Working Diagnosis:
Adhesive capsulitis of right shoulder

Treatment:
Patient had 50% improvement in pain after neck epidural steroid injection but no increase in range of motion. In addition to continuing physical therapy, subacromial injection led to greater than 80% relief of pain.

Outcome:
One month later, passive range of motion with forward flexion was improved to 145 degrees on right (120 degrees with active range of motion), abduction improved to 110 degrees. Three months after subacromial injection, passive range of motion with forward flexion improved to 160 degrees (150 degrees with active range of motion). She was noticing more right neck-based pain and returned to Physical Medicine and Rehabilitation for neck-based interventions.

Author's Comments:
There was no unifying diagnosis in this case, given the patient's underlying cervical radiculopathy and hemiparesis after stroke. The most intriguing aspect was whether her decreased range of motion was due to spasticity from hemiparesis versus true adhesive capsulitis. Spasticity is a velocity-dependent hypertonicity, in which the faster a pressure is applied to a muscle, the harder it resists movement. As such, with slow onset of steady pressure, we would expect passive range of motion to improve. Given that we were unable to assist the patient in reaching overhead even with sustained force, adhesive capsulitis was the most likely diagnosis.

Editor's Comments:
Adhesive capsulitis has an estimated prevalence of 2-5%, with women between the ages of 40-60 making the majority of those diagnosed (1). There is no consensus on the best treatment for adhesive capsulitis; both intra-articular and subacromial steroid injections have shown to produce clinically relevant improvements in pain in the short term (2) whereas nonsteroidal anti-inflammatory medications do not appear to offer much pain relief (1). After a trial of 6-8 weeks of conservative treatment, surgery can be considered (1). Other differentials to consider besides the ones the author listed are: bursitis, neoplasm, arthritis and autoimmune disorders.

References:
1.Ramirez, Jason. Adhesive Capsulitis: Diagnosis and Management. AAFP. March 1, 2019.
2. Kitridis, Dimitrios. Efficacy of Pharmacological therapies for Adhesive Capsulitis of the Shoulder. The American Journal of Sports Medicine. 2019.

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