A 54-year-old man is evaluated for a 6-month history of right shoulder pain. He describes the pain as moderately severe aching that is diffusely localized over the shoulder without radiation to the arm. The pain is constant, although it is worse at night and with any shoulder movement. The pain was insidious in onset and has been progressively worsening. He has had no neurologic or constitutional symptoms. Ibuprofen provides some pain relief.
On physical examination, vital signs are normal. Pain and limited range of motion are noted with both active and passive movement in all planes of motion, as is diffuse tenderness over the anterior and posterior areas of the right shoulder. There is no tenderness to palpation of the bony or soft tissue structures, nor is there cervical spine tenderness. There are no neck symptoms or findings.
Which of the following is the most likely diagnosis?
A. Acromioclavicular joint degeneration
B. Adhesive capsulitis
C. Bicipital tendinitis
D. Rotator cuff disease
MKSAP Answer and Critique
The correct answer is B. Adhesive capsulitis. This content is available to MKSAP 18 subscribers as Question 24 in the General Internal Medicine section. More information about MKSAP is available online.
This patient's clinical presentation is most consistent with adhesive capsulitis, also known as frozen shoulder. Adhesive capsulitis commonly presents as poorly localized, progressive pain described as a deep aching with an insidious onset. Pain is also frequently worse at night and in cold weather. In addition to pain, patients with adhesive capsulitis frequently develop decreased shoulder mobility as the disease progresses. Range of motion (both active and passive) is decreased in all planes of motion. Adhesive capsulitis may be idiopathic (primary adhesive capsulitis) or secondary to several conditions (secondary adhesive capsulitis). Secondary conditions include diabetes mellitus, hypothyroidism, prior surgery or trauma, prolonged immobilization, autoimmune disorders, and stroke.
Acromioclavicular joint degeneration is unlikely to be responsible for this patient's clinical presentation. Patients with acromioclavicular joint degeneration typically report pain localized to the acromioclavicular joint. Physical examination findings include tenderness to palpation of the joint, pain with shoulder abduction beyond 120 degrees, and pain with passive shoulder adduction (a positive cross-arm test).
Bicipital tendinitis typically results in pain localized to the anterior shoulder that may radiate toward the deltoid and into the arm. Pain classically worsens with overhead activity. On examination, tenderness may be elicited by palpating the bicipital groove. Pain also can be reproduced by placing the patient's ipsilateral arm at his or her side while flexing the elbow to 90 degrees and supinating against resistance (Yergason test).
Rotator cuff disease would not be expected to cause pain with both active and passive movement of the shoulder; therefore, it would not account for this patient's presentation.
- Adhesive capsulitis is characterized by loss of shoulder movement accompanied by pain; examination discloses significant loss of both active and passive range of motion.