Studdy 213

A STUDY
TO COMPARE THE EFFECTS OF MAITLAND

MOBILIZATION VS MUSCLE ENERGY TECHNIQUE
ON FACTORS – PAIN, ROM IN FROZEN SHOULDER
A THESIS
SUBMITTED TO SANT BABA BHAG SINGH UNIVERSITY, KHIALA
FOR THE AWARD OF
BACHELOR’S OF PHYSIOTHERAPY
SUBMITTED BY - BULBUL RANI
REGISTRATION NO: 18440059
GUIDE : DR. MANDEEP KAUR MPT (NEURO)
ASSISTANT PROFESSOR, DEPARTMENT OF PHYSIOTHERAPY
SANT BABA BHAG SINGH UNIVERSITY

VILLAGE- KHIALA, PO – PADHIANA
DISTT – JALANDHAR
MARCH, 2023
SANT BABA BHAG SINGH UNIVERSITY (JALANDHAR)
DECLARATION / UNDERTAKING
I,hereby,declare that the research work, embodied in this thesis,entitled “ A
STUDY TO COMPARE THE EFFECTS OF MAITLAND MOBILIZATION VS MUSCLE
ENERGY TECHNIQUE ON FACTORS PAIN , ROM IN FROZEN SHOULDER” for the
Award of
degree of BPT submitted in the department of physiotherapy at SANT BABA BHAG
SINGH UNIVERSITY, KHIALA, JALANDHAR is authentic record of my own work
carried out durng from September 2022 to March 2023 under the supervision of
Dr Mandeep kaur, AP department of physiotherapy. The work present in the
thesis is original and has not been submitted by any other university/institution
for the award of BPT degree.
DATE: SIGNATURE OF THE STUDENT

(BULBUL RANI)
REGISTRATION NO . 18440059
BPT
PLACE :
This is to certify that the above statement made by the candidate is correct to the
best of my /our knowledge.
Signature of Supervisor
1
TO COMPARE EFFECT OF MAITLAND MOBILIZATION VERSUS MET IN FROZEN SHOULDER
Dr . Mandeep Kaur
(AP)
Department of physiotherapy
SBBS University,Jalandhar(Punjab)
Signature of the Guide Signature COD/HOD
2
CERTIFICATE
This is to certify that the thesis entitled “ A STUDY TO COMPARE THE EFFECTS OF
MAITLAND MOBILIZATION VERSUS MUSCLE ENERGY TECHNIQUE ON FACTORS
PAIN ,ROM IN FROZEN SHOULDER”is a bonafide work carried out by Ms BULBUL
RANI, student of BPT, SANT BABA BHAG SINGH UNIVERSITY, KHIALA,
JALANDHAR under my guidance for the degree in BPT during year 2018 – 2023.
This work has not published or submitted elsewhere for the award of any degree.
Date:
Place:
(Guide) Dr. Mandeep Kaur

MPT (Neuro)
(AP)
Department of physiotherapy
SBBSU, Jalandhar(Punjab)
3
DEDICATION
This thesis is dedicated to
To my late Grandfather Mr Lakhu
Ram And
To my Mother , Mrs KIRAN DEVI
( For her endless love, support and
encouragement) And
To my Husband , Mr HARMANJOT SINGH
(for always being a pillar of strength and support to me)
Respected Teachers
Dr Daljit Kaur( MPT,
NEURO) And
To my most amazing and extremely helpful Guide
Dr Mandeep Kaur (MPT , Neuro)
And
To Dr Amrinder Singh ( MPT, Ortho)[Civil hospital Jalandhar]
For continuously helping me throughout my internship period
and providing guidance in my research work
All that I am and all that I Hoped to be , I owe to you.
4
ACKNOWLEDGEMENT
I thank all who in one way or another has contributed in the completion of this
thesis. First, I give thanks to God for protection and ability to do work. The
completion of this undertaking could not have been possible without the
participation and assistance of so many people whose names may not all be
enumerated.
I would like to express my sincere and deep gratitude to my guide Dr Mandeep
Kaur for her consistent support, encouragement and patience for explaining every
fine details regarding my thesis. This thesis would not have been possible without
her directions and support.
I am thankful to Reserved Sant Baba Dilawar Singh ji (Brahm ji) , Sant Baba
Sarwan Singh ji (Honourable chancellor),Prof.(Dr)Dharamjit Singh Parmar(Vice
Chancellor),Dr. Indu Sharma (Registrar), Dr Aneet (Dean Academics), Dr.Vikas
(Dean,US) and Dr. Shweta Singh(COD,Life Sciences), Sant Baba Bhag Singh
University Jalandhar, for providing me an opportunity to carry out my research
work.
It is impossible to extend enough thanks to my family especially my parents Mr

Ashwani kumar and Mrs kiran Devi , Mr Gurmit Singh and Mrs Rashpal Kaur and
to my Brother Ashish Thakur. I am extremely grateful to my parents for their
Love, prayers and sacrifice for educating and motivating me in every best possible
way. Also I would like to mention my sisters Jasmeen kaur and Navneet kaur who
helped me in writing my thesis work. Writing down and editing this thesis would
have been impossible without you.
Also, I would like to thank my friend Aarushi who has been with me throughout
my Bachelor’s, making this journey more memorable and helping me overcome
difficulties.
5
Last but not the least , I would like to thank my husband Mr.Harmanjot Singh
Saini whom I could not thank enough in few sentences , who was always more
worried than me regarding my thesis work. You always kept me motivated to
work more and more harder and to never underestimate my capabilities. You
always came up with new ideas and concepts to help me throughout my research
work. This entire thesis work is not only mine but is entirely and equally dedicated
to you and your constant efforts on me .
Also, I would like to thank physiotherapy staff and Dr Amrinder Singh who helped
me in assessment and data collection of patients in a very precise manner.
I own entire responsibility for all errors and omissions.
Bulbul Rani
BPT (Physiotherapy)
Place :
Date :
6
TABLE OF CONTENTS
FIGURE NO. TITLE PAGE NO.
Chapter 1 INTRODUCTION
Chapter 2 AIMS AND OBJECTIVES
Chapter 3 REVIEW OF LITERATURE
Chapter 4 METHADOLOGY
Chapter 5 RESULTS AND DATA ANALYSIS
Chapter 6 DISCUSSION
Chapter 7 CONCLUSION
7
SUMMARY
Chapter 8
Chapter 9 BIBLIOGRAPHY
Chapter 10 APPENDICES
8
LIST OF FIGURES
SERIAL NO. FIGURE TITLE PAGE NO
FIGURE NO 1 SHOULDER JOINT 16

FIGURE NO 2 DELTOID MUSCLE 18
FIGURE NO 3 TERES MAJOR 19
FIGURE NO 4 TERES MINOR, 21
SUPRASPINATUS,
INFRASPINATUS
MUSCLES
FIGURE NO 5 SUBSCAPULARIS 22
FIGURE NO 6 TRAPEZIUS MUSCLE 22
FIGURE NO 7 LATISSMUS DORSI 23
MUSCLE
FIGURE NO 8 PECTORALIS MAJOR 33
AND MINOR MUSCLES
FIGURE NO 9 MAITLAND CONCEPT 33
FIGURE NO GRADES OF MAITLAND 34
10 MOBILIZATION
FIGURE NO 11 TYPES OF MET 36
FIGURE NO 12 MECHANISM OF MET 38
FIGURE NO 13 HOT PACK
FIGURE NO 14 TENS
FIGURE NO 15
9
LIST OF TABLES
TABLE NO. TABLE TITLE PAGE NO.

TABLE 1.1 Stages of frozen shoulder
10
LIST OF GRAPHS
GRAPH NO. GRAPH TITLE PAGE NO.
11
ABBREVIATIONS
AC ACROMIOCLAVICULAR
SC STERNOCLAVICULAR
FIG. FIGURE
ROM RANGE OF MOTION
FS FROZEN SHOULDER
AC ADHESIVE CAPSULITIS
NO. NUMBER
. FULL STOP
, COMMA
() PARENTHESIS
[] BRACKET
: COLON
‘’’’ ELLIPSIS
/ SLASH
12
ABSTRACT
TITLE- A STUDY TO COMPARE THE EFFECTS OF MAITLAND MOBILISATION VS
MUSCLE ENERGY TECHNIQUE ON FACTORS – PAIN, ROM IN FROZEN SHOULDER
STUDENT - MS. BULBUL RANI, SANT BABA BHAG SINGH UNIVERSITY,
JALANDHAR
SUPERVISOR - Dr. MANDEEP KAUR, MPT (NEURO), Assistant Professor, Sant
Baba Bhag Singh University.
BACKGROUND - Frozen shoulder also named as adhesive capsulitis is a very

common condition seen nowadays. People with frozen shoulder have limitations
in performing both active and passive ROM. Individuals mostly complain in
restricted shoulder movements such as external rotation, abduction have trouble
doing overhead activities such as combing own hairs, lifting things. The cause of
frozen shoulder is idiopathic. It is mostly seen in individuals of age group 40 or
above, more often in women and in population with history of systematic
diseases such as diabetes ,hyperthyrodism, hypothyrodism, cardiovascular stroke
or with a history of rotator cuff injury , broken arm .Techniques such as
mobilization , muscle energy technique are commonly applied to increase ROM
and decrease pain.
OBJECTIVE OF THE STUDY: To compare the effect of maitland mobilisation
versus muscle energy techniques on factors- pain and ROM in STAGE-II frozen
shoulder( Stiffening stage)
METHODOLOGY: The total duration of the study will be half year. Minimum of
30 subjects will be selected between age groups of 45-60 years. The subjects will
be divided into 2 groups (15 subjects in each group)
GROUP A: will be given TENS, HOT PACK ,MAITLAND MOBILISATION.
13
GROUP B: will be given TENS, HOT PACK , MUSCLE ENERGY TECHNIQUE.

