A 65-year-old man presents to his primary care physician for stiffness in his arm. He has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient leads a sedentary life in which he tends to stay home and watch television. He does not engage in any physical or strenuous activity. His temperature is 98.6°F (37°C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min. On physical exam, the patient has decreased passive and active range of motion of his shoulder. The strength of the patient's upper extremity is 4/5 limited by pain. Which of the following is the most likely diagnosis?
Glenohumeral osteoarthritis
Adhesive capsulitis
Subacromial bursitis
Biceps tendinopathy
Adhesive capsulitis
This patient is presenting with stiffness and a decreased range of motion in his shoulders suggestive of a diagnosis of adhesive capsulitis.

Adhesive capsulitis classically presents in elderly, sedentary patients with a chief complaint of stiffness. On physical exam, the key findings are a loss of active, but more importantly, passive range of motion. It is the loss of passive range of motion that suggests a diagnosis of adhesive capsulitis over rotator cuff injuries, biceps tendinopathy, glenohumeral osteoarthritis, and subacromial bursitis. The diagnosis of adhesive capsulitis is made clinically; however, radiography, MRI, and ultrasound can be used to rule out other diagnoses. Treatment includes NSAIDs and physical therapy and can include steroids.

Ramirez reviews the evidence regarding the diagnosis and treatment of adhesive capsulitis. He discusses how non-operative management consists of nonsteroidal anti-inflammatory drugs, short-term oral corticosteroids, intra-articular corticosteroid injections, and physiotherapy. He recommends manipulation under anesthesia and arthroscopic capsule release in patients who fail conservative management.

Incorrect Answers:
Answer B: Biceps tendinopathy presents with pain and weakness overlying the long head of the biceps tendon. This tendon runs in the intertubercular groove on the anterior aspect of the proximal humerus. Patients will often present with pain with resisted flexion of the elbow. Treatment is surgical debridement in patients who fail conservative measures.

Answer C: Glenohumeral osteoarthritis presents with vague and diffuse pain that is exacerbated by activity in addition to a loss of range of motion of the shoulder. Though this patient is experiencing a decreased range of motion, the decreased passive range of motion is more specific for adhesive capsulitis. Treatment is with a total shoulder replacement in patients who fail conservative measures.

Answer D: Rotator cuff impingement presents with pain and weakness of the upper extremity, but also can present with a decreased range of motion as this patient experienced. Of note, the passive range of motion will not be significantly affected by this disease. Treatment is with surgical reconstruction or debridement of the rotator cuff if initial measures fail.

Answer E: Subacromial bursitis presents with localized tenderness, decreased range of motion, pain with motion, and sometimes erythema/edema. Though this patient is experiencing a decreased range of motion and pain with motion, the decreased passive range of motion suggests a diagnosis of adhesive capsulitis. Treatment is with rest and oral anti-inflammatory medications.

Bullet Summary:
Adhesive capsulitis presents with pain and a decreased passive and active range of motion.