Frozen shoulder (FS), also known as adhesive capsulitis (AC), is a painful disorder of the shoulder joint characterized by gradual onset and progressive restriction of both active and passive shoulder movements1. It is a common musculoskeletal condition, with a reported yearly prevalence of 2–5% in the general population. The majority of affected individuals are women, particularly between the ages of 40 and 60 years, and the condition commonly involves the non-dominant hand. In 20–30% of patients, the contralateral shoulder becomes involved over time.2 Although the exact etiology of frozen shoulder remains unclear, several risk factors have been identified, including female gender, trauma, diabetes mellitus, thyroid dysfunction, prolonged immobility, stroke, myocardial infarction, and autoimmune disorders. Pathogenetically, synovitis is believed to stimulate a fibrotic cascade mediated by growth factors such as TGF-beta, ultimately leading to capsular thickening, contracture, and fibrosis3. The natural course of frozen shoulder is generally self-limiting and can be divided into three overlapping stages: the freezing stage lasting 2–9 months, characterized by severe pain and early inflammation; the frozen or stiffening stage lasting 4–12 months, during which pain gradually subsides but significant restriction of shoulder mobility occurs; and the thawing stage, which may extend for 12–42 months, during which pain resolves and range of motion slowly improves, though residual stiffness may persist in some patients4. Clinically, patients often present with insidious onset of pain5, particularly at night, not necessarily related to activity, but exacerbated by even minimal movement. Pain at rest may also be present in the early stages. Functional impairment includes difficulty performing daily activities such as combing hair, dressing, or reaching into back pockets, with women frequently reporting inability to fasten garments behind the back. Examination reveals limitations of both active and passive range of motion, most notably external rotation, which distinguishes frozen shoulder from other shoulder pathologies6. Muscle spasms and subsequent contractures, particularly involving the pectoralis major, periscapular muscles, and later atrophy of the deltoid and supraspinatus, further exacerbate dysfunction7. Differential diagnoses include shoulder arthritis, fractures, dislocations, cervical spondylosis, calcific tendinitis, supraspinatus tendinitis, bicipital tenosynovitis, and subacromial impingement, which should be excluded through careful history and clinical evaluation. Frozen shoulder can be classified as idiopathic or secondary, the latter often following trauma or surgery, with diabetes being a particularly strong association. Treatment of frozen shoulder remains a subject of debate, with both conservative and invasive modalities available.5 Conservative management includes physiotherapy, nonsteroidal anti-inflammatory drugs, corticosteroid injections, and ultrasound therapy, all aiming to reduce pain and improve range of motion. Manipulation under anesthesia, although effective, carries risks of fractures and soft tissue damage. Arthroscopic capsular release is another effective but invasive option requiring surgical expertise. Ultrasound therapy is thought to provide benefits by increasing tissue extensibility, improving local circulation4, and reducing muscle spasm. Intra-articular corticosteroid injections are commonly used, offering superior short-term results compared to physiotherapy or placebo, though long-term efficacy remains uncertain. Both intra-articular and subacromial injections have been studied, with some trials reporting comparable outcomes, while others suggest intra-articular injections may provide better pain relief and functional recovery for up to 12 weeks. However, concerns exist regarding potential cartilage damage from repeated intra-articular steroid use. Functional outcomes following steroid injections are assessed using pain scores, range of motion measurements, and validated scales such as the Shoulder Pain and Disability Index (SPADI) and Constant-Murley Score (CMS), in addition to patient satisfaction surveys. Pain relief is considered the primary therapeutic goal as it facilitates improved mobility and function, thereby enhancing quality of life6,7. The clinical significance of evaluating intra-articular steroid injections lies in addressing gaps in literature regarding their efficacy, safety, and patient-centered outcomes. By understanding their therapeutic role, clinicians can optimize management strategies, minimize morbidity, and improve patient selection for interventions8. This knowledge also has the potential to refine treatment algorithms, reduce long-term disability, and encourage further research on prognostic factors influencing treatment response. AIM To evaluate the efficacy, advantages, and disadvantages of intra-articular steroid injection in idiopathic frozen shoulder unresponsive to NSAIDs, using VAS, SPADI, and Oxford Shoulder Score for outcome assessment.

