A 65-year-old woman comes to the physician because of worsening right shoulder stiffness for the last 3 months. She denies any trauma or previous shoulder problems. She also reports a history of chronic low back pain and knee pain. She works as a librarian and has been lifting more books recently since her library expanded its book collection. Her other medical problems include diabetes, hypertension, and hypercholesterolemia.
Her temperature is 36.5 C (97.7 F), blood pressure is 130/80 mm Hg, pulse is 85/min, and respirations are 14/min. Her lungs are clear and her heart sounds are normal. Muscle strength is 5/5 in the lower extremities with intact sensation and 5/5 in the biceps bilaterally. She has markedly decreased passive and active range of motion in right shoulder. Her reflexes are 2+ throughout and she has a normal gait. The remainder of her physical examination is within normal limits.
Which of the following is most appropriate next step in management?

Question

A 65-year-old woman comes to the physician because of worsening right shoulder stiffness for the last 3 months.  She denies any trauma or previous shoulder problems.  She also reports a history of chronic low back pain and knee pain.  She works as a librarian and has been lifting more books recently since her library expanded its book collection.  Her other medical problems include diabetes, hypertension, and hypercholesterolemia.  
Her temperature is 36.5 C (97.7 F), blood pressure is 130/80 mm Hg, pulse is 85/min, and respirations are 14/min.  Her lungs are clear and her heart sounds are normal.  Muscle strength is 5/5 in the lower extremities with intact sensation and 5/5 in the biceps bilaterally.  She has markedly decreased passive and active range of motion in right shoulder.  Her reflexes are 2+ throughout and she has a normal gait.  The remainder of her physical examination is within normal limits.
Which of the following is most appropriate next step in management?

Quizplus · Accepted Answer

This patient's presentation is most consistent with adhesive capsulitis (frozen shoulder syndrome). This results from chronic inflammation, fibrosis, and contracture of the joint capsule. Adhesive capsulitis (AC) can be idiopathic or due to underlying conditions such as rotator cuff tendinopathy, subacromial bursitis, stroke, diabetes, or humeral head fracture. Patients typically present with gradual onset of more shoulder stiffness than pain with an inability to reach objects or rotate their shoulder. Diagnosis is confirmed on examination with > 50% reduction in both passive and active range of motion. Adhesive capsulitis is a self-limited condition and responds to conservative management in > 90% of patients. However, complete recovery can take up to 6-18 months in some patients. Pain can be controlled with NSAIDs for 1-2 weeks. Stretching exercises to improve range of motion is the treatment of choice. These include pendulum-type swinging of hand held weights, stretching the arm by walking the fingers up a wall, and rubbing the lower back with a towel with both hands. (Choice A) Limiting the activity that predisposed the patient to adhesive capsulitis (e.g., lifting books in this patient) is usually recommended with range of motion exercises to prevent worsening of AC and improve joint mobility. Complete rest may worsen joint stiffening and promote adhesions. NSAIDs can be given for 1-2 weeks to decrease the pain and to help patients perform exercises more comfortably. (Choice B) Oral steroids may be effective for acute AC symptoms, but relief usually lasts only 6 weeks and is not as effective as steroid joint injections. (Choice D) Steroid joint injection is reserved for patients with persistent AC symptoms 6-8 weeks after range of motion exercises, especially in patients with concurrent rotator cuff or bicipital tendinopathy. (Choice E) Rotator cuff strengthening exercises are more useful in patients with underlying rotator cuff tendinopathy that may lead to AC. However, they are added after range of motion improves. Strengthening attempted before range of motion improvement may possibly lead to a further decline of range of motion. Educational objective: Adhesive capsulitis (frozen shoulder syndrome) is due to the lack of glenohumeral joint distensibility leading to > 50% reduction of both passive and active range of motion. Range of motion exercises to strengthen the glenohumeral joint are preferred for acute treatment. Refractory patients may be treated with steroid joint injections after 6-8 weeks. __________ References: Adhesive capsulitis of the shoulder. (http://www.ncbi.nlm.nih.gov/pubmed/20110457)

A 65-Year-Old Woman Comes to the Physician Because of Worsening