Background: Frozen shoulder, also known as Adhesive capsulitis, is a common musculoskeletal disorder that causes discomfort, stiffness, and limited shoulder joint range of motion. This illness is managed using various Physiotherapy techniques such as electrotherapy modalities, manual therapy techniques, exercises, etc. Muscle Energy Technique (MET) is one of the manual therapy technique that have drawn attention as a possible treatment for enhancing shoulder mobility and lowering pain. The objective of this narrative review is to analyze the efficacy of MET in managing frozen shoulder by examining current evidence and discussing how it affects functional outcomes, range of motion, and pain relief. Methods: A thorough analysis of pertinent research and clinical trials on the effectiveness of MET in managing frozen shoulder was carried out. We looked through databases like PubMed, Scopus, and Google Scholar to find papers that had been published during the last 20 years. Reduction of discomfort, enhancement of shoulder mobility, and general functional recovery are among the important outcomes evaluated. Results: According to the research, MET helps people with frozen shoulder move their shoulders more freely, feel less discomfort, and perform better in their daily activities. The method increases flexibility and decreases stiffness by stretching the restricted tissues and facilitating joint movement through voluntary muscle contractions. MET seems to be more beneficial in encouraging active movement and neuromuscular control than passive stretching methods. Conclusion: MET is a potentially effective treatment strategy for frozen shoulder that enhances functional ability, range of motion, and pain alleviation. To create uniform procedures and ascertain its long-term efficacy, more excellent randomized controlled studies are necessary. For patients with frozen shoulder, combining MET with other physiotherapy treatments may result in the best results.
Adhesive Capsulitis (AC), commonly known as Frozen Shoulder, is a disabling self-limiting inflammatory process that affects the capsule of the shoulder joint. It is a clinical ailment that limits most daily activities, particularly those that require overhead movement, by generating a painful and stiff shoulder that restricts the range of motion in a capsular pattern. The shoulder that is impacted by AC hurts worse at night. These signs and symptoms could last for a few months or even years. In 1945, Naviesar coined the term adhesive capsulitis [1]. The prevalence of frozen shoulder is believed to range between 2.4 and 26% [2]. The patient has trouble dressing, keeping one hand close to the mouth, cleaning clothing and dishes, or lifting heavy objects [3].
The signs and symptoms of frozen shoulder (adhesive capsulitis) include a sharp pain around the shoulder, especially at night or with movement. There is difficulty lifting the arm or rotating it, particularly overhead activities such as Trouble reaching behind the back, combing hair, or putting on a coat [4]. There is also a feeling of tightness and restricted motion in the shoulder joint. Discomfort that interferes with sleep, often worsening when lying on the affected side.Symptoms can develop gradually and may last for months or even years if untreated [5].
Frozen Shoulder is classified as primary or idiopathic, and secondary depending upon intrinsic or extrinsic factors [6]. Based on a correlation between the patients’ histology and clinical appearance and their arthroscopy stage (as determined by Navieser), developed four phases of AC. Acute painful stage I, which lasted less than three months, was characterized by excruciating pain at the limits of range of motion. When a local anaesthetic was given, the slight loss of forward flexion, abduction, and internal and external rotation was eliminated. Even when under anaesthesia, “the freezing stage,” the second step, involved a considerable loss of all shoulder motions for three to nine months. The third stage, referred to as “the frozen stage,” lasted for nine to fourteen months during which time the shoulder tightened and the pain subsided. The last stage, sometimes known as “the thawing stage,” manifested itself between the ages of 15 and 24 months and was characterized by minimal pain and a gradual increase in range of motion [7].
Physiotherapy is usually the first-line treatment approach for treating a frozen shoulder, with various exercises and modalities helping to reduce discomfort and ROM maintaining and restoring function [8]. Dr. Fred Mitchell invented the muscle energy technique. [9] Muscle energy techniques, a form of manual therapy uses moderate muscle contractions against resistance to relax and stretch muscles while restoring the normal joint motion. The use of MET relaxes and improves biomechanics, thus enhancing functional capacity [10]. METS (Muscle Energy Technique) has a good effect on biomechanics and increases length, which improves functional performance [11 ].
Etiologies of adhesive capsulitis: While the cause of ACS is unknown, multiple investigations have discovered that patients with ACS had both chronic inflammatory cells and fibroblast cells, indicating the existence of both an inflammatory process and fibroblasts [12].