This prospective study was conducted on the Indian population using radiographic tools at the Orthopedic and Physiotherapy Departments of Medical College and Associated Group of Hospitals, Kota, from November 2022 to January 2024. A total of 45 patients with idiopathic frozen shoulders were selected by convenient sampling. All participants were in the frozen stage of the disease and had persistent pain and restriction of movement despite prior treatment with NSAIDs with or without oral steroids. Written informed consent was obtained from each patient before enrollment. Patients were included if aged between 21–70 years, had at least 50% restriction of external rotation, normal X-rays of the gleno-humeral joint, and symptom duration of at least four months. Patients with diabetes, history of previous shoulder surgery, glucocorticoid allergy, or systemic/local inflammatory conditions were excluded. Eligible patients received intra-articular injections of 2 ml of 2% plain lidocaine with 40 mg methylprednisolone acetate (Depo-Medrol, Pfizer) via anterior or posterior approach, administered at two-week intervals for three doses. Along with the injection, patients were prescribed NSAIDs for five days only during the first dose. Each patient attended five days of supervised physiotherapy after the first injection, followed by a structured home exercise program including wall slides, wand exercises, towel stretch, capsular stretch, pendulum exercise, and shoulder circumduction. Patients were instructed to continue the exercises at home throughout the study period. Follow-up assessments were conducted every two weeks to monitor compliance and outcomes.

Table: 1 Age distribution Age (Years) No. of Patients % 21-30 1 2.22222222 31-40 6 13.3333333 41-50 20 44.4444444 51-60 16 35.5555556 61-70 2 4.44444444 > 70 0 0 Total 45 100 Most of the patients were in the age group 40-60 years. Youngest in the series at the time of study was 21 year and oldest patients was 70 year. Average age in series was 46 years. Table: 2 Occupation Occupation No. of Patients % Farmer 5 11.11111 House Wife 30 66.66667 Sports Person 3 6.666667 Other 7 15.55556 Total 45 100 In our study out of 45 patients 5 were farmers, 30 housewives, 3 sports persons and 7 with other occupations. Table: 3 DOMINANCE of affected hand Dominance No. of Patients % DOMINANT SIDE INVOLVED 31 68.88889 Non DOMINANT SIDE INVOLVED 14 31.11111 Total 45 100 Out of 45 patients 14 (66.66%) patients no dominant shoulder involved and dominant shoulder affected 31 (33.33%) patients Table 6: Chief Complain Chief Complain No. of Patients % Shoulder Pain 38 84.44444444 Stiffness and Shoulder Pain 7 15.55555556 Total 45 100 In this study most patients (38) present with chief complaints of shoulder pain while others present with stiffness and shoulder pain. Table 7: FBS FBS No. of Patients % 70-90 7 15.55556 91-110 27 60 111-130 9 20 131-150 1 2.222222 > 151 1 2.222222 Total 45 100 In this study 27 out of 45 patients having FBS IS 91-110, while one patient having FBS more than 150. Table 8: External rotation, Forward flexion and Abduction & Average Degree of Motion External Rotation Average (Degree of Motion) Forward flexion Average (Degree of Motion) Abduction Average (Degree of Motion) Day-0 52.31 84.22 90 Week -4 60.22 105.11 109.77 Week-8 64.44 123.33 134.88 Week-12 74.64 144.66 159.22 In this study external rotation (ROM) at day 0 is 52.31 degree which improves at 12-week follow-up is 74.64 degree, foreword flexion (ROM) at day 0 is 84.22 degree which improve at 12-week follow-up is 144.66 degree and abduction (ROM) at day 0 is 90 degree which improves at 12-week follow-up is 159.22 degree. Table 9: Comparison of Average Score (pre injection and post injection) Scale Day -0 Week -4 Week-8 Week-12 VAS 7.15 4.42 1.66 0.22 Oxford score 22.91 41.04 44.8 52.06 SPADI SCORE 76.62 64.24 46.26 34.04 At 12 weeks, mean VAS (0.22), SPADI (34.04), and Oxford (52.06) scores showed excellent improvement from baseline values, with consistent progress at each follow-up. All changes were statistically significant, indicating marked pain relief and functional recovery following corticosteroid injection.

