case scenerio frozen shoulder physiotherapy plan

🩺 Case Scenario: Frozen Shoulder in a 45-Year-Old Teacher – Stages & Physiotherapy Plan

📌 Patient Profile

• Name: Mrs. S. (initials used for privacy)

• Age: 45 years

• Gender: Female

• Occupation: High school teacher

• Medical History: Type 2 Diabetes Mellitus for 5 years (controlled on oral hypoglycemics), no prior trauma, no history of surgeries.

• Lifestyle: Sedentary, spends most of her day writing on the board and grading papers.

📌 Presenting Complaint

Mrs. S. visited the outpatient physiotherapy clinic with complaints of:

• Gradual onset of right shoulder pain for the past 3 months.

• Increasing stiffness, making it difficult to perform overhead activities.

• Night pain that disturbs her sleep.

• Difficulty performing daily tasks such as:

  • Combing hair

  • Wearing a sari/shalwar kameez (dressing)

  • Reaching overhead to pick books from the cupboard

On the Visual Analogue Scale (VAS), she rates pain as 7/10 during movement and 4/10 at rest.

📌 Clinical Examination

🔹 Inspection

• No obvious swelling or deformity.

• Slight protective posture with arm held close to body.

🔹 Palpation

• Tenderness over anterior shoulder capsule.

🔹 Range of Motion (ROM)

• Flexion: 90° (painful, restricted)

• Abduction: 80° (restricted, painful)

• External rotation: severely limited (30° only)

• Internal rotation: mildly restricted

🔹 Special Tests

• Painful Arc → Positive

• Capsular Pattern (ER > ABD > IR) → Present

🔹 Investigations

• X-ray: Normal (to rule out fracture, arthritis)

• Blood test: Fasting glucose mildly elevated

Final Diagnosis: Adhesive Capsulitis (Frozen Shoulder), Stage II – Right Shoulder

---

📌 Pathophysiology in Simple Words

Frozen Shoulder (Adhesive Capsulitis) occurs when the shoulder joint capsule thickens and becomes stiff. This reduces joint lubrication and leads to painful restriction of movement. It is commonly associated with diabetes, hypothyroidism, and prolonged immobilization.

📌 Stages of Frozen Shoulder

1. Freezing Stage (2–9 months):

   • Gradual increase in pain (especially at night).

   • ROM begins to reduce.

   • Pain dominates stiffness.

2. Frozen Stage (4–12 months):

   • Pain decreases but stiffness is severe.

   • Shoulder movements very restricted.

   • Daily activities severely affected.

3. Thawing Stage (5–24 months):

   • Gradual improvement in ROM.

   • Functional activities slowly return.

   • Pain minimal.

📌 Physiotherapy Management Plan

🔹 Stage 1: Freezing Stage (Painful Stage)

Goals: Pain relief, maintain available ROM, avoid stiffness.

• Modalities:

  • Superficial heat packs (before exercise).

  • TENS/IFT for pain control.

• Exercises:

  • Pendulum exercises (gentle, pain-free).

  • Assisted ROM using stick or pulley.

  • Isometric contractions (deltoid, rotator cuff).

• Advice:

  • Avoid overuse & painful end-range stretching.

  • Sleep with pillow support under the arm.

🔹 Stage 2: Frozen Stage (Stiffness Stage)

Goals: Increase mobility, reduce stiffness, maintain strength.

• Manual Therapy:

  • Glenohumeral joint mobilizations (Grade II–III).

  • Capsular stretching (especially ER).

• Exercises:

  • Wall climbing (flexion & abduction).

  • Pulleys for assisted abduction/flexion.

  • Theraband strengthening of scapular stabilizers.

  • Gentle yoga-inspired stretches for mobility.

• Home Program:

  • Daily stretching for 10–15 minutes.

  • Encourage use of the arm in functional activities.

🔹 Stage 3: Thawing Stage (Recovery Stage)

Goals: Regain full ROM, strengthen shoulder, return to function.

• Progressive Resistive Exercises:

  • Theraband strengthening (rotator cuff, scapula).

  • Dumbbell exercises (1–2 kg, gradual progression).

• Functional Training:

  • Reaching overhead, lifting light weights.

  • Writing on the board (work-related simulation).

• Proprioception & Coordination:

  • Ball throwing against wall.

  • Closed-kinetic chain exercises (plank variations).

• Patient Education:

  • Explain slow but steady recovery (may take up to 2 years).

  • Emphasize compliance with home exercises.

📌 Progress Notes

• Month 1: Pain reduced from 7/10 → 4/10. ROM slightly improved (flexion 120°).

• Month 3: Abduction increased to 140°, external rotation improved to 50°. Pain 2/10.

• Month 6: Almost full ROM, able to reach overhead, comb hair, and dress without difficulty.

📌 Discussion & Learning Points

• Frozen Shoulder is more common in middle-aged women and those with diabetes.

• Early physiotherapy is essential to prevent prolonged stiffness.

• Recovery follows a natural course of 1–2 years, but rehab accelerates functional gains.

• Key challenge: patient frustration due to slow progress → physiotherapist must provide motivation and reassurance.

📌 Key Takeaway for DPT Students

“Managing Frozen Shoulder requires patience, gradual progression, and continuous patient education. Remember – in the freezing stage focus on pain relief, in the frozen stage focus on mobilization, and in the thawing stage focus on strengthening and function.”