surrounds the articular margins. It is weak and can not maintain integrity of the joint without reinforcement of the superior and inferior AC and the Coraco Clavicular ligaments. Acromioclavicular joint disc: Disc of the ac joint is variable in size and differs individuals, at various times in the life of same individual and between sides of the same individual. Ligaments: i) Superior acromioclavicular ligament. Extends between upper part of the acromial end of the clavicle and adjoining part of the upper surface of the acromian. ii) Inferior Acromioclavicular Ligament: Attached to adjoining surface of the two bones. iii) Coracoclavicular Ligament:

This ligament is divided into a lateral portion, the trapezoid ligament and a medial portion, the conoid ligament.

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Trapezoid ligament:

Attached below to the upper surface of the coracoid process and above to the trapezoid line on the inferior surface of the lateral part of the clavicle. Conoid Ligament: Attached below to the root of the coracoid process just lateral to the scapular notch and above to the inferior surface of the clavicle on the conoid tubercle. Blood Supply : i) ii) Suprascapular Artery Thoraco Acromial Artery

Nerve Supply: Lateral Supraclavicular Nerve Movements: i) ii) Medial and lateral rotation of the scapula Anterior and posterior tipping of the scapula

4. Glenohumeral (GH) joint (or) Shoulder Joint: Type: The shoulder joint is a synovial joint of the ball and socket variety.
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Articular Surfaces: Small glenoid fossa of the scapula articulates with the large head of the humerus. It is a weak joint because the glenoid cavity is too small and shallow to hold the head of the humerus in place. However this arrangement permits great mobility. Stability of the joint is maintained by the following factors: i) ii) iii) iv) The coracoacromial arch The musculotendinous cuff of the shoulder The glenoid labrum which helps in deepening the glenoidfossa And also by the muscles attaching the humerus to the pectoral girdle, the long

head of the biceps, the long head of the triceps and atmospheric pressure. Ligaments of the Joint:

i) ii) iii) iv)

Capsular Ligament Coracohumeral Ligament Transverse Humeral Ligament Glenoid Labrum

i. Capsular Ligament:

It is very loose and permits free movements.


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It is least supported inferiorly where dislocations are common Medially the capsule is attached to the scapula beyond the supraglenoid tubercle and the margins of the labrum Laterally it is attached to the anatomical neck of the humerus with the following exception. Interiorly the attachment extends down to the surgical neck. Superiorly it is deficient for passage of the tendon of the long head of the biceps brachii. The joint cavity communicates with the subscapular bursa, with the synovial sheath for the tendon of the long head of the biceps brachii and often with the infraspinatus bursa. Anteriorly the capsule is reinforced by superior, middle and inferior GH ligaments.

ii. Coracohumeral ligament

Extends from the root of the coracoid process to the neck of the humerus opposite the greater tubercle.

It gives strength to the capsule.

iii. Transverse Humeral Ligament:


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It bridges the upper part of the bicipital groove of the humerus between greater and lesser tubercles. Tendon of the long head of the biceps passes deep to the ligament. iv. Glenoid labrum: It is firbocartilaginous rim which covers the margins of the glenoid cavity, thus increasing the depth of the cavity. Bursae related to the shoulder joint: 1. 2. 3. 4. The Subacromial (subdeltoid) bursae Sub Scapularis bursa, communicates with joint cavity Infraspinatus bursae, may communicates with joint cavity Several other bursae related to the coraco brachialis, teres major, long head of the

triceps, latismus dorsi and the coracoid process are present. Relations:

Superiorly Coracoacromial Arch Subacromial Bursa Supraspinatus and Deltoid Inferiorly: Long head of the triceps Brachii
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Anteriorly: Subscapularis Coraco Brachialis Short head of biceps and Deltoid

Posteriorly:
Infraspinatus Teres minor and deltoid Within the joint: Tendon of the long head of the biceps brachii Blood supply i) ii) Anterior circumflex humeral vessels Pasterior circumflex humeral vessels iii) iv) Suprascapular vessels and Subscapular vessels

Nerve Supply i) ii) Axiallary Nerve Musculo Cutaneous nerve and

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iii) Supra Scapular Nerve.

Movements: S.No. Movement 1 Flesion (1800)

Main Muscles Clavicular head of the pectoralis major anterior fibers of deltoid

Accessory Muscles coraco brachialis short head of biceps

2.

Extension (0-450)

Posterior fibers of deltoid Teres major Latissimus Dorsi Long head of triceps Sternocostal head of the pectoralis major. Pectoralis major Latissimus dorsi Short head of biceps Long head of triceps Teres major Coraco brachialis

3.

Adduction (0-450)

4.

Abduction (0-1800) Deltoid Supraspinatus Serratus anterior Upper and lower fibers of traperzius Medial Roation 0 (0-55 ) Pectoralis major Anteriof fibers of deltoid Latissimus clorsi Teres major Posterior fibres of deltoid Infraspinatus ,Teres Minor.
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5.

Subscapularis

6.

