How should I evaluate and manage the limited range of motion in the left shoulder of a 42‑year‑old man with three years of chronic jaw pain, left‑axillary pain radiating down the left arm, and temperature‑sensitive numbness and paresthesia?

Evaluation and Management of Limited Left Shoulder Range of Motion

Initial Clinical Assessment

Begin with plain radiographs of the left shoulder as your first imaging study 1, 2. Order a standard 3-view series including anteroposterior (AP) views in internal and external rotation plus an axillary or scapula-Y view 1, 2. This is the preferred initial diagnostic approach regardless of whether trauma is suspected, as radiographs effectively identify fractures, dislocations, and glenohumeral alignment issues that require immediate intervention.

Key Clinical Context

Given this patient's constellation of symptoms—chronic jaw pain (3 years), left axillary pain radiating down the arm, temperature-sensitive numbness/paresthesia, and limited shoulder ROM—you must consider both local shoulder pathology and referred pain patterns. The jaw pain raises concern for temporomandibular disorder (TMD), which can produce broadly distributed pain to the deltoid, trapezius, and posterior scapular regions due to extensive convergence of afferent signals in the dorsal horn 3. The location of symptoms may not correspond to the actual pain generator in the shoulder region 3.

Diagnostic Algorithm

Step 1: Rule Out Serious Pathology

Look specifically for:

• Fever, unexplained weight loss, or history of malignancy (suggesting infection or neoplasm) 4
• Significant trauma history
• Neurologic deficits beyond the described paresthesias
• Signs of systemic inflammatory disease

If any are present, expedite specialist referral 4.

Step 2: Characterize the Range of Motion Limitation

Determine whether the limitation follows:

• Capsular pattern (external rotation most limited, then abduction, then internal rotation)—suggests adhesive capsulitis
• Noncapsular pattern—suggests other soft tissue pathology 3

Document specific ROM deficits. Research shows individuals with chronic pain often have reduced abduction (mean difference -7.36°) and lateral rotation (mean difference -8.61°) 5.

Step 3: Assess for Cervical Contribution

Critical pitfall: Shoulder pain frequently coexists with cervical dysfunction. Evaluate neck ROM and endurance, as individuals with shoulder pain demonstrate reduced neck mobility in all directions and decreased muscle endurance 6. Specifically test:

• Neck flexion and contralateral rotation (these have acceptable discriminative capacity for identifying shoulder pain) 6
• Endurance of ipsilateral lateral flexor muscles 6

Step 4: Consider TMD as Primary or Contributing Factor

Given the 3-year history of jaw pain, assess for TMD using clinical criteria 7. The axillary pain and arm radiation could represent referred pain from TMD rather than primary shoulder pathology.

Advanced Imaging (If Radiographs Normal or Indeterminate)

Do not proceed to advanced imaging immediately 4. Most nontraumatic shoulder pain is self-limiting and does not require imaging beyond radiographs unless:

• Symptoms persist despite conservative management
• Significant functional deficit exists
• Surgical intervention is being considered

If advanced imaging becomes necessary:

• MRI without contrast is the next appropriate study for soft tissue evaluation 1
• CT is reserved for complex fracture characterization, not soft tissue assessment 1, 2
• Ultrasound has limited utility beyond rotator cuff evaluation 1

Management Strategy

Initial Conservative Management (First-Line)

Implement conservative care for 6-12 weeks before considering advanced interventions 2, 4:

1. Education: Explain the favorable natural history of most shoulder conditions 4

2. Gentle stretching and mobilization: Focus on increasing external rotation and abduction gradually 8. Active ROM should be increased in conjunction with restoring alignment and strengthening weak shoulder girdle muscles 8.

3. Pain management:

   • Acetaminophen or ibuprofen if no contraindications 8
   • Avoid opioid combinations 7

4. Activity modification: Watchful waiting with symptom-guided activity 4

If TMD is Contributing or Primary

Strong recommendation for cognitive behavioral therapy (CBT) with or without biofeedback, plus supervised jaw exercises and stretching 7. Manual trigger point therapy and mobilization are also strongly recommended 7.

Avoid: Occlusal splints (reversible or irreversible), arthrocentesis, botulinum toxin injections, and benzodiazepines for TMD 7.

Interventional Options (If Conservative Management Fails)

Only after 6-12 weeks of conservative care:

1. For adhesive capsulitis with persistent pain: Consider subacromial corticosteroid injection if pain is thought related to subacromial inflammation 8

2. For spasticity-related pain: Botulinum toxin into subscapularis and pectoralis muscles may be appropriate 8

3. Mobilization with movement (MWM): Demonstrates significant superiority over other mobilization techniques for improving pain (SMD = 1.03), disability (SMD = 0.82), and ROM immediately post-therapy in adhesive capsulitis 9

Critical Pitfalls to Avoid

• Do not order MRI or refer to orthopedics prematurely 4. Structural abnormalities often do not correlate with symptoms and may lead to overdiagnosis and overtreatment.

• Do not assume shoulder pathology is the sole pain generator given the chronic jaw pain and radiation pattern 3.

• Do not pursue surgical intervention for subacromial pain—high-certainty evidence shows no benefit 4.

• Recognize regional interdependence: The neck and shoulder function as an integrated system 6. Addressing only the shoulder while ignoring cervical dysfunction will limit treatment success.

Specialist Referral Indications

Refer only if:

• Suspected serious pathology (infection, malignancy, fracture, dislocation)
• Significant functional or neurologic deficit
• Features of systemic inflammatory disease
• Persistent or worsening pain after 3-6 months of appropriate conservative care 4