Muscle Energy Technique (MET), a manual therapy technique that incorporates active muscle contractions against resistance, has received attention as a potential intervention for increasing mobility, pain relief, and improve function in patients with musculoskeletal problems. Despite its clinical use, there is limited consolidated evidence on its effectiveness specifically for frozen shoulder. This narrative review aims to:
Summarize existing literature on the application of MET in frozen shoulder management.
Evaluate its effectiveness in improving pain, ROM, and functional outcomes.
Identify research gaps and suggest recommendations for future study.
By synthesizing available evidence, this review seeks to provide valuable insights for clinicians, therapists, and researchers, ultimately contributing to more effective and evidence-based rehabilitation strategies for individuals suffering from frozen shoulder.
Keyword searches of the PubMed, Google Scholar, NCBI, and Science Direct databases yielded the studies included in the review. Keywords searched included: Muscle Energy Technique, Frozen Shoulder, Adhesive Capsulitis, Manual Therapy, and Physiotherapy. Studies involving human subjects diagnosed with Frozen shoulder. Some studies included specific age ranges, such as 40-70 years old. Studies that focus on Muscle Energy Technique (MET) as a primary or adjunct intervention for frozen shoulder management were included.
The included studies used validated outcome measures such as the SPADI, VAS, ROM, Numeric Pain Rating Scale (NPRS), and Disabilities of the Arm, Shoulder, and Hand (DASH). Articles in only English language were included. There was no time limit set for this review. However, more recent publications (within the last ten years) were given preference to ensure relevance and inclusion of current evidence.
Articles included in this study were- Randomized controlled trials (RCTs) as well as Clinical trials, Population chosen was adults diagnosed with Frozen Shoulder (Adhesive Capsulitis). Studies including patients in different stages of frozen shoulder (freezing, frozen, and thawing phase) were selected. Studies that focus on Muscle Energy Technique (MET) as a primary or adjunct intervention for frozen shoulder management were included. Studies with insufficient methodological quality (e.g., small sample size, poor study design) were excluded. Also, Studies published in languages other than English & Articles without full-text availability were not included.
Articles for the study were retrieved from databases such as Google Scholar, NCBI, PubMed, and Science Direct. We conducted an analysis based on a study of the literature and attempted to identify physiotherapy techniques for frozen shoulder.
A total number of 34 articles were fetched using keywords-Muscle Energy Technique, Frozen Shoulder, Adhesive Capsulitis, Manual Therapy, Physiotherapy, and Shoulder Mobility. A total of 20 articles were screened for eligibility criteria. Further, 07 articles were excluded as they did not include full text, (Figure 1). Out of these, 13 Full-text articles passed the eligibility criteria & were chosen for the study.
| Authors | Research design | Participants | Treatment protocol | Protocol duration | Outcome measures | Results |
| Iqbal [6] | single-blind randomized control trial | N= 60 | Group A: Spencer Muscle Energy Technique (SMET) + Hot Moist Pack (HMP) Group B: Passive stretching + Hot Moist Pack (HMP) | 3 sessions/ week on alternate days, for 4 weeks. | SPADI, NPRS, Quick DASH, Goniometry | This study suggests that Spencer’s muscle energy technique was found to be more effective than passive stretching exercises in reducing pain, improving joint ROM and functionality in AC. |
| Pattnaik et al. [1] | Quasi-experimental study | N=35 | Group A: Kaltenborn mobilization technique (KMT) Group B: Muscle Energy Technique (MET) | 5 sessions/ week for 2 weeks | SPADI, NPRS, Goniometry | The results of this study showed that although both KMT MET were effective in improving ROM, pain and function, MET showed a significant reduction of pain and improvement in function in patients with chronic shoulder FS. |
| Kotagiri et al. [22] | N=60 | Group A: Muscle energy Technique. Group B: Mobilization | VAS, SPADI, Goniometry | This study proved that METwas more beneficial in improving Pain and decreasing the disability levels in cases of FS as compared to Mobilisation. | ||
| Mallick et al. [23] | N=30 | Group A: Muscle energy Technique + Conventional Physiotherapy | 3 sessions for 1 week | VAS, Goniometry | According to this study. MET effectively improved the range of motion and functional ability, and also reduced pain in early stages of rehabilitation of Frozen shoulder. | |
| Gill et al. [16] | Interventional Study | N=27 | Group A: Conventional Physiotherapy. Group B: Muscle energy Technique + Conventional Physiotherapy | 6 sessions per week for two weeks | VAS, SPADI, Goniometry | This study concludes that among the two groups, the group of MET along with conventional therapy was found tobe more effective in relieving pain, improving range of motion and functional ability frozen shoulder patients. |