Lateral rotation (0-450)

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BIOMECHANICS
GLENOHUMERAL MOTIONS
OSTEOKINEMATICS
The GH joint is having 30 of the freedom. a. b. c. Flexion / Extension Abduction / Adduction Medial / Lateral Rotation

The joint have 1200of flexion and about 500 of extension. The range of medial / lateral rotation of the humerus varies with position. With the arm at the side, medial and lateral rotation may be limited to as little as 50 0 of combined motion. Abducting the humerus to 900 frees the arc of rotation to 1200. The restricted arc of medical / lateral rotation when the arm is at the side is due to the impact of the lesser tubercle on the anterior glenoid fossa with medial rotation and the impact of the greater tubercle on the acromion with lateral rotation. When the arm is abducted, these bony restrictions play little role, so the checks of motion become capsular and muscular.

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The range of abduction of the humerus in the frontal plane will be diminished if the humerus is maintained in neutral or medial rotation.

When the humerus is medially rotated, the humerus will not abduct on the glenoid fossa beyond 600, at neutral rotation 900 of GH abduction can be obtained. The restriction to abduction is caused by the impingement of the greater tubercle on the coracoacromial arch. When the humerus is laterally rotated 350 to 400, the greater tubercle will pass under or behind the arch so, that abduction can continue unimpeded. The forward movement of the humerus in flexion, the greater tubercle slides behind or under the acromion process regardless of rotation. So to achieve full range flexion, not the same need for rotation of the humerus. The range of motions for abduction of the GH joint are reported to be anywhere from 900 to 1200 with varying citations in between. In man and coworkers found active abduction to be limited to 900 when the scapula did not participate in the motion, but claimed 1200 of motion was available passively. The plane of the scapula 300 to 400 anterior to the frontal plane.

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When the humerus elevates in the plane of the scapula (scaption). There is presumably less restriction to motion because the capsule is less twisted than when the humerus is brought further back into the frontal plane.

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ARTHROKINEMATICS:
The convex humeral head is a substantially larger surface and may have a different radius of curvature than the shallow Concave Fossa. Given this incongruence, rotations of the joint around its three axes do not occur as pure spins, but have changing centers of rotation and shifting contact patterns within the joint. There is somewhat surprising lack of consensus on the extent and direction of movement of the humeral head on the fossa. There is agreement that elevation of the humerus requires that the humeral head glide inferiorly in a direction opposite to movement of the shaft of the humerus. For example: Abduction of the humerus as a pure superior rolling of the large humeral head on the small glenoid fossa would cause impaction of the head into the acromion. Abduction of the humerus occuring as a combination of rolling and sliding prevents impaction and allows a full range of motion.

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Although inferior glide of the humeral head is necessary to minimize upward roll of the humeral head, it would appear that the center of rotation of the head still moves superiorly on the glenoid even though the magnitude of reported shift differs.

Additionally, the humeral head may glide anteriorly or pasteriorly and medially or laterally on the fossa. Static stabilization of the dependent arm When the arm is relaxed at the side, the dislocation, effect of gravity is counteracted by the passive tension in the superior capsule, superior glenohumeral ligament and coracohumeral ligament. Dynamic stabilization of the Gleno humeral joint: The Infraspinatus, Subscapularis and teres minor muscles together have a negative translatory component that nearly offsets the positive translatory component of the deltoid force. Gravity acts as a stabilizing synergist to the supraspinatus muscle. Activity of the supraspinatus and gravity produce a resultant force that abducts the humerus and causes the downwards sliding of articular surfaces necessary for a full range of motion.
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The long head of biceps appears to contribute to GH stabilization by centering the head in the fossa, and by reducing vertical and anterior translations. Long head may produce its effect by tightening the relatively loose superior labrum and translating increased tension to the superior and middle GH ligaments. Scapulo Humeral Rhythm: (SHR) The combination of concomitant GH and ST motion is most commonly referred to as Scapulohumeral Rhythm Importance of SHR is : i) Distributing movement between 2 joints will enhance the range of motion with out compromising the stability. ii) Maintaining an optional position between glenoid fossa and humeral head to increase the joint congruency. iii) To maintain the optional length of the muscles and to prevent length tension insufficiency. 20 movement of humerus have 10 rotation of scapula. Setting Phase :

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During the initial 600 of flexion or the initial 300 of abduction of humerus, scapular motion takes place relative to GH motion. During this period, the scapula seeks a position of stability in relation to the humerus. SHR involves the concerned action of SC and ac joints, as well as the ST and GH joints. Phase One : The upper and lower fibres of trapezius combine with the upper and lower fibers of serratus anterior to produce upward rotation of scapula. This motion at the ac joint is prevented by the conoid and trapezoid part of coracoclavicular ligament. Upward rotation would result in movement of coracoid process of scapula inferiorly. This is prevented by coracoclavicular ligament. The upward rotatory force continues to produce no movement at sc joint i.e., elevation of clavicle to produce 300 of upward rotation of scapula and 600 of GH motion.

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Phase Two : As the lower trapezius and serratus anterior continue to generate an upward rotatory force on the scapula, upward rotation at the ac joint is still restrained by the coracoclavicular ligament while the sc joint is now constrained by tension in the costoclavicular ligament.

This causes coracoid process of scapula to pull downwards with the coracoclavicular ligament and carrying to posteriorly located conoid tubercle of clavicle downwards. The resulting motion is rotation of clavicle around its longitudinal axis to produce 300 of upward rotation of scapula and 600 of GH motion to produce a combined 1800 motion.