DATA ANALYSIS: will be performed using SPSS.
KEY WORDS: Maitland mobilisation, Muscle energy technique ,Adhesive

Capsulitis,Stage II frozen shoulder.
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CHAPTER 1
INTRODUCTION
15
INTRODUCTION
In world population frozen shoulder is occuring more commonly and is considered

as major health problem . It is a common shoulder ailment that is marked by pain
and progressive loss of range of motion, particularly in external rotation. Frozen
shoulder appears when the strong connective tissue surrounding the shoulder
joint (called the shoulder joint capsule) become thick, stiff, and inflamed. (The
joint capsule contains the ligaments that attach the top of the upper arm bone
[humeral head] to the shoulder socket [glenoid], firmly holding the joint in place.
This is more commonly known as the "ball and socket" joint.) [1]
The condition is called "frozen" shoulder because the more pain that is felt, the
less likely the shoulder will be used. Lack of use causes the shoulder capsule to
thicken and becomes tight, making the shoulder even more difficult to move -- it
is "frozen" in its position. [2]
Anatomy of Shoulder Joint

The shoulder girdle is composed of the
clavicle and the scapula, which articulates
with the proximal humerus of the upper
limb. Four joints are present in the shoulder:
the sternoclavicular (SC), acromioclavicular
(AC), and scapulothoracic joints, and
glenohumeral joint. lenohumeral joint is a
highly moveable ball-and-socket synovial
joint that is stabilized by the rotator cuff
muscles that attach to the joint capsule, as
well as the tendons of the biceps and triceps
brachii. The humeral head articulates with Figure 1 SHOULDER
JOINT
16
the glenoid fossa of the scapula.[3] It is a shallow articulation, as the fossa

accommodates less than one-third of the humeral head. The labrum, a
fibrocartilaginous ring, attaches to the outer rim of the glenoid fossa and provides
additional depth and stability securing the humeral head .[FIG1] A small number of
fluid-filled sacs known as bursae surround the capsule and aid in mobility. These
are the subacromial, subdeltoid, subscapular, and subcoracoid bursae.
The major movements at the glenohumeral joint are: [4]
 Abduction: upward lateral movement of humerus out to the side,

away from the body, in the plane of the scapula
 Adduction: downward movement of humerus medially toward
the body from abduction, in the plane of the scapula
 Flexion: the movement of humerus straight anteriorly
 Extension: the movement of humerus straight posteriorly
 External rotation: the movement of humerus laterally around its long
axis away from the midline
 Internal rotation: the movement of humerus medially around its long
axis toward the midline
 Horizontal adduction (transverse flexion): the movement of the
humerus in a horizontal or transverse plane toward and across the chest
 Horizontal abduction (transverse extension): the movement of
the humerus in a horizontal or transverse plane away from the chest .
BLOOD SUPPLY AND LYMPHATICS
17
The axillary artery is the major blood vessel in the shoulder, with many of
its branches supplying the area. These branches include the superior
thoracic artery, thoracoacromial artery, lateral thoracic artery, subscapular
artery, anterior humeral circumflex artery, and posterior humeral
circumflex artery. Before becoming the axillary artery, after passing beyond
the lateral edge of the first rib, the subclavian artery also includes branches
that supply the area of the shoulder. The thyrocervical trunk off of the
subclavian artery adds the suprascapular artery and the transverse cervical
artery. The dorsal scapular artery most often branches off of the
subclavian, but may sometimes branch off the transverse cervical artery.[5]
MUSCLES
MUSCLES OF THE SHOULDER JOINT ARE :
Deltoid
Figure 2 deltoid muscle.
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 Function:
 Anterior aspect is responsible for flexion and medial rotation of the arm
 Middle aspect is responsible for the abduction of the arm (up to 90
degrees)
 The posterior aspect is responsible for extension and lateral rotation of
the arm
 Origin: Lateral clavicle, acromion and scapular spine[Fig.2]
 Insertion: Deltoid tuberosity
Teres major
19
Figure 3 TERES MAJOR MUSCLE
 Function: Adduction and medial rotation of the arm

 Origin: Posterior surface of the scapula at its inferior angle [Fig.3]
 Insertion: Intertubercular groove of the proximal humerus on its medial
aspect [Fig.3]
Supraspinatus (Rotator Cuff)
20
 Function: Initiation of arm abduction (first 15 degrees), stabilize

glenohumeral joint
 Origin: Posterior scapula, superior to the scapular spine/supraspinous fossa
 Insertion: Top of the greater tubercle of the humerus[ Fig.4]
Infraspinatus (Rotator Cuff)
 Function: Lateral rotation of the arm, stabilize glenohumeral joint

 Origin: Posterior scapula, inferior to the scapular spine/Infraspinous fossa
 Insertion: Greater tubercle of the humerus, between the supraspinatus and
teres minor insertion[Fig.4]
Teres minor (Rotator Cuff)
 Function: Lateral rotation of the arm,stabilize glenohumeral joint. [Fig.4]

 Origin: Inferior angle of the scapula
 Insertion: Inferior aspect of the greater tubercle
 Innervation: Axillary nerve (C5, C6)
21
Figure 4 Showing TERES MINOR, SUPRASPINATUS,INFRASPINATUS MUSCLE
Subscapularis (Rotator Cuff)

Function: Adduction and medial rotation of the arm, stabilize glenohumeral
joint.[Fig.5]
 Origin: Anterior aspect of the scapula
22
Figure 5 Subscapularis muscle.
 Insertion : Lesser tubercle of the humerus.[Fig No.5]

 Innervation: Subscapular nerves (C5, C6, C7)
Trapezius
Figure 6 Trapezius muscle
23
 Function:
o Upper fibers elevate the scapula and rotate it during abduction of the
arm (90 to 180 degrees) [Fig 6]
o Middle fibers retract the scapula[Fig 6]
o Lower fibers pull the scapula inferiorly.[Fig 6]
 Origin: Skull, nuchal ligament and the spinous processes of C7 to T12

 Insertion: clavicle, acromion and the scapular spine
 Innervation: Accessory nerve (C5, C6)
24
Figure 7Lattismus Dorsi Muscle
Latissmus dorsi
 Function: Extends, adducts and medially rotates the upper limb

 Origin: Spinous processes of T6 to T12, iliac crest, thoracolumbar fascia, and
the inferior three ribs[ Fig 7]
 Insertion: Intertubercular sulcus of the humerus[Fig. 7]
Pectoralis major
25
Figure 8 SHOWING PECTORALIS MAJOR AND MINOR MUSCLES
 Function:
o Clavicular head flexes and adducts arm
o Sternal head adducts and medially rotates the arm
o Accessory for inspiration
 Origin:
o Clavicular head: medial half clavicle[Fig.8]
o Sternocostal head: Lateral manubrium and sternum, six upper costal
cartilages and external oblique aponeurosis
26
 Insertion: Intertubercular groove of the proximal humerus on its lateral

aspect
 Innervation: Medial and lateral pectoral nerves (C6, C7, C8)
Pectoralis minor
 Function: Depression of the shoulder, protraction of the scapula
 Origin: Third, fourth, fifth ribs close to their respective costal cartilages
 Insertion: Coracoid process [Fig.8]
 Innervation: Medial pectoral nerve (C8, T1)
NORMAL RANGE OF MOTION AT VARIOUS MOVEMENTS AT

SHOULDER JOINT :
The glenohumeral joint possesses the capability of allowing an extreme range of

motion in multiple planes
 Flexion – Defined as bringing the upper limb anterior in the sagittal plane.
The usual range of motion is 180 degrees. The main flexors of the shoulder
are the anterior deltoid, coracobrachialis, and pectoralis major. Biceps
brachii also weakly assists in this action.
 Extension—Defined as bringing the upper limb posterior in a sagittal
plane. The normal range of motion is 45 to 60 degrees. The main extensors
of the shoulder are the posterior deltoid, latissimus dorsi, and teres major.
27
 Internal rotation—Defined as rotation toward the midline along a

vertical axis. The normal range of motion is 70 to 90 degrees. The internal
rotation muscles are the subscapularis, pectoralis major, latissimus dorsi,
teres major, and the anterior aspect of the deltoid.
 External rotation - Defined as rotation away from the midline along a
vertical axis. The normal range of motion is 90 degrees. Primarily
infraspinatus and teres minor are responsible for the motion.
 Adduction – Defined as bringing the upper limb towards the midline
in the coronal plane. Pectoralis major, latissimus dorsi, and teres major
are the muscles primarily responsible for shoulder adduction.
 Abduction - Defined as bringing the upper limb away from the midline in
the coronal plane. The normal range of motion is 150 degrees. Due to the
ability to differentiate several pathologies by the range of motion of the
glenohumeral joint in this plane of motion, it is essential to understand how
different muscles contribute to this action.
I. The supraspinatus is responsible for the first 0 to 15 degrees of abduction.
II. The middle fibers of the deltoid are responsible for approximately 15 to 90
degrees of abduction .
Codman defined frozen shoulder as a clinical condition that can hardly be

