Frozen shoulder arises from a soft tissue lesion in the capsuler, marked by pain and limitations in both active and passive glenohumeral motion. It ranks among the most frequent orthopedic musculoskeletal conditions. In the past, it was viewed as a self-resolving issue where "full recovery could be anticipated with confidence." Numerous studies across various therapies have shown that most patients regain near-complete shoulder mobility and substantial symptom relief. Adhesive capsulitis affects 2-5% of the population at large, climbing to 20% among diabetics, with 5-40% risk of opposite shoulder involvement.1,2 Higher rates occur in women, those over 49, diabetics (5-fold increase), cases of cervical disc pathology, extended immobility, hyperthyroidism, stroke or heart attack, autoimmune disorders, and injury.3 Ipsilateral recurrence is uncommon.4 While no single cause is confirmed, links exist to diabetes and other factors.1,3 Elevated levels of IL-1α, IL-1β, TNF-α, COX-1, and COX-2 appear in affected capsules.5 Twin research indicates occurrence 2-3 times beyond random expectation.6 The condition features capsular contraction, thickening, and reduced synovial fluid. Primarily diagnosed clinically, imaging helps rule out alternatives like rotator cuff tears, osteoarthritis, or calcific tendinopathy. Patients typically show pain and restricted passive range, especially in rotation, abduction, and flexion, confirmed via history and exam.7,8 Management spans NSAIDs, physiotherapy, intra-articular steroids, distension arthrography, suprascapular blocks, anesthesia-assisted manipulation, arthroscopic capsular release, or conservative observation.9-21 Intra-articular steroids deliver targeted anti-inflammatory and pain-relieving effects efficiently. Evidence on imaging-guided injections remains limited for superior outcomes, prompting this trial to compare ultrasound-directed glenohumeral (intracapsular) versus subacromial (extracapsular) methylprednisolone acetate in frozen shoulder patients imaging minimizes placement errors.22 In resource-constrained settings, affordable, low-risk options are vital to curb disability. This work assesses which approach yields optimal function as an outpatient procedure.

This prospective, comparative trial was performed in the orthopaedics outpatient department at Narayana Medical College, Nellore. We enrolled 120 patients diagnosed with primary idiopathic adhesive capsulitis after obtaining informed consent. Exclusion criteria included post-traumatic stiffness, calcific tendinitis, acromioclavicular arthritis, rotator cuff pathology, pediatric patients, hemiplegia, uncontrolled diabetes, prior shoulder surgery, recent intra-articular steroid injections (within 6 months), or brachial plexopathy-related stiffness. Patients were randomized into two groups and received a single ultrasound-guided injection (4-12 Hz linear probe) of 80 mg methylprednisolone acetate combined with 2 ml of 2% lidocaine, administered under strict aseptic conditions Follow-up assessments occurred on day 1, and at 1, 3, 6 weeks, and 3 months. Pain was evaluated using the Visual Analog Scale (VAS), while functional outcomes were measured with the Disabilities of the Arm, Shoulder, and Hand (DASH) score and Constant shoulder score.23-25 Blood glucose levels were monitored throughout. STATISTICAL ANALYSIS Patients were profiled using several hemodynamic and demographic data as part of the analysis. Means and standard deviations were used to provide descriptive analysis of quantitative parameters. Inferences between groups were drawn using the independent Student t test, and conclusions within the group were drawn using the paired Student t test. For comparisons and correlations, cross tables were created and the chi square test was applied. A P-value of less than 0.05 was deemed statistically significant. SPSS version 24.0 was used for all analysis.

The average age of the patients in our study was 58.43 in the SA group and 60.25 in the GH group. Of the patients, 45.8% were between the ages of 51 and 60. The youngest patient in our study was forty years old, and the oldest was seventy-eight. A female majority was seen in our investigation, with 63.3% of all affected patients being female. Overall, the ratio of women to men was 1.72:1. 48.3% of non-dominant limbs were involved, with 36.67% on the right side and 63.33% on the left. Blood glucose levels were checked since hyperglycemia is a known side effect of steroid medication. Up to three weeks, the glenohumeral group's random blood glucose values were higher than those of the subacromial group. It rose from 131.48±24.12 pre-op to 160.45±31.01 in the glenohumeral group and from 138.1±17.41 to 153.87±18.81 in the subacromial group. However, 0.05% of patients in the glenohumeral group and 0.016% of patients in the subacromial group experienced nausea or vomiting, and 0.016% of patients in each group experienced a brief bout of dizziness following injection. There were no additional complications for any of the other individuals. Table 1: DASH score comparison between glenohumeral (GH) and subacromial (SA) groups on follow up Follow-up period GH group SA group Total Mean±SD P-value Mean±SD P-value Mean±SD P-value Pre Op 66.95±9.9 67.52±10.65 67.23±10.24 Day 1 62.44±8.95 <0.0001* 62.22±10.14 <0.0001* 62.33±9.51 <0.0001* 1 Wk 55.95±8.38 <0.0001* 55.52±9.68 <0.0001* 55.74±9 <0.0001* 3 Wks 43.04±8.6 <0.0001* 43.47±9.47 <0.0001* 43.25±8.99 <0.0001* 6 Wks 33.25±8.55 <0.0001* 33.57±10.47 <0.0001* 33.4±9.49 <0.0001* 3 Mths 27.45±9.31 <0.0001* 26.81±11.14 <0.0001* 27.14±10.2 <0.0001* Table 2: Constant score comparison between glenohumeral (GH) and subacromial (SA) groups on follow up. Follow-up period GH group SA group Total Mean±SD P-value Mean±SD P-value Mean±SD P-value Pre Op 46.63±7.18 47.92±6.91 47.28±7.05 Day 1 54.7±7.14 <0.0001* 55.46±6.65 <0.0001* 55.07±6.88 <0.0001* 1 Wk 60.8±7.63 <0.0001* 60.91±6.63 <0.0001* 60.85±7.12 <0.0001* 3 Wks 69±6.79 <0.0001* 66.17±6.95 <0.0001* 67.62±6.98 <0.0001* 6 Wks 71.2±7.09 <0.0001* 69.08±6.57 <0.0001* 70.17±6.89 <0.0001* 3 Mths 72.66±7.38 <0.0001* 70.28±6.97 <0.0001* 71.5±7.25 <0.0001* Table 3: VAS score comparison between glenohumeral (GH) and subacromial (SA) groups on follow up Follow-up period GH group SA group Total Mean±SD P-value Mean±SD P-value Mean±SD P-value Pre Op 6.5±0.95 6.37±1.07 6.43±1.01 Day 1 4.21±0.62 <0.0001* 4.33±0.85 <0.0001* 4.27±0.74 <0.0001* 1 Wk 3.82±0.69 <0.0001* 4.19±0.7 <0.0001* 4±0.72 <0.0001* 3 Wks 3±1.01 <0.0001* 3.96±0.83 <0.0001* 3.47±1.04 <0.0001* 6 Wks 2.64±0.94 <0.0001* 2.68±0.96 <0.0001* 2.66±0.94 <0.0001* 3 Mths 2.25±0.86 <0.0001* 2.3±0.72 <0.0001* 2.28±0.79 <0.0001*