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ETIOLOGY
Etiology for the periarthritis shoulder is:
1. IDIOPATHIC: Idiopathic adhesive capsulitis results from capsular fibrosis. The pathologic mechanism for this fibrosis is not well understood. 2. SHOULDER CAUSES: Problems directly related to shoulder joint, which can give rise to periarthritis shoulder they are: 1) Trauma: It occurs due to suddenly in road traffic accidents; any direct or indirect violence over the shoulder joint. 2) Immobilisation: The shoulder is immobilized due to any avulsion fracture of the greater tubercle of the humerus, dislocations, and subluxation. It is also immobilized due to any referred pain. It is intriguing possible etiology factor for Peri arthritis, in patients with stroke or post myocardial infarction. 3) Bursitis:

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Bursitis involves deposition of a calcium salt into the substance of the rotator cuff tendon. This paste like material may escape into the subacromial bursa, causing an acute inflammatory bursitis, which leads to periarthritis shoulder. 4) Tendinitis: In a passive stage with the arm totally dependent, the effect of gravity imposes its stress upon the supraspinatus tendon. Sustained isometric contraction of the supraspinatus muscle has been implicated as on cause of muscular degeneration. When muscles loses its integrity it leads to pathological changes shoulder tendonitis is frequent. The pre disposing factor leading to tendonitis is nutritional deprivation and mechanical stress cause degeneration. 5) Rotator cuff injuries: A rotator cuff rupture can be desired as degenerative thinning and fissuring of the cuff in the Hypo Vascular zone exposed to impingement or direct trauma and consequently leading to tearing of rotator cuff.

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6) Calcification Calcium crystals are often deposited within the models of the collagen hyaline debris. The hydrated calcium may also initiate pain and further impairment. Calcium deposit presents a mechanical obstacle to abduction and over head elevation. Repeated abduction and over head elevation increases inflammation and increase the dissolved calcium. 7) Bicipital Tendonitis: Injuries of the long head of the biceps tendon may occur with forceful elbow flexion or hand supination. 80% cases are associated with on going rotator cuff problems and shoulder impingement syndrome. 8. Degenerative Changes: Any changes in the articulation may lead to degeneration. 9. Over Stretching and exercises : Repeated elevation movements also cause repeated tension with in the tendon. Due to repeated contractions the tendons gets inflammation.

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III. NON SHOULDER CAUSES : Problem no related to shoulder joint and causes shoulder pain due to prolonged immobilization. They are i) Diabetes Millitus: Diabetic patients who are insulin dependent have a high incidence of periathritis shoulder with a marked frequency of bilateral involvement. ii) Cardiovascular Diseases: Cardiovascular diseases with referred pain to the shoulder, which keeps the joint immobile, and causes periarthritis of shoulder joint. iii) Thyroid disorders: The disorder o the thyroid of the both hypo & hyper type are commonly associated with periarthritis shoulder. iv) Cervical disc diseases: Patients with the degeneration of the intervertebral discs of the cervical spine also leads to periarthritis shoulder. v) Neoplastic disorders of thorax:

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Any tumours in thorax cause pain in the shoulder. Other Causes: Reflex sympathetic dystrophy Frozen hand shoulder syndrome Complication of colles fracture can lead to frozen shoulder.

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PATHOLOGY
Pathological events in periarthritis shoulder are 1) During abduction and repeated overhead activities of the shoulder, long head of biceps, & rotator cuff undergo repeated strain. This results in inflammation, fibrosis and consequent thickening of the shoulder capsule, which results in loss of movements. If the movements are continued, then the fibrosis gradually breaks, movements return but never come back to normal. 2) Prolonged activity causes small capsular and biceps muscles to waste faster, load on joint increases and degenerative changes sets in. capsule is fibrosed and shoulder movements are decreased. Macroscopic: Thick and contracted glenohumeral capsule Contracted glenohumeral ligaments and rotatory interval. Microscopic: Chronic inflammation and fibrotic inflammation. Dense capsular matrix. Type I & III collagen
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Fibro blasts & Myofibroblasts Subsynovial Angiogenesis Synovial Layer no involved. Pathological events in degenerative arthritis pathology of shoulder There is a cascade of cellular and bio mechanical events that occurs leading to the breakdown of articular cartilage, which is followed by insufficient cartilage repaid. The biochemical events associated with O.A. include Loss of collagen matrix

Increased water content

Alterations in proteoglycon composition and increased proteolytic enzymes and cytokines The increase in cartilage degeneration and repaid processes results in an increase in cartilage breakdown products as well as increase in the synthesis of cartilage proteoglycons pathological events in.

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Inflammatory arthritis pathology of shoulder : Joint changes progress though the following three stages. Stage I Inflammation of the synovial membrane spread to articular cartilage and other soft tissues. There occurs limitation of joint movements with pain and muscle spasm. Stage II Granulation tissue formation occurs within the synovial membrane & spread to the periarticular tissues. The cartilage starts disintegrating and the joint is filled with granulation tissue. There occurs thickening of the joint capsule tendons and their sheaths impairing the joint movement permanently. Stage III The granulation tissue gets organized into fibrous tissue with adhesion formation between the tendon, joint capsule and the articular surfaces. The articular surfaces get partly covered by cartilage and partly by fibrous tissue. They may give rise to contractures.

