FROZEN SHOULDER (PERIARTHRITIS SHOULDER)

• Inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
• Characterized by functional loss of passive and active shoulder motion with no clear underlying cause 
•  The glenohumeral joint becomes painful and stiff because of the loss of resilience of the joint capsule, possibly with adhesions between its folds
• Often, there is a history of preceding trauma 
• More common among women, aged 40-60 years and in diabetic patients

• Primary, idiopathic form
• Post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injuries)
• Post-surgical (following rotator cuff repair or axillary dissection for malignancy)

Associated conditions

• Diabetes - · Stiffness may be the first manifestation of diabetes and warrants further workup. Increased risk with older age, increased duration of DM and autonomic neuropathy
• Thyroid disorders (autoimmune etiology) 
• Dupuytren's disease
• Atherosclerotic disease
• Cervical disc disease

• Often insidious onset of general shoulder pain preceding any noticeable loss of motion
• Severe restriction of both active and passive range of movements 
• Dull shoulder pain
• Variable character and severity of pain, loss of motion dependent on the stage of disease at presentation 

Stages 

• Freezing or painful stage – minimal synovitis with pain, causing a limitation of motion 
• Frozen or transitional stage - pain decreases but proliferative synovitis with contraction of the capsule and adhesion of the axillary recess continues 
• Thawing stage – Inflammation decreases, movement slowly improves
• This is a self-limiting disease lasting for 6-9 months, after which in most cases, the inflammation subsides, leaving a stiff but painless shoulder

Physical examination

• Inspection-- note any muscle atrophy or scars denoting prior surgery
• Range of movement
• Symmetric loss of active and passive ROM
• Document all motion planes and compare them to the contralateral side
• Limitations in motion may be slight, external rotation deficit most common finding
• A physical examination is usually enough to diagnose frozen shoulder

Investigations

• X- ray: - Disuse osteopenia
• Ultrasound
• MRI to rule out other problems like arthritis or a torn rotator cuff that can also cause pain and limit range of motion
• Blood investigations - to rule out associated conditions e.g. TSH, HbA1c, etc.

Non-operative

• Analgesics
• Hot fomentation
• Physiotherapy
• Intra-articular injection of hydrocortisone may speed up the recovery
• Stiffness can be prevented by continuous shoulder mobilizing exercises

Operative

• Manipulation under anesthesia
• Arthroscopic or open capsular release

Ayurvedic Treatment

Internal medicines 

• Amrutothara Kashaya
• Punarnavadi kashaya
• Prasaranyadi Kashaya
• Guggulu tiktaka kashaya
• Yogaraja guggulu
• Abha guggulu
• Laksha guggulu
• Gandha thaila

Procedure

• Udwarthana - Kolakulathadi choorna
• Dhara – Dhanyamla, Karpasathyadi taila, chinchadi taila
• Lepa – Kolakulathadi, kottamchukkadi
• Jambeera pinda sweda 
• Patra Potala Sweda
• Nasya - Maharajaprasaranyadi Taila , Karpasasthyadi Taila
• Shoulder mobilizing exercises