| Umar et al. [14] | Randomized Control Trial | N=30 | Group A: Muscle energy Technique+ Conventional Physiotherapy Group B: grade II III Kaltenborn mobilizations+ Conventional Physiotherapy | Goniometry | This study shows that muscle energy technique was far more effective in improving flexion and abduction ROM except rotation than Kaltenborn mobilizations in improving Frozen shoulder. | |
| Sharma et al. [18] | Experimental study | N=30 | Group A: capsular stretching + conventional therapy. Group B: Muscle energy Technique (MET) | 5 sessions/ week for three weeks | VAS, SPADI, Goniometry | According to the results of this study, the Muscle Energy Technique was found to be more effective along withconventional treatment in increasing the ROM of patients with adhesive capsulitis in comparison with the capsular stretching. |
| Alam et al. [15] | Randomized Control Trial | N=24 | Group A: Maitland’s mobilization technique and MET Group B: home exercise program (HEP) | 3 times/week for six weeks | NPRS, Goniometry | According to the results, a combination of mobilization along with MET of shoulder demonstrated a significant improvement in pain intensity and ROM when compared to the home exercise program without supervision. |
| Khattak et al. [17] | Randomized Control Trial | N=30 | Group A: Muscle energy Technique + Conventional Physiotherapy. Group B: Conventional Physiotherapy | 3 sessions/ week on alternate days for four weeks | NPRS, Goniometry, SPADI, | This study concluded that MET was seen to be a non-invasive treatment for reducing pain. In addition, MET was proven to increase functional capacity and ROM in individuals with adhesive capsulitis when compared to conventional physical therapy treatment. |
| Afzal et al. [17] | Randomized Control Trial | N= 50 | Group A: Muscle energy Technique. Group B: Conventional Physiotherapy | 10sessions for twoweeks | SPADI, Goniometry | The study found that METs approaches effectively cure adhesive capsulitis, reducing discomfort and impairment compared to control groups. |
| Gill et al. [19] | Randomized Controlled Trial | N=30 | Group A: Muscle energy Technique + Conventional Physiotherapy. Group B: Conventional Physiotherapy | 3 days/ week for four weeks. | VAS, Goniometry, SPADI, | According to the results, the Muscle Energy Technique along with conventional treatment was proven to be significantly effective in reducing pain, disability, and improving ROM in adhesive capsulitis patients. |
| Kumar et al. [20] | Quasi-experimental (one-group intervention study) | N=31 | Group : Muscle Energy Technique (MET) + Conventional Physiotherapy | 5 days/ week for 8 weeks. | NPRS, Digital Inclinometer, WHOQOL | This study showed that Muscle Energy approach in Patients with Diabetic Frozen Shoulder showed a remarkable improvement in pain, Range of motion, muscle strength and joint sense at the end of the treatment program. |
| Anwar et al. [21] | Randomized Controlled Trial | N=30 | Group A: Post Isometric Relaxation (PIR) of Muscle Energy Technique Group B: Grade II and III Kaltenborn Mobilizations | 3 times/ week, for Four weeks | SPADI | This study showed that both techniques were effective but the muscle energy technique have superior treatment efficacy than Kaltenborn Mobilizations in reducing pain intensity, and improving functional ability in patients with adhesive capsulitis. |
The results of this narrative review highlight how well the Muscle Energy Technique (MET) works to treat adhesive capsulitis, or frozen shoulder. According to a number of reviewed research, MET helps frozen shoulder patients to improve their mobility i.e. ROM, reduce pain, & also improve their functional ability more effectively than passive stretching and traditional physiotherapy treatments. This section examines potential mechanisms of action, contrasts MET with other physiotherapy therapies, talks about the consequences of these discoveries, and points out areas that need more research.
Effectiveness of MET in considerably increasing shoulder ROM and lowering pain intensity is supported by a number of the research in this review. In a randomized controlled experiment, for example, Hassan et al. [13] compared MET with conventional therapeutic exercises (CTE) and low-level laser treatment (LLLT) and discovered that MET plus CTE produced better pain reduction and functional improvement outcomes. Similarly, Iqbal et al. [6] found that MET and Spencer’s joint mobility improved joint ROM and functionality more effectively than passive stretching. The underlying principle of MET involves voluntary muscle contractions against resistance, which promotes relaxation and elongation of restricted tissues. This technique enhances neuromuscular control, allowing for gradual and controlled mobility improvements. In contrast, passive stretching techniques do not actively engage muscle contractions, making them less effective in enhancing neuromuscular coordination.