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CLINICAL FEATURES
There are three classical stages in frozen shoulder, according to REEVES. Stage I (or) Stage of pain: Patient complains of acute pain, decreased movements, external rotation greatest followed by loss of abduction and then forward flexion. Internal rotation is least affected. This is lasts for 10 to 36 weeks. Stage II (or) Stage of Stiffness: In this stage pain gradually decrease and the patient complains of stiff shoulder. Slight movements are present this lasts for 4 to 12 months. Stage III (or) Stage of Recovery : Patient will have no pain and movements will have recovered but will never be regained to normal. It lasts for 6 months to two years. 1. Pain : A dull ache comes on which become more intense and constant over a few weeks or months. Pain located at acromioclavicular joint and deltoid first then gradually spread drawn to elbow and up to neck. Pain also located at antero lateral aspect of joint and radiate to the anterior aspect of arm and occasionally flexor aspect of forearm. Pain is worse at night. Especially if the patient lies flat. Pain is noted at the end stage of stretch.
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2. Decreased range of motion: Both active and passive range of motions of shoulder are decreased in periarthritis shoulder. 3. Restriction of Movements: The patient demonstrates a capsular pattern of movement restriction i.e., external rotation, abduction, international rotation. 4. Accessory joint play is reduced. 5. Tenderness: Tenderness is present above the humeral head and over the bicipital groove. 6. Patient is unable to do routine daily activities like combing the hair, in case of women wearing the buttons of their blouse, doing overhead activities etc., 7. 8. 9. Mild to moderate wasting of supraspinatus, infraspinatus and deltoid. May be history of insignificant injury following which the symptoms develop. In late cases, rarefaction in surrounding bones, more of tuberosities.

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DIAGNOSTIC TESTS
1. Active test of range of motion with slight over pressure at the terminal point of each movement. This test will reveal definite capsular restriction of the gleno humeral joint. The movements principally involved will be abduction and external rotation; the movements of flexion and internal rotation are involved to a lesser extent. No apparent muscular weakness will be present in the available range of motion, but over pressure at the end of the range will elicit pain. 2. Active resisted test of range of motion: At the initial range usually there is no pain, however considerable resistance may be painful. 3. Passive test of range of motion : With the patient in supine position it is important of confirm the capsular pattern of restriction of the joint and the diagnosis of adhesive capsulitis. Physical Tests: 1. Rotation screening Test - I

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With slight restriction, the patient is unable to get the hand for up the back, and with severe restriction, he will not be able to get it behind the back at all. 2. Rotation screening Test II Ask the patient to place both hands behind the head to screen external rotation at 900 abduction compare the 2 sides lack of success or restriction is common in frozen shoulder. Differential Diagnosis: Frozen Shoulder Atraumatic Instability Cervical Spondylosis

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INVESTIGATIONS
The laboratory studies are rarely required for evaluation of severe cases of pa shoulder. Whether lab investigation should be considered mandatory in a patient presenting with the classic syndromes of idiopathic cases of shoulder in the absence of symptoms of concomitant system rheumatoid, inflammatory or metastapic disorders remains unclear. The following lab tests are ordered 1. 2. 3. Thyroid stimulating hormone level test The serum triglyceride level test The fasting blood sugar levels in most patients particularly. Those presenting with bilaleral disease. 4. 5. ESR level Free Thyroxine Hormone.

I. Arthrographic Findings:
l

Arthrographic findings appears to be one of the most prevalent characteristics of

long cases of PA shoulder. The shoulder joint can accept 28-35 ml of solution with 16 ml of contrast fluid allowing the best viewing of normal joint.
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The contrast dye is injected posteriorly since the capsule is usually contracted superiorly, inferiorly and anteriorly. Abnormal findings include retraction of the capsule away from the greater tuberosity ragged and irregular outline of the capsule and absence of the dependent axillary fold and poor filling of the biceps. The joint volume is markedly decreased to less than 10 ml, and pain is usually experienced as the capacity is reached. 2. X-Ray : Usually normal but in a few cases sclerosis may be seen on the outer edge of greater tuberosity (Goldings sign) 3. Magnetic Resonance Imaging : MRI is an expensive and non specific test, however if the patient does not improve after a period of time (6 weeks to 3 months) then MRI is approximately to rule out.

It is a special radiological test where magnetic waves are used to create pictures that 100K like slices of shoulder. It can also show the tendon of shoulder and rule out

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whether there has been tear in those tendons that is rotator cuff fear infra articular pathology.

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PREVENTION
The primary consideration in the treatment should be prevention. The golden rule for all painful shoulder syndromes is avoiding prolonged immobilization. Prevention is better than cure dont let the shoulder stiff in the first place. Preventive programme: a. b. c. Prevention of primary capsulitis Prevention of secondary capsulitis and Prevention of further damage

a. Prevention of primary capsulitis It is very difficult to know the on set of the disease in its early phase as the symptoms of pain and stiffness are not acute. From observations noticed that the initial pain and stiffness were elevated when the shoulder was passively taken to its terminal range of overhead abduction in elevation. Secondly, the early symptom is pain in lying on the side of the affected shoulder.

