Differential Diagnosis for Severe Anterior Shoulder Pain Worst at Bedtime

• Single most likely diagnosis
  • Adhesive Capsulitis (Frozen Shoulder): This condition is characterized by severe pain and stiffness in the shoulder, often worse at night, which aligns with the patient's symptoms. The pain typically occurs in the anterior aspect of the shoulder and can significantly impact sleep.
• Other Likely diagnoses
  • Rotator Cuff Tendinitis: Inflammation of the tendons surrounding the shoulder joint can cause severe pain, especially at night when the shoulder is at rest. This condition is common and can be exacerbated by activities that involve lifting or repetitive arm movements.
  • Bursitis: Inflammation of the bursae, fluid-filled sacs that cushion the joints, can cause pain and stiffness in the shoulder, particularly in the anterior region. This condition can also worsen at night.
  • Shoulder Impingement Syndrome: This condition occurs when the shoulder blade puts pressure on the underlying tissues, including the rotator cuff tendons and bursae, when the arm is lifted. It can cause pain, especially at night, and is a common issue in individuals who engage in overhead activities.
• Do Not Miss diagnoses
  • Pulmonary Embolism: Although less common, referred pain from a pulmonary embolism can sometimes be felt in the shoulder region. It's crucial to consider this diagnosis, especially if the patient has risk factors such as recent travel, surgery, or a history of deep vein thrombosis.
  • Myocardial Infarction (Heart Attack): Referred pain from a heart attack can occasionally be felt in the shoulder. Given the potential severity of this condition, it's essential to rule out cardiac causes, especially in patients with cardiovascular risk factors.
• Rare diagnoses
  • Pancoast Tumor: A rare type of lung cancer that can cause shoulder pain due to local invasion of the tumor into the brachial plexus or other structures. This diagnosis is less likely but should be considered in patients with persistent, unexplained shoulder pain, especially if accompanied by other systemic symptoms.
  • Referred Pain from Abdominal Pathology: Certain abdominal conditions, such as gallbladder disease or peptic ulcer disease, can refer pain to the shoulder region. While less common, these diagnoses should be considered, especially if the patient has other symptoms suggestive of abdominal pathology.