What is the most likely diagnosis for chronic shoulder pain with a clicking sound and limited range of motion (ROM) after a direct impact injury from a fall 5 years ago?

Most Likely Diagnosis: Chronic Labral Tear with Secondary Adhesive Capsulitis

The most likely diagnosis is a chronic labral tear with secondary adhesive capsulitis (frozen shoulder), given the 5-year history of persistent pain at rest, limited range of motion, and clicking with circumduction following direct impact trauma. 1

Clinical Reasoning

Primary Pathology: Labral Tear

• Clicking with circumduction is highly suggestive of labral pathology, as the torn labral fragment mechanically catches during shoulder rotation 1, 2
• The mechanism of direct impact from an 8-foot fall creates sufficient force to cause labroligamentous injury, which is a common post-traumatic soft-tissue injury 1
• Labral tears frequently persist chronically if untreated, continuing to cause mechanical symptoms and pain years after the initial injury 2

Secondary Pathology: Adhesive Capsulitis

• Pain at rest combined with limited ROM 5 years post-injury strongly suggests secondary adhesive capsulitis has developed 3, 4, 5
• Adhesive capsulitis commonly occurs concomitantly with other shoulder conditions like rotator cuff tendinopathy and labral pathology 3
• The chronic nature (5 years) makes adhesive capsulitis highly likely, as prolonged shoulder pain and disuse predispose to capsular fibrosis 4, 5, 6

Alternative Considerations (Less Likely)

• Rotator cuff tear: While common after trauma, typically presents with weakness and difficulty with overhead activities rather than clicking with circumduction 1
• Glenohumeral osteoarthritis: Would show progressive stiffness but less likely to cause clicking sounds 7
• Isolated adhesive capsulitis: Would not explain the clicking sound, which indicates intra-articular mechanical pathology 3, 6

Diagnostic Approach

Initial Imaging

• Obtain standard shoulder radiographs (AP in internal/external rotation plus axillary or scapula-Y view) to exclude fracture, dislocation, or significant osteoarthritis 1
• Radiographs can also identify bony Bankart lesions or Hill-Sachs deformities from the original trauma 2

Advanced Imaging

• MR arthrography is the gold standard for diagnosing labral tears and is superior to noncontrast MRI for detecting labroligamentous injuries 1
• In chronic cases (5 years post-injury), MR arthrography is preferred over noncontrast MRI because there will be no acute joint effusion to outline the labral tear 1
• MRI will also identify coracohumeral ligament thickening (>3mm), which is highly specific for adhesive capsulitis 6

Physical Examination Findings to Confirm

• Document both active and passive ROM limitation in all planes, especially external rotation (hallmark of adhesive capsulitis) 4, 6
• Perform O'Brien's test or crank test to provoke labral symptoms and clicking 2
• Assess for painful arc and impingement signs to evaluate for concurrent rotator cuff pathology 1, 2

Critical Pitfalls to Avoid

• Do not assume the 5-year chronicity means the condition is stable or benign—chronic labral tears can cause progressive cartilage damage and secondary osteoarthritis 2
• Do not overlook that adhesive capsulitis may mask the mechanical symptoms of the labral tear until capsular restriction is addressed 3, 4
• Do not order noncontrast MRI as the initial advanced imaging—in chronic cases without acute effusion, MR arthrography provides superior visualization of labral pathology 1
• Do not attribute all symptoms to adhesive capsulitis alone when clicking is present, as this indicates intra-articular mechanical pathology requiring different management 2, 3