Raiyyan Tahsan

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TC(1047).(05).Orthopedics Case No 125:- Frozen Shoulder-2

Frozen Shoulder / Adhesive Capsulitis — বাংলায় ক্লিনিক্যাল নোট

সতর্কতা: নিচের ডোজগুলো adult, non-pregnant, normal renal/hepatic function ধরে educational/clinical reference হিসেবে দেওয়া। রোগীর বয়স, DM/HTN/CKD/PUD/CVD, anticoagulant use, pregnancy, liver disease অনুযায়ী dose/choice পরিবর্তন হবে।

1) Definition — সংজ্ঞা

Frozen shoulder বা Adhesive capsulitis হলো shoulder joint capsule-এর inflammatory–fibrotic disorder, যেখানে কাঁধে ব্যথা এবং active ও passive দুটো movement-ই ধীরে ধীরে কমে যায়—বিশেষ করে external rotation সবচেয়ে বেশি কমে। Diagnosis মূলত history + physical examination দিয়ে করা হয়; USG/MRI একা diagnosis করার test নয়, বরং অন্য রোগ বাদ দিতে adjunct হিসেবে ব্যবহৃত হয়।

2) Cause / Etiology — কারণগুলো

A. Primary / Idiopathic

  • কোনো স্পষ্ট trauma বা surgery ছাড়াই capsule inflammation → fibrosis → contracture হয়।
  • Common age: 40–65 বছর, female-এ তুলনামূলক বেশি।

B. Secondary causes / Risk factors

  • Diabetes mellitus — সবচেয়ে গুরুত্বপূর্ণ association; diabetic patient-এ বেশি resistant/prolonged হতে পারে।
  • Thyroid disease — hypothyroidism/hyperthyroidism।
  • Dyslipidemia।
  • Prolonged immobilization — fracture, stroke, MI, surgery, sling long time।
  • Previous shoulder injury/surgery।
  • Neurological disease — stroke, Parkinsonism।
  • Cardiopulmonary disease — post-MI/post-CABG immobilization।
    Guideline evidence অনুযায়ী diabetes, thyroid disease ও dyslipidemia frozen shoulder risk বাড়ায়।

3) Pathophysiology — কীভাবে রোগ হয়

  • শুরুতে synovium ও joint capsule inflammation হয়।
  • পরে capsule, coracohumeral ligament, rotator interval অঞ্চলে fibrosis ও thickening হয়।
  • Joint capsule tight হয়ে যায় → glenohumeral joint movement কমে → external rotation, abduction, internal rotation সীমিত হয়।
  • Histology-তে inflammatory ও fibrotic change দেখা যায়।

4) Symptoms — উপসর্গগুলো

Stage 1: Freezing / Painful stage

  • কাঁধে diffuse dull aching pain।
  • রাতের ব্যথা বেশি; affected side-এ শুলে ব্যথা বাড়ে।
  • চুল আঁচড়ানো, জামা পরা, পেছনে হাত নেওয়া কঠিন।
  • Movement করলে ব্যথা বাড়ে; ROM ধীরে ধীরে কমতে থাকে।

Stage 2: Frozen / Stiff stage

  • ব্যথা কিছুটা কমলেও stiffness বেশি prominent।
  • Active ও passive movement দুটোই কমে।
  • External rotation সবচেয়ে বেশি limited।
  • Daily activity impairment: জামা পরা, bra hook/পেছনে হাত, overhead কাজ, driving difficulty।

Stage 3: Thawing / Recovery stage

  • ব্যথা কমে।
  • ROM ধীরে ধীরে ফিরে আসে।
  • তবে সবার full recovery হয় না; কিছু রোগীর residual stiffness/pain থাকতে পারে।

5) Clinical diagnosis — কীভাবে clinically diagnosis করবেন

Key diagnostic features

  • Gradual onset shoulder pain।
  • Progressive restriction of active + passive ROM।
  • External rotation + abduction limitation সবচেয়ে suggestive।
  • No major trauma, no systemic infection sign হলে primary frozen shoulder বেশি likely। Guideline অনুযায়ী characteristic history + physical exam-ই diagnostic core।

Examination points

  • Inspect: muscle wasting, posture, scapular dyskinesia।
  • Palpation: diffuse tenderness; focal AC joint tenderness থাকলে AC pathology ভাবুন।
  • ROM:
    • Passive external rotation at side ↓↓↓
    • Abduction ↓
    • Internal rotation/painful hand-behind-back ↓
  • Compare opposite shoulder।
  • Neurovascular exam করুন।
  • Cervical spine screen করুন—neck pain/radiation/paresthesia থাকলে cervical radiculopathy বাদ দিতে হবে।

