A 51-year-old woman comes to the office due to progressive right arm and shoulder pain for 4 months. Washing her hair and reaching the upper shelves of the kitchen cabinets have been difficult. Heating pads and ice packs have not helped. She has had no fever, weight loss, or trauma. Medical history includes hypertension treated with lisinopril and hypothyroidism treated with levothyroxine. On examination, there is mild atrophy of the right deltoid muscle. Palpation of the neck, shoulders, and arms reveal no focal tenderness. Active and passive range of motion of the right shoulder is markedly reduced in abduction, flexion, and internal and external rotation compared to the left. Sensation in the upper extremities and strength in the hands and elbows are preserved. When she walks, the natural swing of the right arm is diminished. Which of the following is the best next step in management of this patient?

Question

A 51-year-old woman comes to the office due to progressive right arm and shoulder pain for 4 months.  Washing her hair and reaching the upper shelves of the kitchen cabinets have been difficult.  Heating pads and ice packs have not helped.  She has had no fever, weight loss, or trauma.  Medical history includes hypertension treated with lisinopril and hypothyroidism treated with levothyroxine.  On examination, there is mild atrophy of the right deltoid muscle.  Palpation of the neck, shoulders, and arms reveal no focal tenderness.  Active and passive range of motion of the right shoulder is markedly reduced in abduction, flexion, and internal and external rotation compared to the left.  Sensation in the upper extremities and strength in the hands and elbows are preserved.  When she walks, the natural swing of the right arm is diminished.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d869_9de5_bc81_277b0a137eb2_MD0003_00 This patient likely has adhesive capsulitis (AC), which presents with gradual onset, poorly localized shoulder pain and stiffness. AC is caused by glenohumeral capsule contracture; it is most common in women age 40-60 and in patients with diabetes mellitus or hypothyroidism. Examination in AC is characterized by reduced active and passive range of motion (ROM) in multiple axes (in contrast to rotator cuff arthropathy, in which passive ROM is preserved). In prolonged cases, deltoid muscle atrophy and loss of arm swing during ambulation may also be seen. Imaging (eg, x-ray, MRI, ultrasound) is not required for diagnosis but is often used to rule out other pathologies (eg, osteoarthritis, fracture). Treatment of AC includes gentle range of motion exercises, often with the assistance of physical therapy. Adjunctive measures include nonsteroidal anti-inflammatory drugs and corticosteroid injections. Surgical intervention (eg, capsular release) is occasionally needed in refractory cases. AC is a self-limited condition but without treatment, patients may have prolonged functional limitation. (Choice A) Bilateral proximal muscle weakness (eg, deltoids, hip flexors) is characteristic of polymyositis and dermatomyositis, for which a muscle biopsy may be indicated. Unlike AC, these conditions present predominantly with weakness rather than pain and stiffness; muscle involvement is bilateral (not unilateral); passive ROM is intact; and muscle atrophy is seen only in advanced disease. (Choice B) Oral corticosteroids are used to treat polymyalgia rheumatica, which presents with bilateral (not unilateral) pain and stiffness in the shoulders and hips. Unilateral shoulder muscle atrophy is uncommon. Because systemic corticosteroids have significant adverse effects (eg, weight gain, hyperglycemia), corticosteroid injections are preferred for AC. (Choice C and D) Cervical radiculopathy and peripheral nerve disorders (eg, demyelination, axonal degeneration), which are assessed with MRI and/or nerve conduction studies, present with upper extremity pain, numbness, and/or weakness but not decreased shoulder ROM. This patient's upper extremity sensation and strength are intact, making a neurological cause unlikely. Educational objective: Adhesive capsulitis results from contracture of the glenohumeral joint capsule and presents with gradual onset shoulder pain and reduced active and passive range of motion. Treatment includes gentle range of motion exercises; adjunctive measures include nonsteroidal anti-inflammatory drugs and corticosteroid injections. References: Adhesive capsulitis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/30811157)

A 51-Year-Old Woman Comes to the Office Due to Progressive