Frozen shoulder typically affects individuals in middle age, spanning the 4th to 7th decades of life. The aging process contributes substantially to its development through factors like reduced shoulder usage, sedentary habits, and the emergence of non-insulin-dependent diabetes mellitus. Research by Milgrom et al. similarly observed a predominance of females among frozen shoulder cases, consistent with our findings.26 However, patient age and gender distributions did not affect functional outcomes in our cohort. Diabetes stands as a well-established risk factor for frozen shoulder; among our 120 participants, 31 (25.8%) had diabetes, aligning closely with rates reported by Carette et al. (27.9% of 93 patients) and Weber et al. (34.8%).27 In contrast, other investigations noted lower prevalence: Shaffer et al. identified diabetes in just 3 of 62 cases, while Uddin reported 42.5% among adhesive capsulitis patients.28,29 The link between thyroid disorders and frozen shoulder lacks definitive confirmation, yet our data revealed hypothyroidism in 31 patients (25.8%), comparable to Schiefer et al.'s finding of 27.2% among 93 frozen shoulder patients.30 In both study groups, the Disabilities of the Arm, Shoulder, and Hand (DASH) score declined markedly at every follow-up interval, mirroring results from Buchbinder's 2004 trial of short-term prednisolone therapy, which demonstrated progressive DASH reductions over 3 months.9 Specifically, glenohumeral scores improved from 66.95±9.9 to 27.45±9.31 by 3 months, while subacromial scores fell from 67.52±10.65 to 26.81±11.14. No meaningful intergroup differences emerged in DASH scores across assessments. Constant scores rose progressively in both arms. Glenohumeral values advanced from 46.63±7.18 to 72.66±7.38 at 3 months, and subacromial from 47.92±6.91 to 70.28±6.97. Both groups achieved statistically significant gains, with equivalence up to 1 week; thereafter, glenohumeral outperformed subacromial from week 3 onward. Oh et al.'s 2011 study likewise reported Constant score improvements in both groups without intergroup disparities at any point.31 We employed the Visual Analog Scale (VAS) to quantify pain, revealing consistent reductions across follow-ups in both cohorts. Glenohumeral VAS dropped from 6.5±0.95 to 2.25±0.86 by 3 months, and subacromial from 6.37±1.07 to 2.3±0.72. The glenohumeral group exhibited lower VAS at 3 weeks, though differences equalized by 6 weeks and 3 months without statistical significance. Oh et al. (2011) documented parallel patterns.31 Bulgen et al.'s investigation into intra-articular steroid injections for painful shoulders enrolled 55 and 42 patients, respectively, featuring similar night pain and global motion restrictions as in our series.32 A key limitation was the absence of a control arm receiving alternatives like physiotherapy plus medication or placebo injections, precluding isolation of placebo contributions to observed benefits. Although debilitating, frozen shoulder benefits from rapid symptom control, which curtails chronic disability and accelerates resumption of daily functions. Such advantages underscore the value of adopting these injection-based approaches in management.

Ultrasound-guided glenohumeral and subacromial methylprednisolone acetate injections both yield substantial improvements in pain (VAS), function (DASH), and shoulder performance (Constant scores) for primary idiopathic adhesive capsulitis patients over 3 months Glenohumeral injections demonstrate a modest advantage in Constant scores beyond 3 weeks, though DASH and later VAS outcomes remain comparable between groups. Given the unreliable nature of spontaneous recovery, early application of these targeted, ultrasound-guided modalities- as safe outpatient procedures offers optimal management to minimize morbidity and expedite functional restoration across frozen shoulder cases.

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