Therefore, the regular practice of this particular movement could be instrumental in prevention, early defection and lessening the impact of this condition. b. Prevention of secondary capsulitis :
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Careful early mobilization to the extreme range of motion needs to be emphasized

for the other benefits of exercise in addition to the prevention of secondary adhesive capsulitis in the following situations. i. All the procedures around the chest and shoulder requiring prolonged immbilisation. ii. All situations requiring prolonged bed rest Ex: coronary artery disease, fractures in the upper limb iii. iv. v. Paralysed arm following stroke. Unconscious patient following stroke. Mastectomy

c. Prevention of further damage i. Suddenly applied jerky stretching and

ii. Crude self styled manipulations by a quack, result in high tensile resistance and give rise to further constriction of the already constricted capsule. Thus there is an increase in pain due to muscle spasm leading to further stiffness.

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Adhesive capsulitis can be avoided through proper measures by education t the masses to seek proper advice on simple terminal stretching of the shoulder.

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MEDICAL TREATMENT
Analgesics to reduce pain Non steroidal anti inflammatory drugs (NSIDS) to reduce inflammation. The oral corticosteroids provides an even stronger anti inflammatory effect than the non steroidal medication. Either medication may be used in conjunction with a subacromial corticosteroid injection. Depending upon the severity of symptoms prescribed a weak tapered course of oral corticosteroid. Corticosteroid dosage in patients with pa shoulder 1. 2. 3. 4. Day 1 to 7 predniselone 40 mg / day

Day 8 to 14 predniselone 30 mg / day Day 15 to 18 predniselone 20 mg / day Day 19 to 21 predniselone 10 mg / day

5.

Day 22+

predniselone

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SURGICAL TREATMENT
It is indicated when pain is severe and persistant. When recovery of motion must be hastend and when a lesion is suspected. Technique : Transacromial approach is used and the acromion is discarded. Subacromial bursa are resected. Splitting the ligaments longitudinally enters the joint. The intra articular biceps tendon is freed when where it is adherent to the capsule and the head of humerus. Its origin at the glenoid rim is cut and the tendon is removed to the point where it enters the bicipital groove. Transverse humeral ligament is cut, the facial roof is split, and the extra articular tendon is elevated. If the tendon is to be fixed to the groove, all soft tissue is curative from the groove and the tendon is replaced and held by sutures run through adjacent drill holes. Otherwise tendon may be attached to the coracoid process. Another alternative is to elevate the lateral wall of the groove with an osteotomy. Post operatively, the arm is immobilized at the side for several weeks

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PHYSIOTHERAPY TREATMENT
IN ACUTE STAGE Aims: 1. 2. 3. To reduce inflammation To reduce pain To maintain muscle strength

P.T. Management : To Decrease pain: 1. Cryotherapy Cryotherapy is helpful in decreasing pain and discomfort especially during the acute phase of disease. Cryotherapy is a treatment of a pathological lesion by use of low temperature to relieve pain and muscle spasm. Cooling by ice cubes will act in a counter irritant, which causes a reduction in acetyl choline and produce an asynchrony of impulse, which can break the pain pattern. It is useful in removing swelling and in the repair.

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Ice applied in with a towel is stroked over the effected part. 2. TENS: (Transcutaneous electrical nerve stimulation) Works on the principle of pain gate mechanism and achieves pain relief by stimulating large afferent fibers preferentially and thus inhibiting transmission of the pain impulse. It is significantly most effective in reducing acute pain. Therefore, tens is an excellent treatment choice when the patient is in discomfort. 3. ULTRASOUND : Ultrasound waves are the sound waves with a frequency of more than 20,000 Hz. Therapeutically 1-3 M.Hz. Useful in reducing the pain Micro massage effect in pulse mode will block the pain pathway by lowering the nerve conducting velocity. It is useful in prior to the stretching capsule. Patient will be in position with arm should be abducted and externally rotated. Treatment duration in 5-6 min.

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2. To decrease inflammation:

Iontophorosis: It is a process by which electrically charged molecules and ions are driven into the tissues with the help of an electric field. It may also be called as ion exchange. During Iontophorosis the tissue is an electrolyte form with electrode pads containing drugs are attached to one sides. When electric charge is applied, the movement of charged ions occurs from the positive to the negative pole through the skin and vice versa. Usually the active electrode placed on the treatment area liberates more ions in the tissues. It is extremely effective in hyper hydrosis and soft tissue inflammation conditions. Salicylate and copper diclophenyle, sodium are used to decrease the inflammation in periarthritis of shoulder. To maintain muscle strength : Strengthening exercises: Aim of strengthening is to restore normal equal function of the shoulder.

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In addition to full range of motion, strength and endurance of the rotator cuff muscles and other shoulder girdle muscles must be regained. Isometric and isokinetic strengthening exercises enhance further healing by increasing blood flow. Strengthening of the rotator cuff muscles are exhibited by the arm at the side and elbow flexed to 900, the hand goes from internal rotation to full external rotation without abduction at the shoulder. If the arm can be abducted to 900 without pain, external rotation can be performed in this position. With the arm in abduction the flexed arm can be rotated extremely against resistance. IN CHRONIC STAGE: Aims : 1. 2. 3. 4. To reduce pain To increase joint range of motion. To decrease spasm To restore joint movement.
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5. To improve functional ability.

