Frozen shoulder is a condition in which movement of the shoulder becomes restricted. Frozen shoulder can be a primary or idiopathic when the aetiology is unknown or it may secondary, when associated with another systemic illness. By far the most common association of a secondary frozen shoulder is diabetes mellitus [1]. The incidence of frozen shoulder in diabetes patients is reported to be 10%-36 [1-3]. The incidence of type 1 and type 2 diabetes is similar [2]. It is commonly a self-limiting condition, of approximately 1 to 3 years duration, though incomplete resolution can occur [4]. Although self-limiting, it can be extremely painful and debilitating affecting the activities of daily living [5]. and there may not be a complete resolution of symptoms in a vast number of cases [6]. There are multiple causes of shoulder pain and may be due to pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases [4]. Frozen shoulder patients usually present in the sixth decade of life, and onset before the age of 40 is very uncommon [7]. The peak age is 56, and the condition occurs slightly more often in women than men (8). In 6-17% of patients, the other shoulder becomes affected, usually within five years, and after the first has resolved. The non-dominant shoulder is slightly more likely to be affected [8].

The condition has a typical clinical course and characteristically passes through three defined stages, progressing

over several years [8-13].

Stage 1(Acute Or Freezing Stage): Insidious in onset. It consists of gradually increasing pain and stiffness and lasts between 2 months and 9 months [8].

Stage 2 (Frozen or Steady-State Stage): Loss of range of motion is most pronounced in this stage and it lasts between 4 months and 20 months.

Stage 3 ( Thawing or Recovery Stage): It is characterized by resolution of pain and gradual recovery and lasts between 5 months and 26 months [8,11].

Neiaser and Neviaser have described four stages based on the arthroscopic appearance [13].

• Associated co-morbidity like DM, deranged thyroid function
• Patient taking steroids and immunosuppressive drugs
• Associated shoulder disorders

Patients were randomized into two groups. Group 1: Single Site Injection (SSI) group received steroid injection through posterior approach and Group 2: Novel three-site ( NTS )group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid)

The test population consisted of 19 female (38%) and 31 male (62%) patients. The right side was involved in 28 (56%) of cases while the left was involved in the remaining 22 (44%) of cases. All cases were right hand dominant.

• In the SSI group, after painting and draping, a single injection of 40 mg of methylprednisolone acetate mixed with 2 ml of 2% lignocaine was prepared and instilled through the posterior approach (2 cm below and lateral to angle of acromion directed towards coracoid).
• In the NTS group, the same solution was further diluted with 8 ml normal saline and instilled at three sites under all aseptic precaution (a) Posterior site injection: it was given 2 cm below and lateral to angle of acromion directed towards coracoid. (b) Subacromial site injection: it was above the spine directed towards the acromioclavicular joint through supraspinatus muscle and gradually internal rotating during (c) Subcoracoid site injection: it was obtained by running the needle on subscapularis surface 0.5–1 cm inferior and lateral to coracoid passing towards the lateral third of coracoid, arm externally rotated during instillation of steroid.

The second sitting was repeated after 3 weeks in both the groups. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score (annexure 1) at initial, 3 weeks, 6 weeks and 6 months.

There was no significant difference in the baseline values of the components of CONSTANT scores. Patients in Group 2(NTS group) had a faster rate of improvement and also attained near-normal scores.

1. Pain: The pain scores had significantly improved at successive visits in both the groups;

Table-5: Comparison of Constant Score (ACTIVITY OF DAILY LIVING) in both groups (Total score 20)

Table-6: Comparison of Constant Score (RANGE OF MOVEMENT) in both groups (Total Score =40)

Table-7: Comparison of Constant Score (POWER) in both groups (Total score=25)

Table-8: Comparison of Total Constant Score in both groups (Total Score= 100)

In 1934, Codman introduced the term “frozen shoulder” [14].

shoulder (13), and Hannafin et al have described a correlation between the arthroscopic stage, the clinical examination, and the histological appearance of the tissues [7]. Evidence shows a synovial inflammation with subsequent reactive capsular fibrosis. A dense matrix of type I and type III collagen is laid down by fibroblasts and myofibroblasts in the joint capsule. Subsequently, this tissue contracts [7].

Increased growth factors, cytokines, and expression of matrix metalloproteinases in capsular biopsy specimens obtained from patients with primary and secondary frozen shoulder indicate that these are involved in the inflammatory and fibrotic cascades seen in the frozen shoulder [7]. Cytokines and growth factors are involved in the initiation and termination of repair processes in musculoskeletal tissues through regulating fibroblasts, and the remodelling process is controlled by matrix metalloproteinases and their inhibitors.

An association between frozen shoulder and Dupuytren's disease has been identified, and this may be related to matrix metalloproteinase inhibitors [7]. In a study by Depalma [33]. he told me there is a contracture of the capsular ligament. There was a restriction in external rotation in the neutral position of the shoulder due to the involvement of coraco- humeral ligament. Also, restriction in external rotation in mid-elevation was found due to contracture of the middle glenohumeral ligament (MGHL) while restriction in external rotation in abduction position was due to contracture of the anterior inferior glenohumeral ligament (AIGHL).

Involvement of inferior capsule causes restriction of abduction in neutral rotation and PIC (posterior inferior capsule) causes internal rotation restriction. In a true frozen shoulder there is an almost complete loss of external rotation. This is the pathognomonic sign of a frozen shoulder [8,37]. In a frozen shoulder, all other movements of the joint are reduced, and if movement occurs this usually comes from the thoracoscapular joint.

Newer studies investigating biomarkers present in the synovial fluid suggest that chronic inflammation is present.

Kim et al compared glenohumeral aspirations from patients with AC (adhesive capsulitis) and healthy controls [38].

The use of intra-articular steroid injections remains controversial. A Cochrane review from 2003 concluded that it may be beneficial in the short term, but the effect may be small and not maintained [42]. More recently, a meta-analysis by Page et al. reported that a glucocorticoid injection may be more beneficial than a combination of manual therapy and exercise [43].

Steroid injection into the GH (glenohumeral ) joint, accompanied by therapeutic shoulder exercises, is one of the most well-known approaches, regardless of the aetiology for the frozen shoulder [9,44,45]. However, low accuracy of injection into the GH joint without radiologic guidance [46,48]. the relative ease of access into the subacromial (SA) space, improvement of frozen shoulder symptoms after a SA steroid injection in certain patients, few reports discussing the effects of SA pathology on frozen shoulder, and the effect of steroid injections into the SA space raise questions regarding the etiology of the disease entity and how we should approach this peculiar shoulder disorder [45,49]. GH steroid injections are not always effective for primary frozen shoulder.

The inaccuracy of joint injections is likely a major reason for this, because several authors [46,47]. have reported a low accuracy of GH injections without image guidance, reporting a 26.8% accuracy for the anterior approach [47]. In a study by Oh et al., it was found that a single triamcinolone injection in the GH joint was no superior to the subacromial injections, indicating the multiple pathological sites of the disorder [50].

Rizk et al reported a randomized trial comparing 4 groups:intra-articular methylprednisolone and lidocaine injection,intrabursal methylprednisolone and lidocaine injection,intra-articular lidocaine injection, and intrabursal lidocaine injection. In their study, 40 mg of methylprednisolone was injected weekly for 3 weeks [51].

There was no significant difference in outcomes between intrabursal injections and intra-articular injections. The injection of steroids with lidocaine had no advantage over lidocaine alone in restoring shoulder motion; however, partial, transient pain relief occurred in two-thirds of the steroid-treated patients.

In our study, patients we found that patients in Group 2(NTS group) had significantly more range of abduction, external and internal rotation by about