defined, it is complicated to enclose it in a single pathological mechanism, and
therefore, even less easy to define its treatment. Instead, the term “adhesive
capsulitis” was introduced by Neviaser [9] to describe a tissue inflammation
condition . Shoulder stiffness is very common often related with a history of
shoulder trauma or underlying disease, when left untreated results in frozen
shoulder . As conditions like diabetes are increasing , chances of developing
frozen shoulder are at high risk.
28
 Frozen shoulder is mainly by an insidious and progressive loss of active and

passive mobility in the glenohumeral joint presumably due to capsular
contracture.
Frozen Shoulder may be:
1. Primary - Onset is generally idiopathic (it comes on for no attributable

reason)
2. Secondary - Results from a known cause, predisposing factor or surgical
event.[10] A secondary frozen shoulder can be the result of several
predisposing factors. For example, post surgery, post-stroke and post-
injury. Where post-injury, there may be an altered movement pattern
to protect the painful structures, which will in turn change the motor
control of the shoulder, reducing the range of motion, and gradually
stiffens up the joint.
EPIDEMIOLOGY OF FROZEN SHOULDER
Adhesive capsulitis occurs in up to 5%. Females are 4 times more often affected
than men, while the non-dominant shoulder is more prone to be affected
ETIOLOGY OF FROZEN SHOULDER
29
The etiology of frozen shoulder is not yet fully understood. However, some
plausible risk factors have been identified:
 Diabetes mellitus (with a prevalence up to 20%)
 Stroke
 Thyroid disorder
 Shoulder injury
 Dupuytren disease
 Parkinson disease
 Cancer
 Complex regional pain syndrome
PATHOPHYSIOLOGY OF FROZEN SHOULDER

Frozen Shoulder (FS) is a common cause of shoulder pain associated with
restricted active and passive range of motion. Although this condition has been
recognized as a clinical disease entity for about 150 years, we still have not
unraveled the pathophysiology yet. FS has often been described as a self-limiting
condition, with recovery within two to three years for the majority of patients [6].
However, symptoms of mild to moderate pain and stiffness are reported in 27–
50% of patients at long term [7]. Even in patients with a favorable natural course
of the condition, there is still an extensive period to deal with pain, and functional
limitations. Frozen shoulder is usually described as fibrotic, inflammatory
contracture of the rotator interval, capsule, and ligaments. However, the
development of AC remains not fully understood. Although disagreements exist,
the most recognized pathology is cytokine-mediated synovial inflammation with
fibroblastic proliferation based on arthroscopic observations. Additional findings
include adhesions around the rotator interval caused by increased collagen and
nodular band formation.
30
The structure usually affected first is the coracohumeral ligament the roof of the
rotator cuff interval. Contraction of the coracohumeral ligament limits external
rotation of the arm, which is usually first affected in early AC. In advanced stages,
thickening and contraction of the glenohumeral joint capsule develop, further
limiting the range of motion in all directions.[8]
STAGES OF FROZEN SHOULDER

 Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with
sharp pain at extremes of motion, and pain at night with sleep interruption
which may last anywhere from 2-9 months.
 Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss

of GH motion in capsular pattern. Pain is apparent only at extremes of
movement. This phase may occur at around 4 months and last till about 12
months.
 Resolution/thawing phase: Spontaneous, progressive improvement in

functional range of motion which can last anywhere from 5 to 24 months.
Despite this, some studies suggest that it's a self limiting condition, and
may last up to three years. Though other studies have shown that up to
40% of patients may have persistent symptoms and restriction of
movement beyond three years.
31
TABLE 1.1 [STAGES OF FROZEN SHOULDER]
Diagnosis
Clinical diagnosis
Primary frozen shoulder is essentially clinical diagnosis. Frozen shoulder is
characterized by an insidious and progressive loss of active as well as passive
mobility in the glenohumeral joint mainly due to capsular contracture. Patients
typically demonstrate a characteristic history, clinical presentation, and recovery.
Clinical syndromes include pain, a limited range of motion (ROM), and muscle
weakness from disuse . There are four movements that are useful in the
examination—flexion, abduction, internal rotation, and external rotation.
32
Flexion , abduction and internal rotation are evaluated with active and passive
mobilization, while external rotation is evaluated only with passive mobilization.
MANAGEMENT OF FROZEN SHOULDER

The main approaches to treat frozen shoulder are to increase ROM with active ,
passive movements along with mobilisation and muscle energy technique.The
goal is to maintain and gain ROM and achieve painfree shoulder movement after
treatment.
Modalities such as TENS help to decrease shoulder pain and HOT PACK when
given prior to movement , help relax the shoulder muscles which ultimately aids
in providing relaxation to patient and perform smooth ,less painful active and
passive movements.
Transcutaneous Electrical Nerve Stimulation ( T.E.N.S)

is the use of electrical current produced from a device to stimulate nerves for
therapeutic purposes to reduce pain of any origin by using the application of
pulsed rectangular monophasic/biphasic current with the pulse duration of 50-
200 us and frequency of 1-120Hz and a maximum peak current of 50mA-100mA
applied through surface electrodes.
HOT PACK /HYDROCOLLATOR PACK:

Hot pack (hp) are noninvasive modalities that are commonly used in the
management of both acute as well as chronic pain arising from several
conditions.Commercially, available hot packs are usually a canvas cover filled with
a hydrophillic substance such as bentonite . HOT packs are kept in a commercial
water filled container that maintains a temprature of 71 degree Celsius.
33
MAITLAND MOBILIZATION
The international Maitland Teachers Association(IMTA) defines the maitland
concept as a process of examination, assessment and treatment of
neuromusculoskeletal disorder by manipulative physiotherapy.[11]
Grades I and II of maitland mobilization techniques are primarily used for treating
joints limited by pain. The oscillations may have an inhibitory effect on the
perception of painful stimuli by repetitively stimulating mechanoreceptors that
block nociceptive pathways at the spinal cord or brain stem levels.These
nonstretch motions help move synovial fluid to improve nutrition to cartilage
whereas Grades III and IV are primarily used as stretching manoeuvres.
Appropriate selection of mobilization technique for treatment can take place after
a thorough assessment and examination.[12] Different Glides used in shoulder joint
are –
 A-P (Anteroposterior)
 P-A (Posteroanterior)
 Longitudinal Caudad
 Longitudinal Cephalad
 Joint Distraction
 Medial Glide
 Lateral Glide
This glides are applied on the basis of convex – concave rule which states
that
 When a convex surface (i.e Humeral Head) moves on a stable concave

surface (i.e Glenoid Fossa) the sliding of the convex articulating surface
occurs in the opposite direction to the motion of the bony lever (i.e the
Humerus)
34
The opposite can be said for
 When a concave surface (i.e Tibia; talocrural joint) is moving on a stable

convex surface (i.e Talus) sliding occurs in the same direction of the bony
level.
Examples:To improve shoulder flexion one have to perform an A-P
mobilisation due to the way the convex humerus articulates with the concave
glenoid fossa.
Fig.9 MAITLAND CONCEPT
GRADES OF MAITLAND MOBILIZATION
35
Fig.10 GRADES OF MAITLAND MOBILIZATION
M.E.T [ MUSCLE ENERGY TECHNIQUE]
Muscle energy technique(MET) help relieve restriction and pain at the shoulder. It
is unique in its application as the client provides the initial effort while the
practitioner facilitates the process. It is a standardized series of shoulder
treatments with broad application in diagnosis, treatment, and prognosis. It is
developed by Spencer , D.O. in 1916. Spencer technique is an articulatory
technique with seven different procedures used to treat shoulder restriction
caused by adhesive capsulitis. In this technique passive,smooth,rythmic motion is
designed to stretch contracted muscles,ligaments,and capsules.Most of the force
is applied to
36
end range of motion. This technique increases pain free range of motion through
stretching the tissues,enhancing lymphatic flow, and stimulating increased joint
circulation. Muscle energy is a direct and active technique; meaning it engages a
restrictive barrier and requires the patient’s participation for maximal effect.
TYPES OF M.E.T
There are mainly 2 types of MET :
1. Autogenic Inhibition MET

 Post Isometric Relaxation (PIR)
 Post Facilitation Stretching (PFS)
2. Reciprocal Inhibition MET
1) AUTOGENIC INHIBITION:
-Autogenic inhibition reflex is a sudden relaxation of muscle upon the

development of high tension. It is a self-induced, inhibitory, negative feedback
prolong lengthen reaction against tear muscles. Golgi tendon organs are
receptors responsible for that.
Autogenic inhibition (historically known as the inverse myotatic reflex or

autogenetic inhibition) shows a decrease in the excitability of a contracting or
stretched muscle that in the past has been merely ascribed to the increased
inhibitory input arising from Golgi tendon organs (GTOs) within the same muscle.
The reduced efferent (motor) send to the muscle through autogenic inhibition is a
factor that will help muscle elongation.
37
Figure 11 NEUROMUSCULAR INHIBTION
Golgi tendon organs are receptors responsible for that Autogenic inhibition
(historically known as the inverse myotatic reflex or autogenetic inhibition) shows
a decrease in the excitability of a contracting or stretched muscle that in the past
has been merely ascribed to the increased inhibitory input arising from Golgi
tendon organs (GTOs) within the same muscle.
The reduced efferent (motor) send to the muscle through autogenic inhibition is a
factor that will help muscle elongation.
Ex. GTOs sense muscular tension within muscles when they contract or are
stretched. When the GTO is activated during contraction, it causes inhibition of
the contraction (autogenic inhibition), which is an automatic reflex. Static
stretching is one example of how muscle tension signals a GTO response.
38
 –POST ISOMETRIC RELAXATION (PIR):- Post Isometric Relaxation is a technique

