A 55-year-old woman comes to the office with right shoulder pain for the past 2 months. The patient is unable to raise her arm or reach for objects. Her right hand is dominant, but she has recently been using her left more due to the problems on the right. The patient lives with her disabled spouse, who had a stroke 8 months ago. Before the pain, she had taken care of his daily activities and helped transfer him from his bed to wheelchair but is now unable to do so. The patient's other medical conditions include type 2 diabetes mellitus, Graves disease, hypertension, and hypercholesterolemia. On examination, there is markedly decreased passive and active abduction, flexion, and rotation at the right shoulder. Palpation of the shoulder and acromioclavicular joint do not reproduce the pain. The remainder of the physical examination is unremarkable. X-ray of the shoulder is shown below. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 55-year-old woman comes to the office with right shoulder pain for the past 2 months.  The patient is unable to raise her arm or reach for objects.  Her right hand is dominant, but she has recently been using her left more due to the problems on the right.  The patient lives with her disabled spouse, who had a stroke 8 months ago.  Before the pain, she had taken care of his daily activities and helped transfer him from his bed to wheelchair but is now unable to do so.  The patient's other medical conditions include type 2 diabetes mellitus, Graves disease, hypertension, and hypercholesterolemia.  On examination, there is markedly decreased passive and active abduction, flexion, and rotation at the right shoulder.  Palpation of the shoulder and acromioclavicular joint do not reproduce the pain.  The remainder of the physical examination is unremarkable.  X-ray of the shoulder is shown below.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d2e9_896a_bc81_03df125192e8_MD0003_00 This patient has chronic shoulder pain with decreased passive and active range of motion (ROM), consistent with adhesive capsulitis (sometimes termed frozen shoulder). Adhesive capsulitis is characterized by loss of the normal distensibility of the glenohumeral joint capsule due to chronic inflammation, fibrosis, and contracture. It is most common in middle-aged and older individuals, and the risk is increased in patients with diabetes mellitus, thyroid disorders, and chronic immobility. It is also common in patients with rotator cuff tendinopathy or fracture of the proximal humerus. Patients with adhesive capsulitis typically report gradual-onset shoulder stiffness that limits the ability to flex, abduct, or rotate the humerus. The diagnosis is confirmed by demonstrating a reduction in both passive and active ROM in multiple planes. X-ray findings, as in this patient, are usually normal, and imaging is used primarily to rule out other causes of pain. (Choice B) Calcific tendinopathy of the shoulder is caused by hydroxyapatite deposits in the rotator cuff tendons. It is characterized by pain during abduction, which may be severe. Active ROM may be limited because of pain, but passive ROM remains normal, and calcifications of the tendons are visible on x-ray. calcifications of the tendons (Choice C) Osteoarthritis of the glenohumeral joint can decrease both active and passive ROM. However, this condition is relatively uncommon, and most patients have a history of significant past shoulder trauma. (Choices D and E) Rotator cuff tears often follow an injury (eg, fall on outstretched hand) and typically cause weakness with active shoulder abduction and rotation. Rotator cuff (primarily supraspinatus) tendonitis is an overuse syndrome characterized by painful abduction and external rotation (eg, heavy lifting above the shoulder). Patients with these disorders may resist manipulation of the arm because of pain, but passive ROM is normal. Educational objective: Adhesive capsulitis is characterized by pain and loss of distensibility of the glenohumeral joint capsule due to chronic inflammation, fibrosis, and contracture. It is often seen in patients with diabetes mellitus, thyroid disorders, chronic immobility, rotator cuff tendinopathy, and fracture of the proximal humerus. Examination shows decreased active and passive range of motion in multiple planes. X-ray findings are normal. References: Adhesive capsulitis of the shoulder. (http://www.ncbi.nlm.nih.gov/pubmed/21885699)

A 55-Year-Old Woman Comes to the Office with Right Shoulder