Red flags

  • Fever, severe night pain with weight loss।
  • Recent trauma/fracture suspicion।
  • Cancer history।
  • Neurological deficit।
  • Hot swollen joint।
  • Sudden loss of power—rotator cuff tear suspicion।

6) Investigations — specific approach

Frozen shoulder-এ routine investigation diagnosis confirm করার জন্য নয়; differential diagnosis বাদ দিতে করা হয়।

A. X-ray shoulder — first-line when needed

  • AP view + axillary/scapular Y view।
  • Purpose:
    • Glenohumeral osteoarthritis বাদ দেওয়া।
    • Calcific tendinitis দেখা।
    • Fracture/dislocation বাদ দেওয়া।
    • Tumor/destructive lesion suspicion বাদ দেওয়া।

B. Ultrasound shoulder

  • Purpose:
    • Rotator cuff tear/tendinopathy।
    • Subacromial bursitis।
    • Biceps pathology।
    • Adjunct findings: coracohumeral ligament thickening, inferior capsule/axillary recess thickening, rotator interval abnormality।
  • USG একা frozen shoulder diagnose করার test নয়।

C. MRI shoulder

  • Indications:
    • Atypical presentation।
    • Trauma history।
    • Marked weakness—rotator cuff tear suspicion।
    • Failure of 6–12 weeks adequate conservative treatment।
    • Pre-procedure/surgical planning।
  • MRI alone diagnosis নয়; clinical diagnosis-এর adjunct।

D. Laboratory tests

  • FBS/RBS + HbA1c: diabetes screen/control assessment।
  • TSH ± FT4: thyroid disease suspicion/known thyroid disorder।
  • Lipid profile: dyslipidemia risk association।
  • CBC, ESR, CRP: fever, inflammatory arthritis, infection, malignancy suspicion থাকলে।
  • Uric acid/RF/anti-CCP: routine নয়; clinical suspicion থাকলে।

7) Differential diagnosis

  • Rotator cuff tendinopathy/tear।
  • Subacromial impingement।
  • Calcific tendinitis।
  • Glenohumeral osteoarthritis।
  • AC joint arthritis।
  • Cervical radiculopathy।
  • Biceps tendinopathy।
  • Shoulder instability/dislocation history।
  • Septic arthritis।
  • Tumor/metastasis।

8) Complications — রোগের জটিলতা

  • Chronic pain: দীর্ঘদিন ব্যথা থাকলে sleep disturbance ও daily function কমে।
  • Persistent stiffness: অনেকের ১–২ বছর বা তার বেশি stiffness থাকতে পারে।
  • Loss of shoulder function: জামা পরা, মাথায় হাত নেওয়া, পেছনে হাত নেওয়া কঠিন হয়।
  • Muscle wasting/disuse weakness: ব্যথার কারণে shoulder কম নড়ালে deltoid/rotator cuff weakness হয়।
  • Contralateral shoulder involvement: এক কাঁধ ভালো হলেও অন্য কাঁধ আক্রান্ত হতে পারে, বিশেষ করে diabetic patient-এ।
  • Psychological impact: chronic pain → anxiety, irritability, poor sleep।
  • Treatment-related complications: NSAID-induced gastritis/renal issue, steroid-induced hyperglycemia, injection-site pain/infection—এগুলো রোগের নয়, চিকিৎসার ঝুঁকি।

9) Treatment management — guideline-based

Core principle

Frozen shoulder treatment-এর ৩টি লক্ষ্য:

  1. Pain control
  2. ROM restoration
  3. Function recovery

Manual therapy + ROM exercise shoulder function ও ROM improve করতে পারে; intra-articular steroid injection pain/function improve করতে পারে, এবং steroid injection + physiotherapy একসাথে দিলে benefit বেশি হতে পারে। Hydrodilatation steroid injection-এর সাথে selected case-এ বিবেচনা করা যায়।

A. Non-pharmacological treatment

1. Patient education

  • রোগটি সাধারণত slow recovery disease।
  • জোর করে painful manipulation করবেন না।
  • Pain-free বা tolerable range-এ exercise করতে হবে।