developed by Karel Lewitt. Post Isometric Relaxation(PIR) is the effect of the
decrease in muscle tone in a single or group of muscles, after a brief period of
submaximal isometric contraction of the same muscle. PIR works on the concept
of autogenic inhibition.
Autogenic and reciprocal inhibition both occur when certain muscles are
inhibited from contracting due to the activation of the Golgi tendon organ
(GTO) and the muscle spindles. These two musculotendinous proprioceptors
located in and around the joints and muscles respond to changes in muscle
tension and length, which helps manage muscular control and coordination.
The GTO, located between the muscle belly and its tendon, senses increased
tension when the muscle contracts or stretches. When the muscle contracts,
the GTO is activated and responds by inhibiting this contraction (reflex
inhibition) and contracting the opposing (antagonist) muscle group. This
process is known as autogenic inhibition. (fig, 11)
The GTO response plays an important role in flexibility. When the GTO inhibits
the (agonist) muscle’s contraction and allows the antagonist muscle to
contract more readily, the muscle can be stretched further and easier.
Autogenic inhibition is often seen during static stretching, such as during a
low-force, long-duration stretch. After 7 to 10 seconds, muscle tension
increases and activates the GTO response, causing the muscle spindle in the
stretched muscle to be inhibited temporarily, which makes it possible to
stretch the muscle further.(Fig.11)
39
The muscle spindle is located within the muscle belly and stretches along with
the muscle itself. When this occurs, the muscle spindle is activated and causes
a reflexive contraction in the agonist muscle (known as the stretch reflex) and
relaxation in the antagonist muscle. This process is known as reciprocal
inhibition.
MECHANISM OF ACTION:
Muscle energy is a direct and active technique; meaning it engages a restrictive

barrier and requires the patient’s participation for maximal effect.
Figure 12 MECHANISM OF MET
40
As the patient performs an isometric contraction, the following physiologic

changes occur:-
 Golgi tendon organ activation results in direct inhibition of the agonist’s muscles.
 A reflexive reciprocal inhibition occurs at the antagonistic muscles.(FIG 12)
 As the patient relaxes, agonist and antagonist muscles remain inhibited allowing
the joint to be moved further into the restricted range of motion.
Benefits of MET:
1. Restoring normal tone in hypertonic muscles

2. Strengthening weak muscles
3. Preparing muscle for subsequent stretching restricted mobility. A restrictive
barrier describes the limit in the range of motion that prevents
4. Improved joint mobility
USES:
 Lengthen a shortened, contractured, or spastic muscle.
 Strengthen physiologically weakened muscles.
 Reduce pain.
 Stretch the tight fascia.
 Reduce localized edema.
 Mobilize an articulation with
41
Muscle Energy Techniques can be used for frozen shoulder in which the goal is
to cause relaxation and lengthening of the muscles and improve range of
motion (ROM) in joints.
42
CHAPTER – 2
AIMS AND OBJECTIVES
43
AIM OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in
Grade II adhesive capsulitis.
OBJECTIVE OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in
Grade II adhesive capsulitis.
HYPOTHESIS
NULL HYPOTHESIS
There will be statistically non-significant difference between Maitland
mobilization versus muscle energy technique on factors pain,range of
motion(ROM) in grade II frozen shoulder.
EXPERIMENTAL HYPOTHESIS
There will be statistically significant difference between Maitland mobilization
technique versus Muscle energy technique on factors pain, range of motion
(ROM)in grade II frozen shoulder.
44
NEED OF THE STUDY
The physiotherapy interventions for the management of Adhesive Capsulitis which is

commonly known as Frozen Shoulder is wide and variable, and Some interventions
used are Maitland Mobilization and Muscle Energy Technique. There is an increased
awareness of this condition , but still have difficulty to manage it, thus, the patients
with this condition have maintained some functional stability by the support of this
treatment and helpful for the daily activities in life. Thus, there is need to find out to
compare the effectiveness of Maitland Mobilization versus Muscle Energy
Technique on factors R.O.M and Pain in Grade 2 Frozen shoulder .
45
SIGNIFICANCE OF THE STUDY
This comparative protocoal will be helpful in dealing with the problems , disciples
in the medical sector which is recommended for the management of Stage II
Adhesive Capsulitis among geratric, diabetic and other individuals suffering from
Frozen Shoulder, who underwent Shoulder Trauma or any other cause that led to
stiffening of shoulder joint along with pain and restriction in movements , making
the daily life activities of lifting , combing , holding difficult and painful.
46
OPERATIONAL DEFINATIONS :
MOBILIZATION:
They are passive skilled manual therapy techniques applied to joints and related
soft tissues at varrying speeds and amplitudes using physiological or accessory
motions for therapeutic purposes. The technique of mobilization used in the study
is Maitland mobilization .
MAITLAND MOBILIZATION :
Maitland concept is named after its pioneer Geoffery Maitland. It has 5 grades.
GRADE I-[small amplitude movement at the beginning of the available range of

movement]
GRADE II- [large amplitude movement at within the available range of movement]
GRADE III- [large amplitude movement that moves into stiffness or muscle spasm]
GRADE IV - [small amplitude movement stretching into stiffness or muscle spasm]
GRADE V-[small amplitude, quick thrust,manipulation at end range.
. lower grades I and II are used to reduce pain and irritability.

. Higher grades III AND IV are used to stretch the joint capsule and passive tissues
which support and stabilize the joint to increase range of movement.
47
MUSCLE ENERGY TECHNIQUE (M.E.T):
The muscle energy technique (MET) which is used to stretch or lengthen the muscle
and fascia that lack flexibility, is a manual therapy intervention. .It is a form of
manual therapy technique that uses muscle’s own energy in the form of gentle
isometric contractions to relax the muscles via autogenic or reciprocal inhibition and
to lengthen the muscle.
In MET, the patient must exert force by contracting the targeted muscle against the
therapist's counterforce before relaxing and receiving a passive stretch from the
therapist. Three to five contractions can be included in one MET application, each
contraction is hold for 5 seconds and each contraction is followed by a stretch that
ranges from 3 - 5 seconds to 30-60 seconds13. This technique can be used for any
joint with restricted ROM. One of the indications for using this technique is to
normalize the joint range of motion.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S):
It is a non-invasive method of electrical stimulation to reduce pain of any origin by

using the application of pulsed rectangular monophasic /biphasic current with the
pulse duration of 50-200us and frequency of 1-120 HZ and a maximum peak
current of 50mA-100mA applied through surface electrodes. It works on blocking
the pain and alters the level of pain. The 3 forms of TENS are High TENS, Low TENS
and Burst TENS which varies in intensity and frequency. The frequency of TENS
most
48
commonly used is 100-150 Hz, in continuous mode with 12-30mA intensity for
time duration of 10 -15 minutes.
HOT PACK/HYDROCOLLATOR PACK:
Hot pack (HP) is the most traditional method of providing superficial heating. It
has been suggested that a deep heating agent could produce a greater increase in
tissue extensibility than superficial heating
Commercially available hot packs are usually a canvas cover filled with a
hydrophillic substance such as bentonite . Hot packs are kept in a commercial
water filled container that maintains a temperature of approximately 71 degree
Celsius.
49
CHAPTER - 3
REVIEW OF LITERATURE
50
REVIEW OF LITERATURE
Abhay kumar et al.(2012) did clinical study on effictiveness of maitland

techniques in idiopathic shoulder adhesive capsulities in two groups .The study
confirmed that addition of the maitland mobilization technique with the
combination of exercise have proved their efficacy in pain and improving R.O.M
and shoulder function .[12]
Mehboob ali et al.(2022) studied effectiveness of Muscle energy Technique and

Maitland Mobilization technique on pain,(R.O.M),disability index in the patients
with adhesive capsulitis.They concluded that Maitland Mobilization is more
effective in reducing pain and increasing function and Disability among the
patients having adhesive capsulitis as compared to MET for pain ,ROM and
shoulder function. [13]
Noman Ghaffar Awan et al(2022) compared the effectiveness of movement with

mobilization and muscle energy technique in reducing pain and improving
functional status in patients with frozen shoulder. The outcome assessment
instruments, goniometer for ROM’’ And shoulder pain, and disability index,’’
revealed that Motion by Mobility is more effective than Muscle Energy Technique
in increasing ROM and operational condition ‘’ of patient havinf frozen shoulder.
Movement with mobilization is more effective in allevating pain , and enhancing
functional capacity in patients with shoulder pain. [14]
51
Samiksha Sathe et al(2018) did a comparative study on effects of Maitland
mobilization versus conventional physiotherapy in patients with adhesive
52
capsulitis. On the basis of this study, they concluded that there is a more
significant increase in ROM, SPADIscore,and a significant decrease in pain on
NPRS by Maitland Mobilization therapy along with conventional therapy as
compared to conventional physiotherapy alone.[15]
Suzie Notan,Mira Meeus et al(2016)did study to systematically review the

literature for efficacy of isolated articular mobilization technique in patients with
adhesive capsulitis. Overall, they concluded mobilization techniques have
beneficial effects in patients with primary AC of the shoulder . [16]
Narayan Anupama,Jagga,Vinay(2014) did a experimental study using convenient

random sampling of 30 patients ,divided into groups of two . Each group divided
into 15 each,GroupA(Experimental),Group B (Control). Control group was treated
with conventional physiotherapy treatment alone. The Experimental group was
treated with MET for shoulder Flexion,Abduction,and External rotation along with
Conventional physiotherapy treatment. The results showed that Group A of
Experimental Study shows better result than Group B . Thus , concluded that
muscle energy technique is effective on functional ability of shoulder in adhesive
capsulitis. [17]
Ujwal L YEOLE et al (2017) conducted a randomized controlled trial on