Numerous studies have contrasted MET with various physiotherapy methods, including traditional physiotherapy, Maitland’s mobilization, and Kaltenborn mobilization. Results indicate that although other methods work, MET typically offers more advantages as for reducing pain and increasing ROM.
MET vs. Kaltenborn Mobilization: Research by Pattnaik et al. [1] and Umar et al. [14] showed that both MET and Kaltenborn mobilization greatly increase range of motion and reduce discomfort. MET, on the other hand, was determined to befar more effective in improving active mobility & functional outcomes.
MET vs. Maitland’s Mobilization: Alam et al. [15] investigated the combination of MET and Maitland’s mobilization and found that it increased ROM and reduced pain more than a home exercise program alone.
MET vs. Conventional Physiotherapy: According to a number of research, such as those by Gill et al. [16] and Khattak et al. [17], MET produces noticeably better outcomes when paired with conventional physiotherapy than when used alone. MET seems to have a synergistic impact that improves functional outcomes when combined with exercises and mobilization modalities.
The following physiological and neuromuscular processes explain why MET is so successful in treating adhesive capsulitis:
MET makes use of the reciprocal inhibition principle, which states that as agonist muscles contract, antagonist muscles relax. Joint mobility is increased and muscle stiffness is decreased by this procedure. By increasing blood flow to the injured shoulder, active contractions in the MET lessen inflammation and encourage tissue repair. Also, MET improves proprioceptive feedback, which results in improved neuromuscular coordination. This is crucial for frozen shoulder patients to regain shoulder function. MET involves sustained muscle contractions followed by relaxation, which helps in stretching the joint capsule and breaking adhesions, thereby improving mobility.
There is no universally accepted MET protocol for frozen shoulder. Different studies used varying frequencies, durations, and techniques, making it difficult to making it difficult to directly compare the results.Many studies had brief follow-up duration, typically lasting 2 to 4 weeks. Long-term studies are needed to determine whether MET provides sustained benefits beyond the initial rehabilitation period. Several studies had small sample sizes, which may restrict the generalizability of their findings.
Large randomized controlled trials are required to strengthen the evidence base. Most studies compared MET with other physiotherapy techniques but did not evaluate its effectiveness relative to pharmacological treatments such as corticosteroid injections or NSAIDs. Future studies should consider subgroup analyses based on factors such as age, severity of frozen shoulder, and comorbidities (e.g., diabetes) to determine whether certain populations respond better to MET.
Based on the available evidence, MET is an effective and promising treatment modality for frozen shoulder. This paper reviews various randomized controlled trials, interventional studies, and quasi-experimental studies, demonstrating that MET outperforms passive stretching and conventional physiotherapy in improving shoulder mobility. The technique’s ability to enhance neuro muscular control, increase circulation, and reduce joint stiffness makes it a valuable tool for rehabilitation. Combining MET with manual therapy, mobilization techniques, and exercise programs may offer the most comprehensive rehabilitation strategy for patients with frozen shoulder.
In conclusion, MET should be considered a primary intervention in the physiotherapy management of adhesive capsulitis. While more high-quality research is needed to establish definitive guidelines, present evidences suggests that MET is a safe, non-invasive, and effective way to help patients recover from a frozen shoulder.
MET- Muscle Energy Technique
FS- Frozen shoulder
AC- Adhesive Capsulitis
ROM- Range of Motion
SPADI- Shoulder Pain & Disability Index
NPRS- Numerical Pain Rating Scale
VAS- Visual Analogue Scale
DASH- Disabilities of Arm, Shoulder & Hand
WHOQOL- World Health Organization Quality of Life
SMET- Spencer Muscle Energy Technique HMP- Hot Moist Pack
Ethics approval and consent to participate: Ethical clearance was obtained from the Institutional Ethical Committee of Dr. D. Y. Patil Education Society, Kolhapur, Maharashtra, India.
Consent for publication: Not applicable
Availability of data and material: All data generated or analysed during this study are included in this published article.
Competing interests: The authors declare that they have no competing interests
Funding: Self
Authors’ contributions: PS analyzed and interpreted the patient data regarding Frozen shoulder. AR performed the treatment protocol. UP & PM were major contributors in writing the manuscript. All authors read and approved the final manuscript.”
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