The Elusive Etiology of “Frozen Shoulder”

[David Brown]

I recently evaluated a shoulder patient who had over the last year undergone a move from the west coast to Charlottesville due to a high stress job, experienced a heart attack a few months later requiring an implanted pacemaker, and now has experienced an insidious and quick onset of right shoulder pain and loss of mobility in all directions. Combined Apley IR/ER style motions are the most problematic for this patient. The patient had been dealing with this pain for about 6 months before making an appointment with PT services. Even though the patient has been undergoing large amounts of stress with other ailments and the stress of the move, I didn’t detect much in the sense of yellow flags and he was fairly optimistic about his situation. He did mention his frustration with his symptoms as he did not have any idea why this occurred as there was no MOI and he is also annoyed about how difficult it is for him to dress himself in the morning and engage in recreational activities like biking, rock climbing, and throwing the frisbee with his children.
Upon assessment, the patient exhibited a capsular pattern loss of active motion coupled with a hard end feel with passive motion with associated joint hypermobility in all planes. He was experiencing a high level of pain in association with any arm movements approaching 90 degrees and anything past that was excruciating for him. In reflection, I realized what made my differential unnecessarily difficult was me trying to still conduct many of my special tests to rule out labral and RTC pathology. Because the patient was already experiencing a high level of irritability and had difficulty holding his arm in 90 degrees of flexion without pain, full/empty can, speeds, and O’Brien’s were all positive. I was able to discern with specific questions about where the patient was experiencing pain and was still able to properly differentiate his symptoms well enough that I felt confident about my diagnosis. But I feel like I could have done a better job and changed the testing position of the shoulder if I knew already that normal testing positions would be painful for the patient. I feel like generally speaking many of these special tests aren’t the greatest or clear cut and can sometimes muddy up what could have been a more clear cut diagnosis; especially when the patient is experiencing a high level of pain. Also, by taking the patient through these tests I feel like I flared up his shoulder symptoms unnecessarily without gaining any additional information.
Despite all of this I believe I still got good buy-in with him. I feel like I did a good job explaining the pathophysiology of adhesive capsulitis and the idea of loss of motion in a capsular pattern in a way that he understood. The only challenging educational piece that I experienced with him is that the etiology for this condition isn’t clear. Many patients, especially those that experience an onset of painful symptoms for seemingly no reason and without any MOI, want an explanation as to why they are experiencing what they are experiencing, and it can be difficult to explain that conditions like this don’t have a clear etiology. I explained many of the factors and comorbidities that have been found to be correlated with adhesive capsulitis but I could tell he wasn’t satisfied with the answer. He understood though by the end of the conversation that joint mobilization and restoration of mobility through PROM and AAROM would be important to return to his prior level of function. I found this case, although fairly easy to diagnose other than some wasteful special tests that I could have done without, to be challenging from an educational standpoint. And this is understandably so as this can be a very debilitating condition to deal with when there isn’t clear cut explanation as to why it occurs.

[Author]

Posts