effictiveness of movement with mobilization in adhesive capsulitis of shoulder .
Two groups of 15 each participants were formed namely Group A ,Group B.
(n=30). Group A unerwent maitland mobilization with movement whereas Group
B performed supervised exercise only.They concluded that movement with
mobilization proved to be a better technique for improving range of motion and
pain in adhesive capsulitis of frozen shoulder.[18]
53
Sami S Almureef et al (2020) gave a systematic review of effectiveness of

mobilization with conventional Physiotherapy in Frozen shoulder.The review
includes randomized controlled trials . The result concluded that mobilization
program with conventional therapy designed for frozen shoulder can be more
effective in increasing shoulder ROM .[19]
Shah Atika Suri ,Misra Anand(2013) did a study to establish best and efficient
protocol for treatment of idiopathic adhesive capsulitis.30 subjects including both
sexes between 40-60 years,, diagnosed adhesive capsulitis were selected and with
lottery random sampling method were assigned in two groups (A and B ) with 15
subjects each. Group A received moist pack for 15 min, Active ROM exercises and
Maitland mobilization. Group B received moist pack for 15 min,active ROM
exercises and MET (muscle energy technique).All the subjects were measured for
pain by VAS, for all shoulder movements by goniometer on first day before
starting treatment and on 15th day after treatment. Research concluded that MET
can potently be of value and as soon as the pain subsides. Maitland mobilization
can be incorporated to increase ROM.[20]
NITHYA JAISWAL et al (2019) studied efficacy of muscle energy techniques as an

adjunct with mulligans mobilization in adhesive capsulitis.The results showed a
significant improvement in pre and post levels of both groups . Mulligans’s
mobilization along with Muscle Energy Technique is found to be more effective in
improving quality of life in subjects with adhesive capsulitis of shoulder than
mulligans mobilization alone.[21]
Muhammad Hashim et al.(2022) did a comparative study of maitland

mobilization and Muscle Energy Technique on pain ,Range of motion and
functions in adhesive capsulitis. The study concluded that Maitland
mobilization is more effective in
54
reducing pain and increasing function and disability among the patients having
Adhesive Capsulitis as compared to MET for pain,ROM and shoulder functions.
[22]
Dr Abdullah Al Shehri et al. (2018) published a research paper on efficacy of

maitland mobilization in frozen shoulder. The study comprised of a total of 40
patients in randomized control trial .They concluded that Maitland Mobilization
improves the symptoms of frozen shoulder . Better improvement was shown by
Maitland’s mobilization group. [23]
N Maricar (2009) published a single case design on effect of maitland

mobilization and exercise for the treatment of shoulder adhesive capsulitis. The
purpose of this single-case design was to investigate the response of shoulder
motions, pain, and function to two commonly used physiotherapy management
approaches. The Shoulder Pain and Disability Index (SPADI) was used to monitor
pain and functional disability, and four shoulder movements (flexion, abduction,
internal, and external rotations) were measured. The results were evaluated by
using single-case design analysis method of Split Middle Technique and visual
observation. The results showed that the exercise plus mobilization intervention
shows promise as a cost- effective management.
Kiran Satpute , Suie Reid et al. (2021) did a study to assess the effects of
mobilization with movement (MWM) on pain, range of motion (ROM), and
disability in the management of shoulder musculoskeletal disorders. Six databases
and Scopus, were searched for randomized control trials. The ROB 2.0 tool was
used to determine risk-of-bias and GRADE used for quality of evidence. Meta-
analyses were performed for the sub-category of frozen shoulder and shoulder
55
pain
56
with movement dysfunction to evaluate the effect of MWM in isolation or in

addition to exercise therapy and/or electrotherapy when compared with other
conservative interventions. Out of 25 studies, 21 were included in eight separate
meta-analyses for pain, ROM, and disability in the two sub-categories.The results
interpreted that for shoulder pain with movement dysfunction, the addition of
movement with mobilization significantly improved pain.
Aime F.Kachingwe, Beth Phillips et al.(2013) did a randomized controlled

trial to compare the effectiveness of four physical therapy interventions in the
treatment of primary shoulder impingement syndrome: (1) supervised exercise
only, (2) supervised exercise with glenohumeral mobilizations, (3) supervised
exercise with a mobilization-with-movement (MWM) technique, or (4) a control
group receiving only physician advice. Thirty-three subjects diagnosed with
primary shoulder impingement were randomly assigned to one of these four
groups. Main outcome measures included 24-hour pain (VAS), pain with the Neer
and Hawkins- Kennedy tests, shoulder active range of motion (AROM), and
shoulder function (SPADI). The MWM group had the highest percentage of
change in AROM, and the mobilization group had the lowest. This pilot study
suggests that performing glenohumeral mobilizations and MWM in combination
with a supervised exercise program may result in a greater decrease in pain and
improved function.
Manmitkaur A Gill , Bhavika P Gohel et al .(2018) did an interventional study to

study the effect of Muscle Energy Technique on pain in adhesive capsulitis and to
study the effect of Muscle Energy Technique on function in adhesive
capsulitis.The patients were divided randomly in control group and interventional
group. In control group patients received only conventional physiotherapy in the
form of hot packs for 10 minutes, Codman‟s exercise, finger ladder exercises,
wand exercises, active exercises and capsular stretching. In interventional group
57
patients were treated with MET for shoulder flexion, abduction and external
rotation along with
58
conventional treatment. The protocol for MET includes 5 repetitions/set, 3

sets/session, 1 session/day for 15 days. Treatment was given once a day for 15
days except Sunday to both groups. VAS score, shoulder ROM and shoulder pain
and disability index was taken before and after the treatment in both groups. The
results concluded that: conventional physiotherapy and MET along with
conventional physiotherapy, both are individually effective in relieving pain,
improving range of motion and functional ability in patients with adhesive
capsulitis, but among these two, the group which received MET along with
conventional physiotherapy is found to be more effective in relieving pain,
improving range of motion and functional ability in patients with adhesive
capsulitis
Ayesha Razaaq et. al (2022) did a comparative study to compare the effect of
muscle energy technique versus Mulligan mobilization with movement on pain,
range of motion and disability in patients of adhesive capsulitis. The
study comprised patients of either gender aged 30-70 years with adhesive
capsulitis stage 2. The subjects were randomised using the lottery method into
Mulligan mobilisation with movement group A, and the muscle energy technique
grouo B. Conventional treatment, including hot packs and exercises like pulley
rope exercise, wall climbing, and shoulder wheel, were part of both the groups.
Each technique was applied five times per set, 2 sets per session 3 days a week for
three weeks. The results showed of the 70 individuals assessed, 64(91.4%) were
included; 32(50%) in each of the two groups. The mean age in group A was
49.93±6.69 years, while in group B it was 49.17±8.92 years. Group A showed
significantly better results compared to group B (p<0.05). Muscle energy
technique and Mulligan mobilisation with movement were both found to be
effective, but the latter was significantly better compared to the former.
Raksha R. Jivani , Dharti N Hingarajia (2021) published a research paper on

59
comparative study on effect of Spencer Muscle Energy Technique Versus
60
Maitland’s Mobilization Technique on Pain, ROM and Disability in Patients with

Frozen Shoulder. Total 58 patients with frozen shoulder were included. Inclusion
criteria were male and female with age of 40 to 60 year with unilateral frozen
shoulder (at least 3-month duration). Patients were randomly allocated in two
groups with 29 patients in each group: SPENCER MET and Conventional
physiotherapy and MM and conventional physiotherapy for 5days a week with
total duration of 4 weeks. Pre and post intervention assessment was carried out
by using VAS, SPADI and ROM. Data was analysed by using SPSS 15 version. The
study concludes that both the techniques used in the present study i.e., Spencer
Muscle Energy Technique and Maitland Mobilization are effective for improving
pain, reducing disability, and increasing ROM. However, SPENCER MET is the
more effective for improving pain, reducing disability, and increasing ROM
compared to Maitland Mobilization in patients with frozen shoulder.
Arvind kumar(2015) did a comparative study on the efficacy of Maitland

mobilization versus Muscle energy technique on frozen shoulder. A quasi-
experimental approach was followed with two experimental groups or
comparison, using before and after treatment scores.A total number of 30
patients are selected, male and female patient between age group 40 – 65 years
were selected.A total duration of the study is one month. The duration of
programmed for each subject is four week’s once a day, for six days a week.
Group A patients were given Maitland’s mobilization technique of suitable grades
for 24 sitting in 4 weeks. Group B patients were given muscle energy techniques
for 24 sitting in 4 weeks. 3- 5 muscle contractions with 5-7 seconds each
contraction (not more than 20% of total muscle strength) for three
repetitions.The patients attended physical therapy session daily i.e 6 days in a
week.Maitland’s mobilization. The results concluded that patients with frozen
shoulder largely benefit from manual therapy treatment techniques. Maitland’s
Mobilization is more effective in improving range of motion
61
and decreasing functional disability in patients with frozen shoulder as compared

to Muscle Energy Technique.
Ekelund and Rydall (1992) compared the outcomes of patients treated with
distension arthrography, local anesthetic and manipulation followed by physical
therapy. At four to six weak follow up, 91% of the subject who had undergone this
combination of treatment reported complete or partial relief of pain and 82%
exhibited normal active range of motion or near normal active range of motion.
Placzek J D et al (1998) studied the long term effect of glenohumeral joint

