PERIARTHRITIS SHOULDER

By
Dr.Sindhu.MPT(Ortho)
 Anatomy
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).

TO HELP YOUR SHOULDER MOVE MORE EASILY, SYNOVIAL

FLUID LUBRICATES THE SHOULDER CAPSULE AND THE JOINT
ANATOMY OF SHOULDER
JOINT
ANATOMY OF SHOULDER
JOINT
 Peri-arthritis Shoulder / Frozen Shoulder
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
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 PLANES WITH RADIOGRAPHIC
APPEARANCE.
FIG: FROZEN
SHOULDER/PA
 Risk factors for frozen shoulder/PA
include:-

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. Surgical trauma.
 Clinical Feature
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.TENDERNESS
CLASSIFICATION OF 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.
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 PLANES.
STAGE CAN BE LAST FROM 3 TO 18 MONTH
3) THIRD STAGE (STAGE OF RECOVERY )----

FINAL STAGE IS RESOLUTION PHASE. IT IS CHARACTERISED

BY NO PAIN WITH SLOW RECOVERY OF MOTION. LOSS OF
EXTERNAL ROTATION WITH ARM AT SIDE OF THE PATIENT.
DIAGNOSING PERIARTHRITIS:-

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. ELEVATED WHITE BLOOD CELL (WBC) COUNT
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
NSAI
D
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
ANTACI
D S:-
ANTACI
DS
3. CALCIUM THERAPY WITH
VITAMIN D3
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.
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. THERAPEUTIC MODALITIES ICE FOR 20 MIN, ULTRASOUND
FOR 5 TO 7 MINS, HVPGS FOR 25 MINS.
APPLY MOIST HEAT BEFORE THERAPY AND ICE PACK AT THE END OF
SESSION.
5.INITIALLY FOCUS ON FORWARD FLEXION AND INTERNAL AND
EXTERNAL ROTATION
6. ACTIVE ROM EXERCISES.
7. ACTIVE ASSISTED ROM EXERCISES.
8. PASSIVE ROM EXERCISES.
9.A SUSTAINED STRETCH, OF 15-30 SECONDS
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.
GOALS
* PAIN CONTROL BY SAME 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.
1. THERMOTHERAPY
DEEP HEATING MODALITIES SUCH AS SWD, UST 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.
PASSIVE GLIDING WITH
LONGITUDINAL TRACTION :-
PASSIVE MOBILIZATION OF SH. IN A
FORWARD STOOPING
POSITING
MUSCLE
STRENGTHENIN
1.START WITH ROTATOR CUFF STRENGTHENING EXERCISES 3
G
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.
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.
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.
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.
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.
POSTERIOR CAPSULE
STRETCHING
ANTERIOR CAPSULE
STRETCHING
POSITION:
TO DECREASE
GRAB YOUR AFFECTED HAND BEHIND YOUR BACK AS FAR AS
SHOULDER STIFFNESS:-
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.
1. WALL & LADDER EXERCISES EXERCISE.
OTHER EXERCISES
2. SHOULDER
:
& WHEEL EXERCISE
3. FINGER LADDER EXERCISE.

Wall
&
ladder
exe.
THANK YOU