6.

To gain confidence.

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P.T. MANAGEMENT :
1. Short ware diathermy : (SWD) It is a high frequency current commonly used at a frequency of 27.12 MHZ. with a wavelength of 11 metres. In PA shoulder the method of application is contra planar where use electrodes are place over the opposite aspect of the limb so the effect is deeper in the treatment part. Electrode type may be pad or disc electrodes. Patient position for pad electrode is supine lying and for disc electrode in sitting position. Duration of treatment is 20-30 min. Effects & Uses: Relieves pain Increases metabolism Increases blood supply Reduces muscle spasm.

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2. Paraffin wax: Paraffin wax is superficial heating agent that uses conductivity as the primary form of heat transfer. The boiling point is 52% to 54% but during application it is reduced to 400 to 450C Method of application is by dipping a towel in the melted wax and keeping on the shoulder for 3 to 5 minutes and the patient is used to move the limb actively up to pain free region and then therapist increases the range of motion passively. Effects & Uses: Decreases the pain and spasm. Increases the local temperature superficially. Increased blood flow washout the metabolic waste products and decreases the pain. 3. Hydro collator Packs: Application of hydro collator packs causes moist heat. Effects & Uses : Reduce pain and spasm

4. Massage : It is to relieve pain and spasm.


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The manipulation that are used as follows. a. Kneading : It is a type of pressure manipulation, which is performed all over the 3 types of

deltoid muscles and reduces the muscles spasm and relaxes the muscle. b. Friction : It is given around the shoulder joint so that the synovial fluid around the joint by

loosing the adhesions and tightness of the shoulder structures. c. Picking up: Performed over deltoid, biceps muscles. It gives a squeezing effect, which increases the elasticity of muscles fibers and maintain muscles properties. 5. Inter Ferential Therapy : (IFT) It is a form of electrical treatment in which two medium frequency currents are used to produce a low frequency effect. The principle on which it is based is it produces the LF effect where two medium frequency currents cross in the patient tissue. Beat frequency is the

difference between the two medium frequency currents.

Methods of Application :
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The patient is in sitting position. One channel of electrodes placed anteriorly and posteriorly to the shoulder. Other channel electrodes placed one on above the shoulder and other at deltoid insertion. Duration of treatment is 15-20 minutes. Effects & Uses: Relieves pain Produces placebo effect and relieves pain. Reduces muscles spasm. Improves blood supply. 6. Pulsed Ultra Sound : Duration of treatment is 10-20 minutes. Effect : To break down the adhesions and to reduce pain. 7. Moist Heat : Applied in the form of hydro collator packs. Effects :

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Reduces pain Decreases muscle spasm To improve shoulder joint movements : 1. Free Exercises : a. b. Stoop stride sitting : arm swinging forward and backward. Half reach fallout standing : One arm swinging backward, forward and circling. c. Arms crossed sitting : One arm lateral rotation with swinging obliquely forwards and upwards. d. Stride standing : arm swinging across, sideways and sideways upwards and circling. e. Walk standing : overhead throw

f.

Walk standing : throw and catch quoits.

2. Codmans Pendular Exercises : These are techniques use the effects of gravity to distract the humerus from the glenoid fossa.

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They help to relieve pain through gentle traction and oscillating movements and provide early motion of joint structures and synovial fluid. Patient Position & Procedure : Standing with the trunk flexed at the hips about 900 the arm hangs loosely downward in a position between 600 & 900 flexion. A pendulum of swinging motion of the arm is initiated by having the patient move the trunk slightly back & forth. Motion of flexion, extension, abduction, abduction and circumduction can be done. Increase the arc of motion as tolerated. This technique should not cause pain. If patient cannot balance themselves leaning over, have them hold on to a solid object or lie prone on a table. If the patient experiences back pain from bending over, use the prone position.