translation (gliding) manipulation on range of motion, pain and functions in
patients with frozen shoulder. Thirty-one patients underwent brachial plexus
block followed by translation manipulation of glenohumeral joint. Changes in the
range of motion and pain were assessed before manipulation with the patient
under anesthesia, immediately after manipulation with the patient still under
anesthesia, at early follow up (5.3±3.2 weeks) and to long term follow up
(14.4±7.3 months). Passive range of motion increased significantly for flexion,
abduction, external rotation and internal rotation. Significant decrease in visual
analog pain score between initial evaluation and the follow up assessment also
occurred.
MUBASHSHIRAH FIRDAUS, ANSARI AND RITA SHARMA (2022) did a case study is
to check the effect of Virtual Reality versus Conventional Physiotherapy in the
patients having stage II Frozen Shoulder. Outcome measure taken were Pain and
functional disability measured by Shoulder pain and disability index scale (SPADI),
Range of Motion (ROM) measured by Universal Goniometer. Physiotherapy was
incorporated to see the outcomes in large number of patients who were seeking
62
the treatment with the help of this technique. The benefits of above mentioned
63
Physiotherapy lead to pain reduction, simultaneously increasing functional

independence and reduction in fear of avoidance and improvement in sleep
pattern and quality.
64
CHAPTER – 4 ( METHADOLOGY)
65
METHEDOLOGY
STUDY DESIGN - Experimental study.
SETTING - Study was done in outpatient department of civil hospital Jalandhar.
DURATION OF STUDY - Total duration of study was half a year.
SAMPLE SIZE - A minimum of 30 subjects were selected for the study, minimum
of 15 subjects in each group.
SAMPLING - Convenient sampling.
SELECTION CRITERIA :
All the subjects were selected on the basis of following criteria.
INCLUSION CRITERIA :
1. Age group between 40 – 60 years.
2. Gender both males and females.
3. Patients diagnosed with grade II adhesive capsulitis. (Frozen Stage),
Restriction in all the movements of shoulder flexion , Abduction and
External Rotation.
66
4. Unilateral frozen shoulder .

5. Patients willing to participate in study and co-operative.
EXCLUSION CRITERIA :
1. Any surgery related to affected shoulder.
2. Fracture of shoulder joint.( Malunion ,Nonunion)
3. Infection (any infection involving shoulder).
4. Skin lesions involving shoulder.
5. Patients above the age of 60 and below 40 years.
6. Rheumatoid arthritis.
7. Neurological deficits affecting shoulder function.
8. Subjects with rotator cuff lesion and tendon calcification.
9. Pain or disorders of cervical spine, elbow, wrist or hand of
affected side.
10. Uncooperative patients.
INSTRUMENTATION :
 T.E.N.S
 Hot packs
 VAS Questionnaire
 Shoulder Pain and Disability Index(SPADI).
 Goniometry.
67
PROTOCOL
Subjects with Stage II ( frozen stage) shoulder pain who visited civil hospital
Jalandhar were selected by convenience sampling method. Patients who meet
the inclusion criteria were selected in the study. A written consent was obtained
from all the subjects. A minimum of 30 subjects were selected for the study and
were conveniently divided into two groups with 15 subjects in each group.
GROUP A GROUP B
T.E.N.S, Hot pack , Maitland T.E.N.S , Hot pack, muscle energy
Mobilization . technique. (MET)
TOOLS :
 Visual analogue Scale.
 Mobility i.e , all shoulder range of motions (ROM) were measured using
universal goniometer in degrees.
 Functional disability of shoulder was measured using shoulder pain and
Disability index . (SPADI).
PROCEDURE :
INTERVENTION FOR GROUP A :
68
In all the subjects of Group A, an electrical hot pack sized 35.5 × 68.5 cm was used
to deliver superficial heating at shoulder joint for 10 minutes in supine lying
position. The temperature was set at 63°C. The subjects were informed that the only
purpose of the heating was to relax muscles and produce a feeling of comfortable
warmth. If they felt that the heat was excessive, the temperature of the electrical
Hot pack was adjusted immediately to ensure that the heat remained at a
comfortably warm level only throughout the treatment.(fig.13)
Fig. 13 HOT PACK
69
To perform Maitland mobilization, patient was in supine lying with arm abducted to
30 degrees and therapist was in walk standing position holding proximal end of the
humerus and maintaining a lateral humeral distraction in its midrange position.
Glenohumeral caudal, anterior and posterior glide mobilization were given at the
rate of 2-3 glides per second for 30 seconds for each glide,given for 5 sets (Fig.14) ,
fig (15), fig. (16).The technique was applied thrice a week for four weeks (12
sessions).
Glenohumeral caudal glide
Indications
To increase abduction .
Patient Position
Supine lying and the arm in the loose pack position. The therapist supports the
arm between the trunk and the elbow.
Hand placement
One hand of the therapist is placed in the axilla to give distraction (grade 1)
The therapist's other hand(webspace) is kept just below the acromion process.
Mobilizing force
70
The force is applied on the head of the humerus in the inferior direction,
through the hand which is placed superiorly. Fig. (14)
Figure 14 CAUDAL GLIDE
GH posterior glide
Indications
To improve flexion and internal rotation of the shoulder
Position of patient
Supine lying while keeping the arm in resting position.Position of the

therapist and hand placement (Fig. 15)
71
The therapist stands with the back towards the patient, in between the arm
and the trunk.
The distal aspect of the arm is grasped against the trunk of the therapist to
give grade one distraction to the shoulder joint.
Another hand is placed over the joint (distal to anterior margin) to provide
the mobilizing force.
Mobilizing force
The head of the humerus is glided posteriorly.
Figure 15 POSTERIOR GLIDE
72
GH anterior glide
Indications
To increase the extension of the shoulder with external rotation.
Position of the patient
Prone lying at the edge of the plinth, the limb is in resting position.
Position of the therapist with hand placement
The patient's arm is supported on the therapist's thigh and the therapist
stands on the top of the table and places one hand over the arm to give
distraction at GH joint.
Mobilizing hand's ulnar border is placed just next to the posterior angle of the
acromion.
Mobilizing force
It is applied to the humeral head in the anterior direction. Fig. (16)
73
Figure 16 ANTERIOR GLIDE
TENS (Trans cutaneous electrical nerve stimulation) in Asymmetric biphasic

mode with 150 Hz frequency and the intensity was set according to level of
capacity for 10 minutes. Patient is in sitting position , Two channels of tens are
74
used which are applied over deltoid muscle as well as concerning painful area of .
(Fig. 17)
shoulder
Figure 17 TENS
INTERVENTION FOR GROUP B :
In all the subjects of Group B, an electrical hot pack sized 35.5 × 68.5 cm was used
to deliver superficial heating at shoulder joint for 10 minutes in supine lying
position. The temperature was set at 63°C. The subjects were informed that the only
purpose of the heating was to relax muscles of shoulders and pproduce a feeling of
75
comfortable warmth. If they felt that the heat was excessive, the temperature of the
electrical Hot pack was adjusted immediately to ensure that the heat remained at a
comfortably warm level only throughout the treatment.
Figure 18 Hot pack
Patients were initially offered 7 to 10 minutes of heating pack control treatment

(fig.18)
, after which the glenohumeral joints were moved via muscle energy
technique. The afflicted shoulder was elevated as the patient was laying on their
side. With the proximal hand, the therapist stabilized the shoulder girdle, and in 7
separate motions, the distal hand applied force into the shoulder’s constricted
barrier. In 7 distinct movements, the therapist used force on the shoulder’s
constrictive barrier with the distal hand while supporting the shoulder girdle with
the proximal hand. These included glenohumeral pump, distraction, abduction with
internal rotation, shoulder extension, circumduction with compression, and
shoulder flexion. Following the complete action, patients were encouraged to use
their muscles to 5 seconds against little resistance provided by the therapist.The
exercise was done 3- 5 times with rest periods .(fig 19, 20, 21, 22, 23, 24, 25)
76
FIG .19 shoulder extension (MET) FIG. 20 Circumduction with Compression(MET)
FIG.21 Shoulder flexion (MET) FIG . 22 Shoulder internal rotation(MET)
77
Fig. 24 ABDUCTION AND ADDUCTION (MET)

FIG.23 CIRCUMDUCTION WITH TRACTION (MET)
Fig.25 Distraction with circumduction(MET)
78
After application of M.E.T , TENS (Trans cutaneous electrical nerve stimulation)

in Asymmetric biphasic mode with 150 Hz frequency and the intensity was set
according to level of capacity for 10 minutes. Patient is in sitting position , Two
channels of tens are used which are applied over deltoid muscle as well as
concerning painful area of shoulder.
Fig. 26
common shoulder exercises are taught and performed with both groups
Fig 26 ( Home exercise) for both A and B groups
79
CHAPTER – 5 ( METHODOLOGY)
80
TABLE NO . Shows comparison between the Group A and Group B on the basis Of gender.
Gender
Frequency (%)
Group A Group B
Male% 46.7 40.0
Female% 53.3 60.0
Male 7.00 6.00
Female 8.00 9.00
Figure No:
Ge n d e r D is t r ib u t io n
Male% Female%
100%
90%
80%
53.3
70% 60.0
60%
50%
40%
30%
46.7
20% 40.0
10%
0%
Group A Group B
Gender
81
Table No:
Comparison
Unpaired T Test AGE
Group A Group B
Mean 51.13 54.13
S.D. 4.882 3.852
Number 15 15
Maximum 60 59
Minimum 45 47
Range 15 12
Mean Difference -3.00
Unpaired T Test 1.868
P value 0.0722
Table Value at 0.05 2.05
Result Not-Significant
Figure No:
Comparison Between the Groups