2. Physiotherapy / home exercise

  • Pendulum exercise।
  • Wand-assisted external rotation।
  • Wall climbing/finger ladder।
  • Cross-body adduction stretch।
  • Towel stretch for internal rotation।
  • Posterior capsule stretch।
  • Scapular stabilization।
  • Frequency: দিনে 2–4 বার, প্রতিবার 5–10 মিনিট, pain-tolerable range।

3. Heat/ice

  • Exercise-এর আগে warm compress 10–15 min।
  • Exercise-এর পর pain flare হলে ice pack 10 min।

4. Follow-up

  • 4–6 সপ্তাহ পর pain, ROM, sleep, ADL reassessment।
  • No improvement বা atypical feature থাকলে imaging/referral।

10) Pharmacological treatment — Bangladesh doctors commonly use

Important prescribing rule

একসাথে দুই NSAID দেবেন না—যেমন diclofenac + naproxen/etoricoxib/aceclofenac একসাথে নয়। NSAID lowest effective dose, shortest duration. NSAID use-এ GI bleeding, renal impairment, BP rise, CVD risk এবং anticoagulant/ACEI/ARB/diuretic interaction বিবেচনা করতে হবে।

1) Paracetamol

  • Generic name: Paracetamol / Acetaminophen
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  • Bangladesh available brand examples: Napa 500 mg/1000 mg, Ace 500 mg, Fast 500 mg/1000 mg, Feva 500 mg, Napa Rapid 500 mg — MedEx-listed.
  • Dose: 500–1000 mg PO 6–8 hourly PRN; সাধারণভাবে max 3 g/day safer limit।
  • Duration: 3–7 দিন; chronic daily use avoid unless monitored।
  • কেন used হয়: mild–moderate pain, night pain কমাতে; NSAID contraindicated হলে safer first option।
  • Side effects: usually safe; overdose → hepatotoxicity।
  • Interaction: warfarin-এর সাথে regular/high dose use করলে INR/bleeding risk বাড়তে পারে; alcohol/liver disease-এ caution।

2) NSAID — Diclofenac sodium

  • Generic name: Diclofenac sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative; COX inhibitor
  • Bangladesh available brand examples: Voltalin 50 mg tablet/SR 75–100 mg/injection 75 mg/3 ml, Diloren 50 mg, Diloren SR 100 mg, G-Diclofenac 50 mg, Diclofenac gel 1% — MedEx-listed.
  • Dose:
    • Tablet 50 mg PO BD/TDS after meal
    • SR 100 mg OD after meal
    • Topical gel 1% locally 3–4 times/day
  • Duration: oral 5–10 দিন; topical 1–2 সপ্তাহ।
  • কেন used হয়: inflammatory pain ও painful ROM limitation কমাতে, যাতে physiotherapy tolerate করা যায়।
  • Side effects: dyspepsia, gastritis, GI bleeding, renal impairment, edema, BP rise, CV risk।
  • Interaction: warfarin/DOAC/aspirin/SSRI/steroid → bleeding risk; ACEI/ARB + diuretic + NSAID → AKI risk; antihypertensive effect কমাতে পারে।

3) NSAID — Naproxen sodium

  • Generic name: Naproxen sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Bangladesh available brand examples: Naprox 500 mg, Naproxin 250/500 mg, Napryn 250/500 mg, Napryn gel 10%, Naprox Plus 375/500 mg + Esomeprazole 20 mg — MedEx-listed.
  • Dose: 250–500 mg PO BD after meal।
  • Duration: 5–10 দিন।
  • কেন used হয়: longer-acting NSAID; night pain ও inflammatory pain কমাতে।
  • Side effects/interactions: diclofenac-এর মতো NSAID class effects; PUD/CKD/CVD/anticoagulant use-এ caution।

4) COX-2 selective NSAID — Etoricoxib

  • Generic name: Etoricoxib
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Bangladesh available brand examples: Etorix 60/90/120 mg, Oricox 30/60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Etoshine 60/90 mg — MedEx-listed.
  • Dose: 60 mg OD or 90 mg OD after meal; lowest effective dose।
  • Duration: 3–7 দিন; prolonged use avoid।
  • কেন used হয়: significant pain/inflammation; GI risk তুলনামূলক কম হতে পারে, কিন্তু CV/BP risk বেশি বিবেচনা করতে হয়।
  • Side effects: dyspepsia, edema, hypertension, renal impairment, CV thrombotic risk।
  • Interaction: antihypertensive effect কমাতে পারে; anticoagulant/antiplatelet/steroid-এর সাথে bleeding risk; ACEI/ARB/diuretic-এর সাথে renal risk।

