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. An appropriate diagnosis is made after the patient is evaluated. Which of the following is the best next step in management of this patient?

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. An appropriate diagnosis is made after the patient is evaluated.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Management of adhesive capsulitis (AC) is dependent on the severity of pain and limitation in activity. AC is frequently self-limited, although complete recovery can take up to 6-18 months and residual stiffness is common. Most cases may be managed with resting the shoulder combined with gentle range of motion (ROM) exercises, such as pendulum-type swinging of hand-held weights and walking the fingers up a wall. Patients with significant limitation in function or those who do not improve after 2-3 months of ROM exercises can receive a glucocorticoid injection into the joint; this may be combined with saline distension of the joint space. More aggressive physical therapy may also be considered, either alone or in combination with steroid injection, but evidence for benefit is limited. (Choice A) Oral glucocorticoids are not routinely recommended for AC as they provide only temporary relief and are associated with significant systemic side effects. Intra-articular injection is preferred if glucocorticoids are needed. Nonsteroidal anti-inflammatory drugs also provide only temporary relief and have little utility in AC. (Choice C) Surgery is typically reserved for patients who do not respond to conservative therapy, usually after several months to a year. (Choice D) Therapeutic ultrasound, laser therapy, and acupuncture have been advocated for AC, but current evidence does not show significant benefit. (Choice E) Tumor necrosis factor-alpha inhibitors (eg, etanercept, infliximab) are indicated for treatment of rheumatoid arthritis and psoriatic arthritis. Psoriatic arthritis most commonly affects the distal interphalangeal joints of the fingers and toes; although larger joints may be affected, psoriatic arthritis is usually associated with destructive changes on x-ray. Educational objective: Mild adhesive capsulitis may be managed with rest and gentle range of motion exercises. Glucocorticoid injection is recommended for patients with more severe symptoms and those who do not improve with conservative measures. References: Adhesive capsulitis of the shoulder. (http://www.ncbi.nlm.nih.gov/pubmed/21885699) Manual therapy and exercise for adhesive capsulitis (frozen shoulder). (http://www.ncbi.nlm.nih.gov/pubmed/25157702)

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