60.00
54.13
51.13
50.00
40.00
30.00
20.00
10.00 4.882 3.852
0.00
Group A Group B
AGE
Comparison
Mean S.D.
Within Group Analysis (Repeated ANOVA)

82
Table No:
. Group A
VAS
Repeated ANOVA
BASELINE DAY 7TH DAY 14TH
Mean 7.00 4.07 1.60

S.D. 0.845 0.884 1.056
Median 7 4 2
Number 15 15 15
DF1 2
DF2 28
F Test 379.46
Table Value 3.340
P value <0.001
Result Significant
Tukey’s method for
Pairwise comparison BASELINE
Mean Difference &
DAY 7TH 2.93Sig DAY 7TH
Result>
DAY 14TH 5.4Sig 2.47Sig
Figure No:
Comparison within the Group

7.00
7.00
6.00
5.00
4.07
4.00
3.00
2.00 1.60
0.884 1.056
0.845
1.00
0.00
VAS
Group A
Mean S.D.
Table No:
83
. Group B
VAS
Repeated ANOVA
Mean 7.13 4.80 2.33
S.D. 1.060 1.082 0.724
Median 7 5 2
Number 15 15 15
DF1 2
DF2 28
F Test 264.30
Table Value 3.340
P value <0.001
Result Significant
Mean Difference &
Result>
Figure No:

8.00
7.13
7.00
6.00
4.80
5.00
4.00
3.00 2.33
2.00 1.060 1.082

0.724
1.00
0.00
VAS
Group B
Mean S.D.
Table No:
84
. Group A
SPADI
Repeated ANOVA
Mean 67.26 52.45 21.37

S.D. 7.491 6.283 5.762
Median 66.3 53.8 19.2
Number 15 15 15
DF1 2
DF2 28
F Test 258.68
Table Value 3.340
P value <0.001
Result Significant
Mean Difference &
Result>
Figure No:

70.00 67.26
60.00
52.45
50.00
40.00
30.00
21.37
20.00
7.491 6.283
10.00 5.762
0.00
SPADI
Group A
Mean S.D.
Table No:
85
. Group B
SPADI
Repeated ANOVA
Mean 67.62 59.01 30.94
S.D. 4.921 4.377 6.505
Median 68.8 59.2 28.5
Number 15 15 15
DF1 2
DF2 28
F Test 442.99
Table Value 3.340
P value <0.001
Result Significant
Mean Difference &
Result>
Figure No:

70.00 67.62
59.01
60.00
50.00
40.00
30.94
30.00
20.00
4.921 6.505
10.00 4.377
0.00
SPADI
Group B
Mean S.D.
Between the Group Analysis (Unpaired T test)
86
Table No:
VAS
Unpaired T Test BASELINE DAY 7TH DAY 14TH

Group Group Group Group Group Group
A B A B A B
Mean 7.00 7.13 4.07 4.80 1.60 2.33
S.D. 0.845 1.060 0.884 1.082 1.056 0.724
Number 15 15 15 15 15 15
Maximum 8 9 6 7 3 4
Minimum 6 6 3 3 0 1
Range 2 3 3 4 3 3
Mean Difference 0.13 0.73 0.73
Unpaired T Test 0.381 2.033 2.219
P value 0.7062 0.0517 0.0348
Table Value at 0.05 2.05 2.05 2.05
Result Not-Significant Not-Significant Significant
Figure No:

8.00
7.00 7.13
7.00
6.00
4.80
5.00
4.07
4.00
3.00 2.33
2.00 1.60
1.060 1.082 1.056
0.845 0.884 0.724
1.00
0.00
Group A Group B Group A Group B Group A Group B
VAS
Mean S.D.
Table No:
87
SPADI
Unpaired T Test BASELINE DAY 7TH DAY 14TH

Group Group Group Group Group Group
A B A B A B
Mean 67.26 67.62 52.45 59.01 21.37 30.94
S.D. 7.491 4.921 6.283 4.377 5.762 6.505
Number 15 15 15 15 15 15
Maximum 77.7 74.6 60 65 37.5 44.6
Minimum 51.2 60 33.8 51.5 13.8 22.5
Range 26.5 14.6 26.2 13.5 23.7 22.1
Mean Difference 0.36 6.56 9.57
Unpaired T Test 0.156 3.318 4.267
P value 0.8775 0.0025 <0.0012
Table Value at 0.05 2.05 2.05 2.05
Result Not-Significant Significant Significant
Figure No:

70.00 67.26 67.62
59.01
60.00
52.45
50.00
40.00
30.94
30.00
21.37
20.00
7.491 6.283 6.505

10.00 4.921 4.377 5.762
0.00
Group A Group B Group A Group B Group A Group B
SPADI
Mean S.D.
Table No:
88
GROUP A VAS SPADI
DAY DAY DAY DAY

Sub SEX AGE BASELINE BASELINE
7TH 14TH 7TH 14TH
A 1 45 7 4 0 66.2 60 20
B 2 46 6 3 0 61.5 48.8 18.8
C 2 49 6 3 1 68.5 58.5 26.9
D 2 60 7 4 1 65.4 51.2 21.5
E 2 54 8 3 1 51.2 33.8 16.9
F 2 47 6 4 2 59 46.3 19.2
G 2 59 7 4 2 66.3 52.5 13.8
H 1 48 8 5 2 66.9 57.5 19.2
J 2 47 7 4 2 74.6 53.8 20.8
K 2 49 8 5 3 74.6 51.2 21.5
L 1 56 8 5 3 76.2 53.1 18.8
M 1 51 8 6 3 77.7 53.8 17.7
N 1 47 6 3 0 75.4 55.4 19.2
O 1 56 6 4 2 65.4 56.2 28.7
P 1 53 7 4 2 60 54.6 37.5
89
GROUP A VAS SPADI
DAY DAY DAY DAY

Sub SEX AGE BASELINE BASELINE
7TH 14TH 7TH 14TH
A 1 47 7 4 2 62.5 53.1 25.4
B 1 55 7 4 1 62.3 55.4 27.7
C 2 48 6 4 2 64.6 56.2 25.4
D 1 54 9 6 3 70 59.2 32.3
E 2 57 7 4 2 68.8 59.2 22.5
F 2 48 6 6 3 71.3 61.5 33.1
G 1 57 6 3 2 61.5 52.5 32.5
H 2 59 6 5 2 74.6 65 42.3
J 1 54 8 5 3 68.8 61.5 44.6
K 2 55 6 4 2 71.5 62.3 39.2
L 1 53 7 5 2 72.3 61.5 29.8
M 2 58 9 7 4 73.8 64.6 28.5
N 2 54 8 6 3 70 63.1 27.7
O 2 59 8 5 2 60 51.5 26.9
P 2 54 7 4 2 62.3 58.5 26.2
90
CHAPTER - 6 ( DISCUSSION)
91
In this study 30 patients were included and divided into 2 groups. All of them
suffering from Stage II Frozen shoulder. The 2 groups were made so as to compare
the effectiveness of Maitland mobilization versus muscle energy technique in both
two groups. Analysis of the results of this study showed that both Maitland
Mobilization technique and MET are an effective treatment for adhesive capsulitis
but Maitland Mobilization is more effective in increasing both active and passive
joint ROM, while MET is more effective in reducing pain in patients with adhesive
capsulitis. The response from Maitland mobilizations are explained to be different
from MET as Maitland mobilization is a passive technique and MET is active
technique.
In a study done by Muhammad Hashim et al.(2022) between maitland

mobilization and Muscle Energy Technique on pain ,Range of motion and
functions in adhesive capsulitis. It was concluded that Maitland mobilization is
more effective in reducing pain and increasing function and disability among the
patients having Adhesive Capsulitis as compared to MET for pain,ROM and
shoulder functions.
As discovered by Maitland the technique is passive direct articulatory procedure,
it would have relieved the joint restriction more effectively the MET.18 MET does
not involve direct thrust through a physiologic and restrictive barrier it introduces
minimal force relieving the joint hypo mobility through the isometric contraction
of shoulder muscle.9 Repetitive passive joint oscillations carried out at the limit of
the joint’s available range may have a mechanical effect on joint mobility and
improve a joint restriction, stretch joint capsules, lubricate tissues, induce
metabolic changes in soft tissues, cartilage bone, increases range of motion, alters
joint mechanics, and counters the effects of joint immobilization.(K) Maitland GD:
Peripheral manipulation. Ed. 3. Butterworth-Heinemann. Boston, 1991.
92
Arvind kumar(2015) did a comparative study on the efficacy of Maitland