5) NSAID — Aceclofenac

  • Generic name: Aceclofenac
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • Bangladesh available brand examples: Aceflex 100 mg, Nofenac 100 mg, Ostoflex 100 mg/SR 200 mg, Preservin 100 mg/SR 200 mg, Acedol SR 200 mg — MedEx-listed.
  • Dose: 100 mg PO BD after meal; SR 200 mg OD।
  • Duration: 5–10 দিন।
  • কেন used হয়: pain + inflammatory stiffness control; physiotherapy tolerance বাড়াতে।
  • Side effects/interactions: NSAID class—GI bleed, renal impairment, BP/CV risk, anticoagulant interaction।

6) PPI gastroprotection — Pantoprazole / Omeprazole

  • Generic name: Pantoprazole sodium / Omeprazole
  • Therapeutic category: Anti-ulcerant, gastroprotection
  • Pharmacological class: Proton pump inhibitor
  • Bangladesh available brand examples:
    • Pantoprazole: Pantonix 20/40 mg, Pantobex 20/40 mg, Pantolok 20/40 mg, Proton-P 20/40 mg — MedEx-listed.
    • Omeprazole: Losectil MUPS 20/40 mg, Cosec-MUPS 20/40 mg, O-20 20 mg, Nuprazol 20 mg — MedEx-listed.
  • Dose: Pantoprazole 20–40 mg OD before breakfast; Omeprazole 20 mg OD।
  • Duration: NSAID course চলাকালীন 5–14 দিন; high GI risk হলে clinician decision।
  • কেন used হয়: NSAID-induced gastritis/ulcer risk কমাতে; frozen shoulder directly treat করে না।
  • Side effects: headache, diarrhea/constipation; long-term use → hypomagnesemia, B12 deficiency, fracture/infection risk।
  • Interaction: clopidogrel-এর সাথে omeprazole/esomeprazole avoid করা ভালো; pantoprazole generally preferred when PPI needed with clopidogrel।

7) Oral corticosteroid — selected early painful stage only

  • Generic name: Prednisolone
  • Therapeutic category: Anti-inflammatory steroid
  • Pharmacological class: Systemic glucocorticoid
  • Bangladesh available brand examples: Deltasone 5/10/20 mg, Pred 5/10/20 mg, Pednisol 5/10/20 mg, Inflagic 20 mg, Deltapred 5/10 mg — MedEx-listed.
  • Dose examples used in studies/clinical practice:
    • Prednisolone 30 mg OD for 2–3 weeks then stop/taper depending on duration and clinician judgment; অথবা
    • 10 mg OD 4 weeks then 5 mg OD 2 weeks—older study regimen।
  • Duration: usually short course; long-term avoid।
  • কেন used হয়: early freezing stage-এ severe pain/night pain দ্রুত কমাতে; long-term benefit limited।
  • Side effects: hyperglycemia, BP rise, dyspepsia, mood change, insomnia, infection risk, osteoporosis, HPA-axis suppression। Oral steroid evidence inconclusive; adverse effects বিবেচনায় first-line হিসেবে routine use না করাই ভালো।
  • Interaction: NSAID + steroid → GI bleed risk; diabetes drugs dose adjustment লাগতে পারে; vaccine/infection caution।

8) Intra-articular corticosteroid injection — high-yield option

A. Triamcinolone acetonide

  • Generic name: Triamcinolone acetonide injection
  • Therapeutic category: Intra-articular anti-inflammatory
  • Pharmacological class: Glucocorticoid corticosteroid
  • Bangladesh available brand examples: Cenolon 40 mg/ml, Trialon 40 mg/ml, Trecilon 40 mg/ml, Triacin 40 mg/ml, Triamon 40 mg/ml, Intracort 40 mg/ml — MedEx-listed.
  • Dose: commonly 20–40 mg intra-articular glenohumeral injection ± local anesthetic; preferably US-guided if expertise available।
  • Frequency: usually single injection; repeat হলে সাধারণত ≥3 months interval, clinical need অনুযায়ী।
  • কেন used হয়: pain দ্রুত কমায়, sleep improve করে, physiotherapy করার সুযোগ বাড়ায়; guideline-এ IA steroid injection এবং IA steroid + physiotherapy recommended/considered।
  • Side effects: post-injection flare, facial flushing, transient hyperglycemia, skin hypopigmentation/atrophy, infection rare, tendon injury rare। Diabetic patient-এ glucose monitoring দরকার।
  • Interaction/caution: uncontrolled diabetes, local/systemic infection, anticoagulant therapy, severe immunosuppression—risk-benefit assess।