In our study comprising 45 patients with idiopathic frozen shoulders, the majority belonged to the middle-age group. Only 1 patient (2.2%) was between 21–30 years, while 6 patients (13.3%) were in the 31–40 year group. The highest proportion, 20 patients (44.4%), were in the 41–50 year age group, followed by 16 patients (35.6%) in the 51–60 year group. A smaller number of patients, 2 (4.4%), were in the 61–70 year group, and none were above 70 years. This shows that frozen shoulders predominantly affected individuals between 40 and 60 years of age in our study population. In the present study of 45 patients with idiopathic frozen shoulder, the majority were housewives, accounting for 30 patients (66.7%). Farmers constituted 5 cases (11.1%), while sports persons represented 3 cases (6.7%). The remaining 7 patients (15.6%) belonged to other occupations. This distribution highlights that frozen shoulder was most commonly observed among housewives in our study group, followed by individuals engaged in farming and other occupations, with sports persons being the least affected. In our study of 45 patients with idiopathic frozen shoulders, the dominant side was more frequently affected. A total of 31 patients (68.9%) had involvement of the dominant shoulder, whereas 14 patients (31.1%) had the non-dominant side affected. This indicates that frozen shoulders showed a clear predilection for the dominant arm in our study population. In the present study, shoulder pain was the most common presenting complaint, reported by 38 patients (84.4%). Stiffness associated with shoulder pain was noted in 7 patients (15.6%). Thus, pain emerged as the predominant symptom bringing patients to medical attention, while a smaller proportion experienced both pain and stiffness simultaneously. In our study population of 45 patients, the majority had fasting blood sugar (FBS) levels within the range of 91–110 mg/dl, accounting for 27 patients (60%). Seven patients (15.6%) had FBS between 70–90 mg/dl, while 9 patients (20%) were in the range of 111–130 mg/dl. Only 1 patient each (2.2%) had FBS levels between 131–150 mg/dl and above 151 mg/dl. This shows that most patients had normal to mildly elevated FBS levels, with very few cases showing higher values. In this study, improvement in shoulder range of motion was assessed over 12 weeks following intra-articular steroid injections and physiotherapy. At baseline (Day 0), the average external rotation, forward flexion, and abduction were 52.31°, 84.22°, and 90°, respectively. By Week 4, these values improved to 60.22°, 105.11°, and 109.77°. Further progress was observed at Week 8, with averages of 64.44°, 123.33°, and 134.88°. At the final follow-up at Week 12, external rotation reached 74.64°, forward flexion 144.66°, and abduction 159.22°, indicating substantial gains in shoulder mobility over the study period. In this study, pain and functional outcomes were evaluated using VAS, Oxford Shoulder Score, and SPADI at baseline and during follow-up. At Day 0, the mean VAS was 7.15, Oxford score 22.91, and SPADI 76.62, indicating significant pain and disability. By Week 4, VAS decreased to 4.42, Oxford score improved to 41.04, and SPADI dropped to 46.26. At Week 8, further improvement was noted with VAS 1.66, Oxford score 44.8, and SPADI 34.04. By Week 12, patients achieved near-complete recovery with VAS 0.22, Oxford score 52.06, and SPADI showing marked functional improvement, reflecting the effectiveness of intra-articular steroid injection combined with physiotherapy. This study shows that corticosteroid injections significantly improve shoulder pain and function in adhesive capsulitis for up to 12 weeks, with no proven long-term benefit. Similar results were observed in diabetic patients, likely due to the self-limiting nature of the disease. The comparable long-term improvement in placebo groups suggests that benefits may arise from joint capsule distension rather than the corticosteroid itself. A recent Cochrane review9 investigated the efficacy of distension arthrography and found a lack of reliable evidence to establish the effectiveness of this technique. In addition, all the studies that involved placebo injections used the same volume as the steroid injection. The results showed that those who were injected with steroids had more significant improvement than those who were injected with saline or lignocaine, thus suggesting that the steroid component rather than the volume of the injection was responsible for the improvement. Compared with physiotherapy alone, corticosteroid injections may offer significantly greater improvements in SPADI score,10 VAS score OXFORD score and ROM11 by 12 weeks of follow-up, but show similar outcomes at longer term follow-up.10,11 Combined corticosteroid injection and physiotherapy treatment may also result in greater improvements in SPADI score and ROM than either treatment alone.9 The use of physiotherapy alone is, however, of limited benefit.(17) Ryans et al12 found physiotherapeutic interventions to be more effective than corticosteroid injections in improving ROM in the early stages, as compared to the studies by Carette and van der Windt.13 A possible explanation was that this study used specific proprioceptive neuromuscular facilitation (PNF) exercises in the physiotherapeutic group, whereas PNF was not used in the other two studies. This could explain why Ryans et al’s48 study was the only one that found physiotherapeutic interventions more effective than corticosteroid injections at improving external rotation.