mobilization versus Muscle energy technique on frozen shoulder. A quasi-
experimental approach was followed with two experimental groups or
comparison, using before and after treatment scores.A total number of 30
patients are selected, male and female patient between age group 40 – 65 years
were selected.A total duration of the study is one month. The duration of
programmed for each subject is four week’s once a day, for six days a week.
Group A patients were given Maitland’s mobilization technique of suitable grades
for 24 sitting in 4 weeks. Group B patients were given muscle energy techniques
for 24 sitting in 4 weeks. 3- 5 muscle contractions with 5-7 seconds each
contraction (not more than 20% of total muscle strength) for three
repetitions.The patients attended physical therapy session daily i.e 6 days in a
week.Maitland’s mobilization. The results concluded that patients with frozen
shoulder largely benefit from manual therapy treatment techniques. Maitland’s
Mobilization is more effective in improving range of motion and decreasing
functional disability in patients with frozen shoulder as compared to Muscle
Energy Technique.
93
APPENDIX 1
CONSENT FORM
I have been informerd by Ms. Bulbul rani, a student in SANT BABA Bhag Singh University,
Jalandhar that study entitled “ To Compare the effects of Maitland Mobilization VS Muscle
Energy Technique on Factors – Pain , ROM in Frozen shoulder” is being conducted. The
purpose of this study is to compare the effect of Maitland mobilization Versus Muscle Energy
Technique in patients of Grade II Frozen shoulder. As a part of this study , the subject will have
to fill a questionnaire
I understand that there is no risk involved in this study. All the information regarding me will
be kept confidential, only Ms Bulbul Rani and her guide Dr. Mandeep kaur , MPT (NEURO),
will have access to the name of the subjects participating in this study and will not be shared
with any other person. I understand that my consent is voluntary and I have my right to
withdraw or discontinue the participation at any stage of the study without assigning any
reason to it.
I , BULBUL RANI, have explained to Mr./ Ms./Mrs._______________ the purpose of the
research , the procedure, required in the language he / she could understand to the best of
my ability.
I,_____________ voluntarily agree to participate in her study . My entire questions have been
answered satisfactorily . I reserve my right to withdraw at any instant and I have the contact
address of Ms Bulbul Rani if required any further information.
signature of the Participant Signature of Researcher
94
APPENDIX – 2
PAIN ASSESSMENT (VAS SCALE)
VISUAL ANALOGUE SCALE
95
APPENDIX – 3
Patient’s Name _______________ Number______________Date____________

Shoulder Pain and Disability Index (SPADI)
The Patient is instructed to choose the number the number that best describes their level of
pain and extent of difficulty using the involved shoulder. The pain scale is summed up to a
total of 50 while the disability scale sums up to 80. The
total SPADI score is expressed as a percentage. A score of 0 indicates best 100 indicates worst.
A higher score shows more disability.
In scoring SPADI, any question missed should be taken out of the total score of each subscale.
i.e if 1 question is omitted in the pain section, the total score is divided by 40.
Scoring instructions
To answer the questions, patients place a mark on a 10cm visual analogue scale for each
question. Verbal anchors for the pain dimension are “ no pain at all” and “worst pain
imaginable” and those for the functional activities are “No Difficulty” complete and is the only
reliable and valid region – specific measure for the shoulder.
INTERPRETATION OF SCORES
Total pain score _________/ 50 x 100 =%
(Note: if a person does not answer all the questions divide by the total of possible score,eg. if
1 question missed divide by 40)
Total disability score___________/ 80x100=%
( Note : if a person does not answer all the questions divide by the total possible score, eg. if
1 question is missed divided by
Total SPADI score ____________/ 130x 100 =%
(Note : if a person does not answer all questions divide by the total possible score,eg.if one
question is missed divide by 120)
The means of these two subscales are averaged to produce a total score ranging from 0(best)
to 100(worst).
Minimum detectable change (90% confidence) = 13 points.
(change less than this may be subject to measurement error)
Shoulder Pain and Disability Index (SPADI)

Please place a mark on the line that best represents your experience during the last week
attributable to your shoulder problem .
96
Pain scale
How severe is your pain?
Circle the number that best describes your pain where 0 = no pain and 10 = the worst pain
imaginable.
At its worst ? 0 1 2 3 4 5 6 7 8 9 10
When lying on the involved side ? 0 1 2 3 4 5 6 7 8 9 10
Reaching for something on a high shelf ? 0 1 2 3 4 5 6 7 8 9 10

Touching the back of your neck ? 0 1 2 3 4 5 6 7 8 9 10
Pushing with the involved arm ? 0 1 2 3 4 5 6 7 8 9 10
DISABILITY SCALE
HOW MUCH DISABILITY DO YOU HAVE ?
Circle the number that best describes your experience where 0 = no difficulty and 10 = so
difficult it requires help.
Washing your hair ? 0 1 2 3 4 5 6 7 8 9 10
Washing your back ? 0 1 2 3 4 5 6 7 8 9 10
Putting on a undershirt or jumper? 0 1 2 3 4 5 6 7 8 9 10
Putting on a shirt that buttons downs the 0 1 2 3 4 5 6 7 8 9 10

front ?
Putting on your Pants? 0 1 2 3 4 5 6 7 8 9 10
Placing an object on high shelf? 0 1 2 3 4 5 6 7 8 9 10
Carrying a heavy object of 10 pounds ( 4.5 0 1 2 3 4 5 6 7 8 9 10

Kilograms)
97
Removing something from your back 0 1 2 3 4 5 6 7 8 9 10
pocket ?
APPENDIX – 4
SUBJECTIVE EXAMINATION
Name :
Age :
Gender :
Occupation :
Address :
Chief Complaint :
History of –
● Present illness
● Past illness
● Medical
● Surgical
Pain evaluation –
● Site
● Onset
● Type
● Pattern
● Relieving factors
98
● Aggravating factors
VAS
OBJECTIVE EXAMINATION
Observation :
Built –
● Ectomorphic
● Mesomporphic
● Endomorphic
Gait
Posture
Attitude
Deformity
ON PALPATION
● Tenderness
● Temperature
● Swelling
SENSORY EVALUATION
● Superficial
● Deep
MOTOR EXAMINATION
99
● R.O.M
⮚ ACTIVE
⮚ PASSIVE
● Reflexes
● Manual Muscle Testing
SPECIAL TEST:
● NEER TEST
● Hawkins kennedy Impingement Test
● YOCUM’S TEST
⮚ RADIOLOGICAL INVESTIGATION
⮚ X- RAY OF AFFECTED SHOULDER
⮚ M.R.I OF AFFECTED SHOULDER
APPENDIX-5
DATA COLLECTION FORM

NAME
10
TO COMPARE EFFECT OF MAITLAND MOBILIZATION VERSUS MET IN FROZEN SHOULDER 0
AGE
GENDER
DATE
OCCUPATION
CHIEF COMPLAINT
GROUP
VARIABLES BASELINE AFTER 7TH AFTER 14TH

SESSION SESSION
VAS
SPADI
10
TO COMPARE EFFECT OF MAITLAND MOBILIZATION VERSUS MET IN FROZEN SHOULDER 1

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A STUDY

TO COMPARE THE EFFECTS OF MAITLAND

SANT BABA BHAG SINGH UNIVERSITY

DATE: SIGNATURE OF THE STUDENT

Signature of the Guide Signature COD/HOD

(Guide) Dr. Mandeep Kaur

It is impossible to extend enough thanks to my family especially my parents Mr

I own entire responsibility for all errors and omissions.

FIGURE NO. TITLE PAGE NO.

Chapter 2 AIMS AND OBJECTIVES

Chapter 3 REVIEW OF LITERATURE

Chapter 5 RESULTS AND DATA ANALYSIS

SERIAL NO. FIGURE TITLE PAGE NO

FIGURE NO 1 SHOULDER JOINT 16

TABLE NO. TABLE TITLE PAGE NO.

GRAPH NO. GRAPH TITLE PAGE NO.

BACKGROUND - Frozen shoulder also named as adhesive capsulitis is a very

GROUP B: will be given TENS, HOT PACK , MUSCLE ENERGY TECHNIQUE.

KEY WORDS: Maitland mobilisation, Muscle energy technique ,Adhesive

In world population frozen shoulder is occuring more commonly and is considered

Anatomy of Shoulder Joint

the glenoid fossa of the scapula.[3] It is a shallow articulation, as the fossa

The major movements at the glenohumeral joint are: [4]

 Abduction: upward lateral movement of humerus out to the side,

BLOOD SUPPLY AND LYMPHATICS

Figure 2 deltoid muscle.

Figure 3 TERES MAJOR MUSCLE

 Function: Adduction and medial rotation of the arm

Supraspinatus (Rotator Cuff)

 Function: Initiation of arm abduction (first 15 degrees), stabilize

Infraspinatus (Rotator Cuff)

 Function: Lateral rotation of the arm, stabilize glenohumeral joint

Teres minor (Rotator Cuff)

 Function: Lateral rotation of the arm,stabilize glenohumeral joint. [Fig.4]

Figure 4 Showing TERES MINOR, SUPRASPINATUS,INFRASPINATUS MUSCLE

Subscapularis (Rotator Cuff)

Figure 5 Subscapularis muscle.

 Insertion : Lesser tubercle of the humerus.[Fig No.5]

Figure 6 Trapezius muscle

 Origin: Skull, nuchal ligament and the spinous processes of C7 to T12

Figure 7Lattismus Dorsi Muscle

 Function: Extends, adducts and medially rotates the upper limb

Figure 8 SHOWING PECTORALIS MAJOR AND MINOR MUSCLES

 Insertion: Intertubercular groove of the proximal humerus on its lateral

NORMAL RANGE OF MOTION AT VARIOUS MOVEMENTS AT

The glenohumeral joint possesses the capability of allowing an extreme range of

 Internal rotation—Defined as rotation toward the midline along a

Codman defined frozen shoulder as a clinical condition that can hardly be

 Frozen shoulder is mainly by an insidious and progressive loss of active and

Frozen Shoulder may be:

1. Primary - Onset is generally idiopathic (it comes on for no attributable

EPIDEMIOLOGY OF FROZEN SHOULDER

ETIOLOGY OF FROZEN SHOULDER

PATHOPHYSIOLOGY OF FROZEN SHOULDER

STAGES OF FROZEN SHOULDER

 Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss

 Resolution/thawing phase: Spontaneous, progressive improvement in

TABLE 1.1 [STAGES OF FROZEN SHOULDER]