A 45-year-old man comes to the physician for pain and stiffness in his left shoulder for the past 3 months. His symptoms were mild in the beginning and intermittently affected his daytime activities. The pain and stiffness have worsened in the past month and are constant throughout the day and night. The pain is worse with lying on the shoulder. The patient, a professional painter, recalls no injury and has no other symptoms. He has a history of type 1 diabetes mellitus, depression, and psoriasis. Examination of the left shoulder shows no focal tenderness but global restriction in all directions with both active and passive range of motion. The right shoulder joint has normal range of motion. The remainder of the physical examination is within normal limits. X-ray of the left shoulder is normal without significant osteoarthritis of the glenohumeral joint.
Which of the following is the most likely cause of this patient's shoulder pain?

Question

A 45-year-old man comes to the physician for pain and stiffness in his left shoulder for the past 3 months.  His symptoms were mild in the beginning and intermittently affected his daytime activities.  The pain and stiffness have worsened in the past month and are constant throughout the day and night.  The pain is worse with lying on the shoulder.  The patient, a professional painter, recalls no injury and has no other symptoms.  He has a history of type 1 diabetes mellitus, depression, and psoriasis.  Examination of the left shoulder shows no focal tenderness but global restriction in all directions with both active and passive range of motion.  The right shoulder joint has normal range of motion.  The remainder of the physical examination is within normal limits.  X-ray of the left shoulder is normal without significant osteoarthritis of the glenohumeral joint. 
Which of the following is the most likely cause of this patient's shoulder pain?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0a4_0e1b_8f63_9bbc5f8cf3b5_MD0005_00 This patient's clinical features - shoulder pain with decreased active and passive range of motion (ROM) - are most consistent with adhesive capsulitis (AC) (frozen shoulder syndrome). AC can be idiopathic or secondary to underlying conditions such as rotator cuff tendinopathy (most common), subacromial bursitis, paralytic stroke, diabetes mellitus, or humeral head fracture. The glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis, and contracture of the joint capsule. AC typically begins with shoulder pain that is often worse at night. Patients then develop gradual shoulder stiffness (with or without pain) that limits their ability to flex, abduct, or rotate the humerus. The diagnosis is confirmed clinically with >50% reduction in both passive and active ROM in >2 planes (especially external rotation and abduction) compared to the unaffected shoulder. Imaging (x-ray, ultrasound, MRI) is not required for diagnosis but may occasionally be needed to rule out other etiologies of shoulder pain. (Choice A) Avascular necrosis of the humerus is most often seen in patients with a history of glucocorticoid use or other predisposing medical conditions (eg, lupus, sickle cell disease). Patients typically have progressive pain and stiffness, but passive ROM is preserved. (Choice B) Subacromial bursitis typically occurs in patients with a history of heavy lifting or repetitive movements, especially with the arm raised above shoulder level. Patients can develop pain on abduction of the shoulder and restricted active ROM. However, passive ROM should be intact. (Choices C and E) Rotator cuff tendinopathy with a partial or complete tear may cause pain with mildly (partial) or severely (complete) decreased active ROM. However, unless there is concurrent adhesive capsulitis, passive ROM is not affected. Educational objective: Adhesive capsulitis is due to chronic inflammation, fibrosis, and contracture of the joint capsule. It can be idiopathic or secondary to rotator cuff tendinopathy, subacromial bursitis, paralytic stroke, diabetes, or humeral head fracture. Patients have shoulder stiffness with a reduction of both passive and active range of motion. References: Adhesive capsulitis: a review. (http://www.ncbi.nlm.nih.gov/pubmed/21322517)

A 45-Year-Old Man Comes to the Physician for Pain and Stiffness