B. Methylprednisolone acetate

  • Generic name: Methylprednisolone acetate
  • Therapeutic category: Intra-articular anti-inflammatory
  • Pharmacological class: Depot glucocorticoid corticosteroid
  • Bangladesh available brand examples: Depo-Medrol 40 mg/ml, Depo-Medrol 80 mg/2 ml, Depomed 40 mg/ml/80 mg/2 ml, Depo-pred 40 mg/ml — MedEx-listed.
  • Dose: commonly 40 mg intra-articular glenohumeral injection।
  • Purpose/side effects/interactions: Triamcinolone-এর মতো।

9) Tramadol + Paracetamol — rescue analgesic, routine নয়

  • Generic name: Paracetamol 325 mg + Tramadol HCl 37.5 mg
  • Therapeutic category: Moderate pain analgesic
  • Pharmacological class: Non-opioid analgesic + centrally acting opioid agonist/SNRI-like analgesic
  • Bangladesh available brand examples: NapaDol 325+37.5 mg, Dolceta 325+37.5 mg, Utracet 325+37.5 mg, Resadol 325+37.5 mg, Tamenol 325+37.5 mg — MedEx-listed.
  • Dose: 1 tablet 6–8 hourly PRN; max paracetamol total dose হিসাব করতে হবে।
  • Duration: 3–5 দিন only if severe pain; avoid long-term।
  • কেন used হয়: severe night pain/acute flare যখন paracetamol/NSAID inadequate বা NSAID contraindicated।
  • Side effects: nausea, dizziness, sedation, constipation, dependence risk, respiratory depression risk।
  • Interaction: alcohol, benzodiazepine, sedatives, antidepressants/SSRI/SNRI/MAOI → CNS depression/serotonin syndrome/seizure risk।

10) Muscle relaxant — only if associated painful spasm; frozen shoulder core drug নয়

Tolperisone

  • Generic name: Tolperisone HCl
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • Bangladesh available brand examples: Myolax 50/100 mg, Myoson 50/100 mg, Tolson 50/100 mg, Musclex 50 mg, Mydocalm 50 mg — MedEx-listed.
  • Dose: 50 mg TDS after meal; short course।
  • Duration: 5–7 দিন।
  • কেন used হয়: associated cervical/shoulder girdle muscle spasm থাকলে; primary capsular stiffness-এর main treatment নয়।
  • Side effects: dizziness, weakness, GI upset, hypersensitivity।
  • Interaction: sedatives/alcohol caution।

Tizanidine

  • Generic name: Tizanidine HCl
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: α2-adrenergic agonist, centrally acting muscle relaxant
  • Bangladesh available brand examples: Relentus 2 mg, Sirdalud 2 mg — MedEx-listed.
  • Dose: 2 mg HS or 2 mg BD/TDS if needed; sedation risk বিবেচনা।
  • Duration: 3–7 দিন।
  • কেন used হয়: painful spasm/sleep disturbance; routine frozen shoulder drug নয়।
  • Side effects: sedation, hypotension, dry mouth, dizziness, liver enzyme rise।
  • Interaction: ciprofloxacin/fluvoxamine avoid; alcohol/sedatives caution।

11) Pregabalin/Gabapentin — frozen shoulder pain-এর routine drug নয়

  • Use only if: burning pain, paresthesia, cervical radiculopathy, diabetic neuropathy, post-herpetic neuralgia suspicion থাকে।
  • Pregabalin brand examples: Pregabalin 25/50/75 mg, SB-Gabalin 25/50/75 mg, Vaxar 25 mg — MedEx-listed examples.
  • কেন routine নয়: Frozen shoulder মূলত capsular fibrosis/inflammation; neuropathic pain medicine core pathology treat করে না।
  • Side effects: dizziness, somnolence, edema, weight gain; renal dose adjustment দরকার।

11) Bangladesh doctors commonly prescribe — practical list

Frozen shoulder prescription-এ সাধারণত নিচের pattern দেখা যায়:

  1. Paracetamol 500 mg — mild pain/night pain কমাতে।
  2. One NSAID only: diclofenac / naproxen / aceclofenac / etoricoxib — inflammatory pain কমিয়ে physiotherapy tolerate করাতে।
  3. PPI: pantoprazole/omeprazole — NSAID gastric protection, বিশেষ করে PUD/elderly/high-risk patient।
  4. Topical NSAID gel: diclofenac gel 1% বা naproxen gel 10% — local pain adjunct।
  5. Intra-articular steroid injection: triamcinolone acetonide 40 mg/ml অথবা methylprednisolone acetate 40 mg/ml — painful/freezing stage-এ high-value option।
  6. Physiotherapy prescription: ROM + capsular stretching + home exercise — management-এর core।
  7. Short rescue analgesic: paracetamol + tramadol — severe night pain হলে short course।
  8. Muscle relaxant: tolperisone/tizanidine — শুধুমাত্র associated spasm থাকলে; routine নয়।

12) Prevention — কীভাবে প্রতিরোধ করবেন

  • Shoulder injury/surgery/fracture/MI/stroke-এর পর prolonged immobilization avoid করুন; medically safe হলে early gentle ROM শুরু।
  • Diabetes থাকলে HbA1c control করুন।
  • Thyroid disease ও dyslipidemia treat করুন।
  • দীর্ঘদিন shoulder pain হলে “rest only” না করে early assessment + guided exercise।
  • Painful range-এর বাইরে জোর করে manipulation করবেন না।
  • Desk worker হলে posture correction, scapular mobility, periodic shoulder movement।
  • Previous frozen shoulder থাকলে opposite shoulder-এ stiffness শুরু হলে early physiotherapy।

Overview / Summary

Frozen shoulder হলো shoulder capsule-এর inflammatory-fibrotic condition, যেখানে কাঁধে ব্যথা ও active-passive ROM দুটোই কমে, বিশেষ করে external rotation। Diagnosis mostly clinical; X-ray/USG/MRI মূলত differential বাদ দিতে। Treatment-এর ভিত্তি হলো education + pain control + physiotherapy। NSAID/paracetamol short course pain control করে; intra-articular steroid injection early painful stage-এ pain/function improve করতে পারে; steroid injection + physiotherapy best practical combination হিসেবে ব্যবহৃত হয়।

Actionable Plan / Steps

  1. History + active/passive ROM পরীক্ষা করে frozen shoulder confirm করুন।
  2. Red flag/trauma/weakness থাকলে X-ray ± USG/MRI।
  3. FBS/HbA1c, TSH, lipid profile করে risk factor assess করুন।
  4. Pain stage হলে paracetamol ± one NSAID short course + PPI if risk।
  5. Severe painful restriction হলে glenohumeral intra-articular steroid injection consider করুন।
  6. একই দিন থেকে gentle ROM + stretching physiotherapy শুরু করুন।
  7. 4–6 সপ্তাহ পর ROM/pain reassess; no improvement হলে specialist referral, hydrodilatation/SSNB/MUA/arthroscopic capsular release বিবেচনা।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. Musculoskeletal pain/soft tissue rheumatism sections.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Rheumatology and musculoskeletal disorders.
  3. Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. NSAIDs, corticosteroids, opioid analgesics.
  4. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Analgesic-antipyretic agents, NSAIDs, glucocorticoids.
  5. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Inflammation, fibrosis and repair principles.

Guidelines / Reviews with DOI

  1. Kelley MJ, et al. Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther. 2013;43(5):A1–A31. DOI: 10.2519/jospt.2013.0302.
  2. Lee BC, et al. Clinical Practice Guidelines for Diagnosis and Non-Surgical Treatment of Primary Frozen Shoulder. Ann Rehabil Med. 2025.
  3. Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005;331:1453–1456. DOI: 10.1136/bmj.331.7530.1453.
  4. Challoumas D, et al. Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. DOI: 10.1001/jamanetworkopen.2020.29581.
  5. Ryan V, et al. The pathophysiology associated with primary idiopathic frozen shoulder: a systematic review. BMC Musculoskelet Disord. 2016;17:340. DOI: 10.1186/s12891-016-1190-9.
  6. Sun Y, et al. Intra-articular steroid injection for frozen shoulder: systematic review and meta-analysis. Am J Sports Med. 2017;45(9):2171–2179. DOI: 10.1177/0363546516669944.
  7. Page MJ, et al. Manual therapy and exercise for adhesive capsulitis. Cochrane Database Syst Rev. 2014. DOI: 10.1002/14651858.CD011275.

Md.Rafiqul Islam Lipu,Date:-17-06-2026 Wednesday,Time:-09-49-12 Pm

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