Synovial inflammation and subsequent fibrosis increase in the glenohumeral joint capsule. With the formation of this fibrosis, the volume of the shoulder joint decreases and movement limitation occurs.
Its etiology and natural course have not been definitively revealed.

HISTORY
Ø In 1875, the French pathologist Duplay named it “Peri-Arthrite Scapula-Humerale”.
Ø Codman described the disease in detail.
Ø In 1945, Neviaser used the term “Adhesive Capsulitis” for synovial changes in the glenohumeral joint.
Ø Lundberg also classified primary and secondary.

EPIDEMIOLOGY
The overall incidence of frozen shoulder is between 2-5%. It varies between 10-40% in people with diabetes (type 1) or thyroid. It is more common in women. No racial differences were noted. It is very likely to be seen in sedentary people.

SYMPTOMS
Pain that does not go away at rest
Pain that makes it difficult to sleep at night
Severe shoulder pain during the day
Limitation of shoulder movements.
Significant reduction in internal/external rotation

DIAGNOSIS
Mostly, the diagnosis is made by patient history, clinical and radiological examination. In general, it makes a sneaky start. There is intense and downward radiating pain around the insertion of the deltoid muscle. The patient has pain that limits daily movements. Atrophy is seen in deltoid and supraspinatus muscles due to inactivity due to pain. Magnetic resonance (MR) examines pathologies in soft tissues such as the rotator cuff, labrum and capsule, but is not used frequently. MR arthrography shows capsule thickness and decreased joint volume. Since approximately 30% of the patients are accompanied by rotator cuff pathology, ultrasound imaging has gained importance.

Cyriax described the capsular pattern in the diagnosis of frozen shoulder. According to this definition, external rotation is more restricted than abduction and internal rotation. The most important finding of frozen shoulder is that the external rotation is less than 50% or less than 30° when the arm is at the side.

External rotation limitation (anterior capsule shortness) in primary frozen shoulder and internal rotation limitation (posterior capsule shortness) in secondary frozen shoulder are more prominent.

TREATMENT
”Treatments are shaped according to stages”

STAGE 1:

Reducing pain and inflammation
Making the patient sleep
Protecting your EHA

CAUTION:
The patient should be informed about the disease. Stages, what to do / not to do during the treatment process.
Anxiety and pain control should be established.
In order to reduce severe pain during sleep at night, the patient should lie on his side with his arm on top and put a pillow under the armpit.

• The active trigger points of the patient should be evaluated well (active trigger points: mostly in the upper and middle trapezius and SCM, serratus anterior and pectoral muscles).
• The patient may need psychological support.
• The patient should be prevented from using a shoulder strap.
• Analgesic, anti-inflammatory and, if necessary, corticosteroid medication should be started or injection therapy should be considered. (with doctor’s advice) Shoulder wheel and finger ladder should never be used.
• Hot modalities should never be applied.

PHYSICAL THERAPY 1:

• Make sure to use ice for 15 minutes after workouts.
  When the +VAS drops to 7 and below, the exercise program can be started; but the pain limit should be very careful.
• Exercises should be done on the back.

• Glenohumeral distraction
• Inferior glenohumeral mobilization
• passive shoulder flexion
• Passive external rotation-internal rotation in the scapular plane
• Passive abduction in the scapular plane
• Scapular retraction
• Soft tissue mobilization techniques for trigger points
• Stretching the upper trapezius and sternocladiomastoid muscles
• Manually stretching the pectoralis major/minor muscles
• Active assistive (with stick) flexion, abduction and rotation exercises in the scapular plane while lying on the back.

PHYSICAL THERAPY 2:

=> If necessary, transcutaneous electrical stimulation (TENS) should be applied for pain.

STAGE 2:

• Reducing pain and inflammation
• Increasing ROM within the limits of pain >>Strengthening the scapulaasic muscles
• To encourage the use of the arm during activities of simple daily living.

CAUTION:

If the pain does not decrease (VAS should be 6 and below), the stage 1 program should be continued. Patients can begin active assistive exercises against gravity while standing.

PHYSIOTHERAPHY:

+Wand exercises and self stretching exercises should be given to patients as a home program.

• Mild stretching exercises can be started within the limits of pain in the direction of flexion, abduction in the scapular plane, and external rotation-internal rotation in the scapular plane.
• Posterior capsule stretching
• Wand (stick) exercises
• Self stretching exercises
• reel exercises
• Scapulatory strengthening exercises.

STAGE 3:

Increasing ROM
To increase the strength of the rotator cuff and scapulatory muscles.
To ensure full independence of patients in their daily living activities.

CAUTION:

  The patient should be informed that ROM cannot reach the same levels in the primary frozen shoulder as in the intact shoulder.
 Attention should always be paid to the level / duration of pain. If the pain is very low intensity and duration should be kept short. As the pain decreases, the intensity and duration can be increased.

PHYSIOTHERAPHY:

• In this phase, intensive stretching can be applied in all planes. If the pain persists for more than 2 hours after the exercise is over (if the pain does not decrease), the intensity and duration should be re-evaluated.

Passive stretching exercises in all directions
Self stretching exercises (frequent repetitions)
Rotator cuff and scapulatory muscle strengthening exercises