Frozen shoulder syndrome causing stiff and painful shoulder is a common disability in the middle aged population. The diagnosis is often used for any painful shoulder condition associated with a loss of motion, but it is important to understand the cause of the symptoms in order for treatment to proceed effectively.5 Histologically, the disease is similar to Dupuytren’s contracture.1

The natural history of the condition is often self-limiting. Common in the 40 - 60 age groups, with female incidence higher, it starts with pain as the first symptom, followed by loss of motion and then persistent stiffness and pain. Normal motion gradually returns, however the length of time for recovery can be prolonged, average being 18 months.

The conservative modalities of treatment include analgesics and physical agents, activity restriction, treatment of underlying cause and physiotherapy. The surgical options are intraarticular steroid injection, hydraulic joint distension,2 manipulation3 and open or arthroscopic release.

Intervention during the natural course of the disease shortens the course of the disability from few months to a few weeks , assuring early return to work and daily activities. Manipulation under anaesthesia is reserved for proved resistant true frozen shoulders without evidence of osteopenia and is contraindicated in post-traumatic or post surgery stiffness. Surgical intervention, in the form of arthroscopic capsulotomy may be required for persistent stiffness.

The objective of the study was to evaluate the results of different treatment modalities of frozen shoulder syndrome (FSS) or adhesive capsulitis (AC) in a series of 30 cases over a period of 18 months.

Fifty cases of painful stiff shoulders were selected for the study and evaluated for the cause of stiffness and pain. Cases with identifiable aetiology e.g.; calcific tendinitis, rotator cuff tear, etc. were grouped separately from those where no specific cause was identifiable. The latter category of cases of idiopathic aetiology were included in the final study as cases of frozen shoulder syndrome (FSS) or adhesive capsulitis (AC). The number of cases in this category were thirty.

Diagnosis of AC was made by examination under anaesthesia, i.e., by demonstrating passive restriction of shoulder movements (global restriction or more specifically restriction of external rotation ). Surgery / arthroscopy as treatment modality or arthrography / arthroscopy as a diagnostic tool was not included as these are not a routine in practice.

This is a prospective study of 30 cases of FSS over a period of 18 months, the purpose being to evaluate the results of three different modalities of treatment of frozen shoulder syndrome viz; physiotherapy, manipulation and arthroscopic release. Data was recorded on a proforma noting personal and medical / surgical history and the pre and post treatment range of movement (ROM) chart. Each case of FSS was allotted a treatment programme according to the duration of symptoms and stage of the disease and the outcomes compared.

Observation and Results

Group A treatment protocol

Pain control with suitable NSAIDs and gradual physiotherapy starting from passive to active assisted ROM exercises. Of the 12 cases, 7 regained painfree ROM in a period of 2 weeks and rest 5 did not show significant improvement in ROM though the pain subsided by 3rd week. The five cases showing no improvement were shifted to treatment plan as for Group B.

Group B treatment protocol

Cases in stage II were subjected to manipulation under anaesthesia (MUA) with steroid injection. Elderly patients were evaluated for fitness for general anaesthesia and shoulder roentgenograms and consent obtained before manipulation. Global restriction of passive ROM was confirmed under anaesthesia before manipulation. The arm was gently abducted upto maximum 90 degrees and externally rotated upto maximum 45 degrees, and a mixture of 3 ml methlyprednisolone acetate (Depo -Medrol) and 2 ml bupivacaine (Sensorcaine 0.5 %) injected in the subacromial space. The arm was kept in abducted and externally rotated position. Adequate pain control was achieved by parenteral analgesics and supervised physiotherapy programme begun same evening , once post procedure roentgenograms were reported normal.

Of the 21 cases (added 5 from Group A), 17 showed significant improvement in ROM and pain and returned to their daily activities at the end of 2 weeks of supervised physiotherapy. Four cases that did not show improvement opted for a second MUA at the end of 4 weeks and 3 of these regained useful painfree ROM by 3rd week of physiotherapy. One case of persistent stiffness was shifted to Group C treatment protocol.

Group C treatment protocol

Cases of residual stiffness and pain were planned for a arthroscopic release. Of the three cases (one from Group B ) two were unfit for the procedure and had poor compliance for physiotherapy because of neurological disease (one Parkinson’s disease and other multi-infarct state ). One case underwent arthroscopic procedure with complete release of all intra-articular adhesions especially the coraco-humeral ligament. There was significant improvement in the ROM with 2 weeks of supervised physiotherapy programme.

IV . Evaluation of outcomes

Each group showed good response to the planned treatment protocol. Of the 12 cases from group A, 7 cases (58 % ) showed significant painfree ROM with NSAIDs and physiotherapy alone.

The remaining 5 opted for MUA like the Group B cases. Of the 21 cases of MUA, 17 cases (80 % ) regained useful ROM with first manipulation. The only case of Group C subjected to arthroscopic release showed good improvement in ROM and return to independent daily activities.

To conclude, staged treatment and proper selection of cases of adhesive capsulitis gives optimum results.

Fig. 1 : Natural course of frozen shoulder syndrome.	Fig. 2 : Course of the disease with staged treatment.

The natural history of frozen shoulder syndrome is essentially self-limiting, but the course of the disease can be prolonged with residual pain and stiffness. Differential diagnosis of adhesive capsulitis from other causes of stiff and painful shoulder is important for a rational therapy.4,5 Literature is extensive but lacks a stage based approach. Of the different treatment modalities of treatment of frozen shoulder syndrome, stagewise treatment3 is important.