3. Assisted Exercise: Towel Stretch : Drop a towel arm the opposite shoulder, grasp with the hand behind patient back. Gently pull the towel upward with other hand so that he should felt the stretch in shoulder and upper arm. Self assisted:
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Overhead stretch : Lie on back with the arms at sides. Left one arm straight up and over the patients head. Grasp the elbow with other arm exert gentle pressure to stretch the arm as far as you can. Cross body reach : Stand and lift one arm at the same height brings its to the front and across the body. As it passes the front of the body grab the elbow with the other arm extent gentle pressure to stretch the shoulder. Self Stretching Techniques: Here the patient should be taught to allow intensity prolonged stretching To increase the flexion & elevation, the patient sits with the side next to the table in front arm resting along with the elbow slightly flexed. The patient is asked to slide the forearm along with the table while bending from the wrist. To increase the abduction the patient is seated as above & asked to slide sideways. The patient is asked to stand 2-3 feet away from the wall without bending the elbow with a full stretched hand against the wall.
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Then the patient is asked to climb the wall with the fingers. This exercise is performed both for flexion and abduction. Pulley Exercises : These are the type of overhead exercises performed by using a pulley placed above the head. The normal arm passively elevates the involved arm by baring the pulley slightly behind the head. The arm gets a further range of motion to over come the stable signs of limitation. Wand exercises: The patient lies in supine position by holding a wand on both sides with an over headed grip and the arm above the chest. Move the elbows fully extended until the arm is over headed. The affected shoulder is fully relaxed while the other arm guides the affected arm and the discomfort areas held in the over headed position for 2-3 seconds. Standing wand Abduction : Patient grips on both sides of the wand & the wand is moved straight away from the body. With the affected arm above & unaffected arm below the wand abduct in sideways. Five repetitions are given.
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Mariners Wheel : The patient is made to stand by the side of the wheel & asked to rotate without bending the elbow. Bracing exercises : The patient is asked to clasp his hand at the back of the head and asked to stretch the hand outwards so the overall range of motion of shoulder is increased. In this the normal arm pulls the limited arm over and behind the hand. Strengthening exercises : a. Isometrics for External Rotators : Position the humerus at the patient side, in slight flexion, slight abduction, and with the elbow flexed 900, apply resistance against the external rotation motion. Isometrics for Abductore : Maintain the humerus neutral to rotation and resist abduction at 00, 300, 450, 600,. If there are no contra indication to motion above 900, preposition the humerus in external rotation before elevating the humerus and resting above 900 abduction. b) Dynamic strengthening for external rotators : (Infraspinatus & Teresminor) : Sitting and standing, using elastic resistance or wall pulley in front of the body at elbow level. Instruct the patient to grasps the elastic material (or) the pulley handle and rotate his / her arm outward.
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Side lying on normal side with involved shoulder upright and arm resulting on the side of thorax with a rolled towel under the axialla. Have the patient use a hand held weight, weight cuff, or elastic resistance and rotate the arm through the desired range of motion. Prone on a treatment table upper arm resting on the table with shoulder at 90 if possible, elbow flexed with forearm over the edge of the table. Lift the weight as far as possible by rotating the shoulder, not extending the elbow. Activation, of the infraspinatus and teresminor is maximized with this exercise.
0 0

Sitting with elbow flexed 90 & supported on a table so that the shoulder is in the resting position. The patient lifts the weight from the table by rotating the shoulder.

Dynamic Strengthening for Abductors (Deltoid & Supraspinatus) 1. Military Press: Sitting, arm at the side in external rotation with elbow flexed & forearm supinated. Have the patient lift the weight straight up overhead. 2. Abduction against gravity : Sitting or standing with a weight in hand. Have the patient abduct the arm to 900, then laterally rotate & elevate the arm through the rest of range.

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Side lying with involved arm upper most. Have the patient lift a weight upto 900. Prone on a treatment table upper arm resting on the table with shoulder at 90 if possible, elbow flexed with forearm over the edge of the table. Lift the weight as far as possible by rotating the shoulder, not extending the elbow. Activation, of the infraspinatus and teresminor is maximized with this exercise.
0 0

Sitting with elbow flexed 90 & supported on a table so that the shoulder is in the resting position. The patient lifts the weight from the table by rotating the shoulder.

Dynamic Strengthening for Abductors (Deltoid & Supraspinatus) 1. Military Press: Sitting, arm at the side in external rotation with elbow flexed & forearm supinated. Have the patient lift the weight straight up overhead. 2. Abduction against gravity : Sitting or standing with a weight in hand. Have the patient abduct the arm to 900, then laterally rotate & elevate the arm through the rest of range. Side lying with involved arm upper most. Have the patient lift a weight upto 900.

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PHYSIOTHERAPY ASSESSMENT
1. SUBJECTIVE ASSESSMENT : 2. OBJECTIVE ASSESSMENT 1. Subjective Assessment : Patient Profile : Name Age Sex : : :

Occupation : Address Date of Admission : :

Chief Complaints : Pain and unable to do routine daily activities live combing the hair, in case of women wearing the buttons of their blouse, during over head activities etc., History : Present Medical History : Includes about the present condition and what is the medication now he has using.
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Also includes whether he was suffering with other conditions now like hypertension, diabetes mellitus, ischimic heart disease and what are the medications he using for that. Past medical history : It includes any illness in the past like trauma, stroke and medication he had taken for that. Family history : Includes about general family health, familial (or) hereditary disease like diabetes. Personal history : It includes the life style of the patient Smoking Alcohol consumption Drug abuse etc. Socio economic history : Poor Middle class Rich

Pain assessment : J Site of pain localized or diffused


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J J J J J J J Side of pain right or left On set sudden, gradual or incidious Type of pain aching / stabbing / throbbing burning Duration of pain Character of pain intermittent / continuous Severity of pain Measured by numerical visual analogue scale (VAS)

0 0 no pain J Irritability mild / moderate / severe

10 10 = untolerable pain

Aggrevating factors: Relieving factors :

Objective assessment :

1. On observation : Swelling Redness


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Skin changes Any abnormal contour in bone / muscle / soft tissue Limb alignment. 2. On palpation : Tenderness : Examination of the bone and their structural alignment to defect tenderness. Warmth Swelling 3. On Examination : a. Vital signs : Temperature Respiratory rate Pulse rate

Heart rate b) Motor Examination :

