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Differential Diagnosis
Complaints of shoulder pain or movement problems are difficult to evaluate. Many shoulder conditions have similar symptoms, causes, precipitating factors and treatments. Multiple pathologic lesions may be present in a single joint.4 In assessing a patient's shoulder pain, the physician must distinguish between true glenohumeral joint problems and extra-articular derangements. Active range of motion will most likely be limited and painful in both cases, but decreased passive range of motion, which is often painful as well, most likely indicates true joint pathology.
If the patient is able to relax and the examiner can elicit full passive range of motion, the etiology of the pain is most likely to be extra-articular. Prolonged soft tissue problems, however, may eventually lead to decreased shoulder range of motion because of the patient's constant guarding of the shoulder. It is imperative to determine the precise source of shoulder pain so that a program of physical therapy can be initiated to prevent compromise of shoulder movement. Extra-articular pain may result from strain or inflammation of muscles, tendons or bursae.
The differential diagnosis of shoulder problems is protean, but physicians should be able to readily recall some of the more common causes of shoulder pain and decreased range of motion. Bicipital tendinitis may affect active shoulder movement and is diagnosed by eliciting tenderness while pressing on the long head bicipital tendon in the bicipital groove. The bicipital tendon passes through the glenohumeral joint.
Pain on extension may be elicited by testing for Yergason's sign. The patient is asked to resist supination of the forearm while the physician presses on the bicipital tendon in the groove on the humerus. Pain with resisted forward flexion (Speed's test), may also be present.
Tendinitis of the rotator cuff is the most common cause of shoulder pain and secondary decreased shoulder mobility that manifests with pain on passive and active abduction.5,6 Pain is usually greater with internal rotation of the shoulder than with external rotation. The key finding is pain in the rotator cuff on active abduction, especially at 60 to 100 degrees of abduction. Ultimately, there may be impingement and a loss of mobility. Tenderness may be elicited anteriorly over the humeral head when the arm is extended. Calcific tendinitis may also lead to impingement.
The subacromial and subdeltoid bursae are contiguous in most persons. Subacromial bursitis manifests with pain when the patient lies on his or her shoulder, or with tenderness on palpation of the space on the lateral aspect of the shoulder just inferior to the acromion along the deltoid. Subacromial bursitis may also be a reactive phenomenon in a patient with a rotator cuff injury. Acromioclavicular joint problems, commonly including osteoarthritis, may also result in decreased passive joint range of motion and local tenderness.
True shoulder pain presents with tenderness on anterior or posterior palpation. Decreased joint motion is compensated for by an increase in scapulothoracic motion during flexion and abduction. Increased scapulothoracic motion stresses other structures around the shoulder and may result in more global pain syndromes, guarding and decreased range of motion.
Adhesive capsulitis has three defined stages: the painful stage, the adhesive stage and the recovery stage.
The evaluation of shoulder instability is important in patients with shoulder pain. Symptomatic subluxation may clinically mimic an acute rotator cuff injury or bicipital tendinitis. A high index of suspicion and a detailed physical examination combining the assessment of laxity in all directions with stress tests can help the physician determine the underlying cause of pain. Correction of any muscle imbalance is paramount to preservation of mobility and function. Muscles around the neck and shoulder girdle should be palpated for tenderness or trigger points to assess for fibromyalgia, myofascial pain syndromes and cervical osteoarthritis.
The correct diagnosis in a patient with restricted shoulder movement on physical examination and any of the previously mentioned findings, such as bursitis or tendinitis, is secondary adhesive capsulitis. The underlying condition is documented as the primary problem leading to secondary adhesive capsulitis.
Adhesive Capsulitis
Features, Presentation and Natural History
Primary idiopathic adhesive capsulitis is difficult to define, diagnose and manage. This condition affects 2 to 3 percent of the population. It tends to occur in patients older than 40 years of age and most commonly in patients in their 50s and in women. Fifteen percent of patients develop bilateral disease. Adhesive capsulitis has been reported in children.
TABLE 2
The Three Stages of Adhesive Capsulitis
Painful stage
• Pain with movement
• Generalized ache that is difficult to pinpoint
• Muscle spasm
• Increasing pain at night and at rest
Adhesive stage
• Less pain
• Increasing stiffness and restriction of movement
• Decreasing pain at night and at rest
• Discomfort felt at extreme ranges of movement
Recovery stage
• Decreased pain
• Marked restriction with slow, gradual increase in range of motion
• Recovery is spontaneous but frequently incomplete
The natural history of adhesive capsulitis and its clinical course is divided into three stages: the painful stage, the adhesive stage and the recovery stage. The painful stage involves gradually increasing pain and stiffness and lasts between three and eight months. Muscle spasms in the trapezius also commonly occur during this phase. A history of a minor strain or injury before onset may be noted; however, it is unclear whether the initial strain is an independent phenomenon or an early awareness of the pain associated with the onset of adhesive capsulitis.
Commonly, patients note a decreased ability to reach behind the back when fastening a garment or removing a wallet from a back trouser pocket. The initial discomfort is described by many patients as a generalized shoulder ache with difficulty pinpointing the exact location of the discomfort. The pain may radiate both proximally and distally, is aggravated by movement and alleviated with rest. Sleep may be interrupted if the patient rolls on the involved shoulder.
This condition progresses to one of severe pain accompanied by stiffness and decreased range of motion. The stiffening increases to the point where the natural arm swing that accompanies normal gait is lost.8 The patient tries to compensate for this loss by using other muscles and increasing scapular rotation to accomplish various activities. This places additional strain on the other muscle groups, leaving them overworked and tender.
The physical examination during the painful stage of adhesive capsulitis may reveal muscle spasm and diffuse tenderness about the glenohumeral joint and the deltoid muscle. An area of pinpoint tenderness is seldom found. With disease progression and in long-standing cases, disuse atrophy of the shoulder girdle may result. Passive and active range of motion in all planes of shoulder movement are lost. This global loss of motion is the primary factor distinguishing adhesive capsulitis from many of the conditions associated with secondary adhesive capsulitis.
The second stage, the adhesive stage, involves increasing stiffness with diminishing pain. Pain decreases at night, and discomfort occurs only at the extremes of motion, although movement is dramatically decreased. This stage lasts four to six months.
The final stage, called the recovery stage, lasts from one to three months and is characterized by minimal pain but severe restriction of movement. This latter stage is self-limiting, with a gradual and spontaneous increase in range of motion. Complete recovery, however, is infrequent. The external rotation range of motion improves first, followed by abduction and internal rotation. Short recovery periods may have associated bouts of pain before each phase of improvement. Although approximately 7 to 15 percent of patients permanently lose their full range of motion, only a few have a true functional disability.
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