This study incorporates a clinical perspective by comparing corticosteroid injections with other common modalities and evaluating the optimum corticosteroid dose and anatomical site of injection. Corticosteroid injections appear to be a useful and effective treatment option in adhesive capsulitis, as they can at least provide good short-term symptom relief, although their long-term efficacy has not been demonstrated. Corticosteroid injections have an additive effect to physiotherapy and home exercise programmes, and thus, may be prescribed concurrently. Patients in the early stages of disease who predominantly have pain symptoms may consider corticosteroid injection early, in an attempt to quickly resolve the symptoms before undergoing physiotherapy or home exercises.

1. Andren, A., & Ryberg, B. (1965). Distention of the shoulder joint in the treatment of adhesive capsulitis. Acta Orthopaedica Scandinavica, 36(3), 288-296. 2. Binder AI, Bulgen DY, Hazleman BL, Roberts S (1984) Frozen shoulder: a long-term prospective study. Ann Rheum Dis 43(3):361–364 3. Binder A, Hazleman BL, Parr G, Roberts S (1986) A controlled study of oral prednisolone in frozen shoulder. Br J Rheumatol 25(3):288–292 4. Border WA, Noble NA (1994) Transforming growth factor beta in tissue fibrosis. N Engl J Med 331(19):1286–1292 5. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD006189. doi: 10.1002/14651858.CD006189. PMID: 17054278; PMCID: PMC 8919374. 6. Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984 Jun;43(3):353-60. doi: 10.1136/ard.43.3.353. PMID: 6742895; PMCID: PMC1001344. 7. Bunker TD, Anthony PP (1995) The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br 77(5):677–683 8. Cho, C. H., Kim, H. S., & Park, S. Y. (2016). Proper placement of corticosteroid injection for the treatment of idiopathic adhesive capsulitis: A comparative study of intra-articular and subacromial injections. Journal of Shoulder and Elbow Surgery, 25(4), 621-628. 9. Lubiecki, M., & Stokols, C. (2007). Adhesive capsulitis: Past, present, and future trends in disease prevalence and treatment options. Journal of Orthopaedic & Sports Physical Therapy, 37(5), 276-285 10. Hazleman BL (1972) The painful stiff shoulder. Rheumatol Phys Med 11(8):413–421. 11. Helbig B, Wagner P, Dohler R (1983) Mobilization of frozen shoulder under general anaesthesia. Acta OrthopBelg 49(1– 2):267–274 12. Ryans, I., Murphy, P., & Thompson, R. (2005). Intra-articular triamcinolone and/or physiotherapy in patients with shoulder capsulitis: A randomized controlled trial. Journal of Shoulder and Elbow Surgery, 14(6), 577-583 13. Van der Windt, D.A.M., Hay, E.M., & Croft, P.R. (1995). Shoulder disorders in the community: prevalence and associated factors. Annals of the Rheumatic Diseases, 54(12), 1048-1053.