1. Active Range of Motion :

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Present of pain or any other symptoms to be noted. Degree of pain to be evaluated active movement is tested to evaluate strength, endurance and flexibility. 2. Passive Range of Motion Test : It could be normal, is excess or restricted. At the end of passive range of motion gentle over pressure is given to assess the end feel. The restriction may be : Capsular type : restriction of overhead abduction and external rotation. Non capsular type : all movements are restricted due to intra articular mechanical blocking or extra articular lesion. Soft end feel : Muscular restriction. Hard end feel : Capsular restriction. Firm End feel : Bony restriction. c. Muscle Power : Assessed by manual muscles testing (MMT) method. 0 1 2 No contraction Flicker of contraction Movement in gravity eliminated position

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3 4 5 Movement against gravity Movement against gravity with minimal resistance Normal

d. Muscle girth measurement : - By using inch type e) Functional activity examination or assessment : The influence of the disease on the functional performance of the patient are examined and recorded on a functional evaluation chart. Activities effected by pa shoulder are : Wearing dress Combing hair Over head activities etc. 4. Investigation : By X-Ray CT Scan MRI etc., 5. Provisional diagnosis : 6. Treatment

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CASE-I
1. Subjective Assessment :
Name Age Sex Occupation Address Chief Complaints : Pain in the left shoulder from six weeks Difficult to move the left shoulder Difficulty in wearing clothes. Present Medical History : History of diabetic & B.P. Using medication for diabetics. Past Medical History : At earlier, she taken analgesics for shoulder pain. Family History : Patients mother was diabetic. Socio - Economic History : Middle Class. Pain Assessment: Slow onset Aching type Constant Aggravating factor Relieving Factor : : : : : P.D.L.Annapurna 45 Years Female Housewife Sivajicafe Centre, Vijayawada.

: Lifting or taking any object from sideways. : Rest

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VAS

2. Objective Assessment :
On Observation : No swelling No muscle wasting On Palpation : Tenderness in front of shoulder Warmth is present On Examination : Vital signs are normal Temperature 370C Respiratory rate 15 per minute Pulse rate 70 / minute Range of Motion : Presence of pain on doing active movements. Active ROM : Flexion 850 Abduction 750 External Rotation 150 Passive ROM: Flexion 900 Abduction 750 External Rotation 150 Muscle Power : Deltoid Rotator Cuff Muscles Extension 200 Adduction 300 Internal Rotation 300 Extension 200 Adduction 300 Internal Rotation 250

: :

Grade 3 Grade 3
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End Feel : Bonny end feel

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Functional Assessment : Unable to do overhead activities Feeling difficulty in clothing. Physiotherapy Management : Aims: To relieve pain To improve Joint ROM To increase mobility of teh shoulder To strengthen the shoulder girdle muscles. Means & Methods: Ice therapy Ultra Sound IFT Mariners wheel exercises Overhead pulley exercises Codmans pendular Exercises Strengthening exercises for deltoid and rotator cuff muscles Mobilization exercises Home Programme : Dos: Codmans Pendular exercises Self assisted and self resisted exercises Wall ladder exercises Ice application or hot water fermentation to reduce pain Donts: Advice not to lift heavy weights with affective shoulder. Advice not to sleep on affected shoulder side.

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CASE-II
1. Subjective Assessment :
Name Age Sex Occupation Address : : : : : K.S.Saraswathi 60 Years Female Housewife Maruthinagar, Vijayawada.

Chief Complaints : Pain in the right shoulder from five weeks Restricted over head activities Unable to comb the hair Feeling difficulty in dressing. Present Medical History : Patient was diabetics Suffering from Asthma. Past Medical History : Taken insulin therapy for diabetic 10 years back opposite side fore arm both bone fracture. Medications using from 10 years for diabetics. Family History : Patients father was diabetic. Socio - Economic History : Middle Class. Pain Assessment: Pain in right shoulder from 5-6 months Diffused pain Sudden onset Continuous pain VAS Aggravating factor : Sleeping on affected shoulder Movement of the left shoulder
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Relieving Factor : Rest

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2. Objective Assessment :
On Observation : No swelling No muscle wasting On Palpation : Tenderness on above and back of the shoulder On Examination : Vital signs are normal Temperature 370C Respiratory rate 15 per minute Pulse rate 70 / minute Range of Motion : Active ROM : Flexion 1000 Abduction 800 External Rotation 200 Passive ROM: Flexion 1100 Abduction 900 External Rotation 250 Muscle Power : Deltoid Rotator Cuff Muscles End Feel : : : Grade 4 Grade 3 Bonny end feel Extension 350 Adduction 350 Internal Rotation 400 Extension 350 Adduction 350 Internal Rotation 400

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Functional Assessment : Patient is unable to reach the hand behind his back. Unable to comb hair. Investigations : X-ray shows decreased to joint space. Physiotherapy Management : Aims: To relieve pain To reduce Joint stiffness To increase joint range of motion To increase mobility of shoulder. Means & Methods: Ice therapy SWD Ultra Sound IFT TENS Exercise Therapy : Active Pendular Exercise Hydro therapy Wall ladder exercises Mariners wheel exercises Home Programme : Regular follow up of pendular exercises. Wall climbing exercises.

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