Frozen shoulder is a known disorder that causes pain, stiffness, and loss of normal range of motion in the shoulder leads to disability that can be serious, and the condition tends to get worse with time if it’s not treated¹. It affects mainly people ages 40 to 60, and women more often than men. Sometimes freezing occurs because the shoulder has been immobilized for a long time by injury, surgery, or illness². The shoulder has greatest mobility and range of motion than any other joint in the body. It is ball and socket variety of joint, in which head of humerus attached to the glenoid cavity also called glenohumeral joint³. The questions of when and how to treat the frozen shoulder can present challenges. Most treatments are conservative; however, indications for surgery do exist⁴. The British Elbow and Shoulder Society/British Orthopedic Association (BESS/BOA) has published recommendations in a patient care pathway for frozen shoulder, with a step-up approach in terms of invasiveness advised⁵. Combination therapy is effective as seen in many researches⁶. Evidence of moderate quality shows that a combination of manual therapy and exercise for six weeks probably results in less improvement at seven weeks but a similar number of adverse events compared with glucocorticoid injection⁷. When used alone, manual therapy has limited efficacy in the management of frozen shoulder. conservative treatments such as injections and physiotherapy are ineffective for a small group of patients⁸. It would be fascinating to see if these patients with a protracted and resistant course of disease might be recognized sooner rather than later.

On Jan 5, 2023, a 50-year-old female patient who was housewife presented with a complaint of right shoulder pain and unable to lift her right hand for 2 months, unable to comb her hairs and squeezing the towel. Symptoms were reported as continuous pain in movement of hand and aggravated when she tried to do some activities in abduction and internal rotation shoulder movement. The NPRS was 8/10. She had history of fall on outstretch hand 5 years back. Earlier, she had taken 3 dose of corticosteroid injections through which she got some relief in pain.

Apley scratch test:  Positive

NPRS Scale:  8/10

Diagnosis:  Right Side Frozen Shoulder

For treatment, it was planned to give Hot fomentation, Combination therapy, shoulder glides anterior, posterior, inferior glide) along with home exercise program.

The patient was asked to take 12 physiotherapy sessions, thrice in a week for four weeks. The patient was asked to lie  in a supine position and hot pack was given for 10 minutes, after that 5 repetitions of shoulder glides (anterior, posterior and inferior). The patient was asked to Codman’s pendulum exercises(10 times in each direction)  and lastly combination therapy of transcutaneous electrical nerve stimulation and ultrasonic therapy was given to patient in which US works as active electrode and TENS channel used as passive electrode was given for 7 minutes duration, having ultrasonic intensity of 1.5 W/cm2 and Tens frequency 200MHz.

Home Exercise Program

1. Towel stretch (10-15 reps)

2. Pendulum exercises (10 reps)

3. Finger ladder exercises in abduction and flexion (10 reps)

Outcome measures were collected at baseline and NPRS score found 1/10 after 12 session and patient was able to do her daily activities. Table 1 and Table 2 shows the Pre and Post NPRS and Rom.

Table 1: Shows the Pre and Post ROM of shoulder joint

Table B: Pre and Post Numerical Pain Rating Score

The effectiveness of combination therapy and shoulder glides are seems to be beneficial in patient to eliminate pain and improving ROM in Frozen shoulder patients.

· It can be done on large sample size to find out the effectiveness.

· Other parameters can also be used.

1. Ewald A. Adhesive capsulitis: a review. Am Fam Physician. 2011 Feb 15; 83(4): 417-22. PMID: 21322517.
2. Challoumas D, Biddle M, McLean M, Millar NL. Comparison of treatments for frozen shoulder: A systematic review and Meta-analysis. JAMA Netw Open. 2020 Dec 1; 3(12): e2029581. https://doi.org/10.1001/jamanetworkopen.2020.29581. PMID: 33326025; PMCID: PMC7745103.
3. Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014 Aug 26;(8):CD011275. https://doi.org/ 10.1002/14651858.CD011275. PMID: 25157702.
4. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc Rev. 2007; 15: 216-221 [PMID: 18004221 https://doi.org/ 10.1097/ JSA.0b013e3181595c22] 
5. Zhang LH, Wang LX, Cui Q, Zhang GW. Efficacy of blood-letting puncture and cupping in the treatment of periarthritis of shoulder: a systematic review. TMR Integrative Medicine. 2018; 2(4): 175-91. https://doi.org/10.12032/TMRIM201802033.
6. Al-Bedah AMN, Elsubai IS, Qureshi NA, Aboushanab TS, Ali GIM, El-Olemy AT, Khalil AAH, Khalil MKM, Alqaed MS. The medical perspective of cupping therapy: Effects and mechanisms of action. J Tradit Complement Med. 2018 Apr 30; 9(2): 90-97. https://doi.org/10.1016/j.jtcme.2018.03.003. PMID: 30963043; PMCID: PMC6435947.
7. Matthew J Page, Sally Green, Manual therapy and exercise for adhesive capsulitis (frozen shoulder. Cochrane Database of Systematic Reviews; August 2014. https://doi.org/10.1002/14651858.CD011275.
8. Dr. Harish Babu J, Dr. Gadhamsetty Sai Ganesh, Dr. Shri Vishnu M, Dr. C Nissanth and Dr. Yeshwanth Subash; Comparison of functional outcome between corticosteroid injection alone vs combination with physiotherapy for frozen shoulder, Jan 2023. https://doi.org/10.22271/ortho.2023.v9.i1a.3272.