What is the differential diagnosis and management for bilateral shoulder stiffness with decreased range of movement in a 77-year-old non-diabetic female?

Bilateral Shoulder Stiffness in a 77-Year-Old Non-Diabetic Female

Differential Diagnosis

The most likely diagnosis in this patient is bilateral adhesive capsulitis (frozen shoulder), though you must systematically rule out rotator cuff disease, glenohumeral osteoarthritis, and polymyalgia rheumatica given the bilateral presentation and age. 1, 2

Primary Differential Considerations:

• Adhesive capsulitis (frozen shoulder) - characterized by diffuse shoulder pain with restricted passive range of motion in all planes, particularly external rotation and abduction 1, 3

  • Primary (idiopathic) frozen shoulder has a prevalence of 2-5% in the general population and typically progresses through three phases: freezing, frozen, and thawing, each lasting months to years 2
  • While diabetes is a major risk factor, adhesive capsulitis occurs in non-diabetics and can be associated with thyroid disorders 2, 3
  • Bilateral presentation occurs but is less common than unilateral 1

• Rotator cuff disease - presents with pain during overhead activities, weakness on empty can and external rotation tests, and positive impingement signs 3

  • In patients over 50 years, rotator cuff tears are increasingly common and can present with stiffness secondary to pain-related guarding 4, 3
  • Bilateral rotator cuff pathology is possible, especially in this age group 5

• Glenohumeral osteoarthritis - in patients older than 50 years, typically presents as gradual pain and progressive loss of motion 3

  • Bilateral presentation would be unusual but possible 3

• Polymyalgia rheumatica (PMR) - critical not to miss in a 77-year-old with bilateral shoulder stiffness 3

  • Presents with bilateral shoulder and hip girdle pain and stiffness, worse in the morning
  • Associated with elevated inflammatory markers (ESR, CRP)
  • Dramatic response to low-dose corticosteroids is diagnostic

• Acromioclavicular osteoarthritis - presents with superior shoulder pain, acromioclavicular joint tenderness, and painful cross-body adduction 3

Initial Diagnostic Workup

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapular-Y view bilaterally) to rule out fracture, glenohumeral or acromioclavicular arthritis, and significant bony pathology. 5, 6

Essential Physical Examination Findings:

• Assess both active AND passive range of motion - adhesive capsulitis shows restriction in both, while rotator cuff disease typically shows preserved passive motion 1, 3
• Test external rotation specifically - most sensitive for adhesive capsulitis 6, 7
• Perform empty can test and external rotation strength testing - weakness suggests rotator cuff pathology 3
• Cross-body adduction test - pain indicates AC joint pathology 3
• Apprehension and relocation tests - positive findings suggest instability (less likely at this age) 3

Laboratory Studies to Consider:

• ESR and CRP - essential to rule out polymyalgia rheumatica in this age group 3
• Thyroid function tests - adhesive capsulitis can be associated with thyroid disorders 3

Conservative Management Protocol

Implement a structured 3-month conservative program focusing on pain control, gentle mobilization with emphasis on external rotation and abduction, and progressive strengthening before considering advanced imaging. 6, 7

Phase 1: Pain Control and Initial Mobilization (Weeks 1-4)

• Analgesics: Use acetaminophen or ibuprofen if no contraindications 6, 7
• Subacromial corticosteroid injection: Consider if pain is thought related to rotator cuff or bursal inflammation 6
• Intra-articular glenohumeral injection: May be beneficial for adhesive capsulitis with or without joint distension 1
• Ice, heat, and soft tissue massage: Apply to reduce pain and inflammation 6, 7
• Apply local heat before exercise - higher strength of recommendation than ultrasound 7
• Complete rest from aggravating activities until acute symptoms resolve 6

Phase 2: Gentle Mobilization (Weeks 2-8)

• Begin gentle stretching and mobilization techniques focusing specifically on external rotation and abduction 6, 7
• Use active, active-assisted, or passive range of motion exercises performed in safe positions 6, 7
• CRITICAL PITFALL TO AVOID: Do NOT use overhead pulleys - they encourage uncontrolled abduction and can worsen shoulder pathology 6, 7
• Gradually increase active range of motion in conjunction with restoring proper joint alignment 6

Phase 3: Strengthening (Weeks 6-12)

• Strengthen rotator cuff and scapular stabilizer muscles 6
• Re-establish proper mechanics of the shoulder and spine 6
• Progress to dynamic stabilization exercises 6
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain 6

Adjunctive Therapies:

• Neuromuscular electrical stimulation (NMES) can be considered for persistent pain 6, 7
• Repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) may be used as adjuncts 6
• For spasticity-related pain (if neurologic component): botulinum toxin injections into subscapularis and pectoralis 6, 7

When to Obtain Advanced Imaging

If symptoms persist beyond 3 months despite appropriate conservative management, obtain MRI without contrast bilaterally to evaluate for rotator cuff tears, labral pathology, or other soft tissue injuries requiring surgical intervention. 6

• MRI without contrast is the preferred modality for evaluating rotator cuff disease and adhesive capsulitis 5
• MR arthrography is reserved for suspected labral tears or when distinction between full and partial thickness rotator cuff tears is needed 5
• Ultrasound is operator-dependent but can evaluate rotator cuff integrity if local expertise available 5

Surgical Considerations

In cases with refractory stiffness after conservative management, arthroscopic capsular release is preferred over manipulation under anesthesia due to lower complication risk. 1

• Manipulation under anesthesia carries various potential risks including fracture and neurovascular injury 1
• After capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcomes 1

Return to Activity

• Return to normal activities only after achieving pain-free motion and adequate strength 6
• Common pitfall: Returning to activity too soon before adequate healing can lead to chronic pain and dysfunction 6
• Duration of conservative treatment typically ranges from 1-3 months depending on severity 6

Special Consideration for Bilateral Presentation

The bilateral nature of this presentation warrants heightened suspicion for systemic causes, particularly polymyalgia rheumatica in this age group, which would fundamentally change management to systemic corticosteroids rather than local shoulder treatment 3.