The patient is a 55-year-old female who lives alone. The patient reports a 7-month history of unilateral shoulder girdle stiffness, pain, and weakness with a diagnosis from the physician of “right frozen shoulder.” There was no history of trauma, but the patient reported an abrupt onset of very severe pain 7 months prior. Within several days, she also had right forearm and thumb pain of lesser severity, and weakness of the right shoulder. The forearm and thumb pain had since resolved, and although there was some restricted motion of the shoulder, the more marked painful stiffness of the shoulder did not occur until 2 or 3 months after the onset of symptoms. The patient also reported pain with sleeping on the shoulder, and pain/stiffness of the shoulder in the morning. After 3 months, she was having difficulties performing her job functions towards the end of her shift and sought medical attention. Thus far she had been treated with a series of two corticosteroid injections, both of which had given her short-term relief.
The patient reports numerous repetitive motions at work. The job also requires some lifting. The patient reports a non-work-related right shoulder injury 5 years ago, which resolved in 2 months with a course of physical therapy, including ROM and strengthening exercises, which she followed for 1 month after discharge from PT.
With the exception of a 10 year history of Type 2 diabetes, and thyroid disease, the patient's past medical and surgical history is unremarkable, except for gallbladder surgery 2 years ago.
At this point in the examination, is it possible to confirm the physician’s diagnosis? Why or why not?
Given the patient's history of the present condition, and the unremarkable past medical history, it is likely that the physician's diagnosis of right frozen shoulder (adhesive capsulitis) is correct. However, without a full examination, confirmation cannot be made at this stage.
What does the history of pain with sleeping on the shoulder, and pain/stiffness in the morning tell the clinician?
Subjective reports of difficulty sleeping on the involved shoulder, and pain and stiffness of the shoulder in the morning are very typical of those patients with adhesive capsulitis.
Why do you think the patient’s symptoms are related to time of day?
There are two times a day when the symptoms appear to worsen: first thing in the morning, and towards the end of the patient's work shift. Both can be explained as being part of the inflammatory/fibrosing process of adhesive capsulitis. The repetitive motions occurring at work are likely increasing the inflammation at the shoulder, while the pain and stiffness in the morning is likely produced by synovitis and the fibrosing process.