Refer to Physical Therapy for Adhesive Capsulitis
The next step is to refer this patient to physical therapy for treatment of adhesive capsulitis (frozen shoulder), which is the most likely diagnosis given her presentation of diffuse shoulder pain with marked limitation in both active and passive range of motion following breast cancer treatment. 1, 2
Clinical Reasoning
Why Adhesive Capsulitis is the Primary Diagnosis
- Breast cancer survivors with a history of mastectomy are at high risk for developing adhesive capsulitis, characterized by progressive loss of range of motion and diffuse shoulder pain 2
- The clinical presentation—difficulty dressing, diffuse pain on palpation, and marked decreased range of motion in both passive and active movements without obvious weakness—is classic for adhesive capsulitis rather than rotator cuff pathology 1
- The 6-month timeline post-fall is consistent with the natural progression of adhesive capsulitis, which can be triggered by trauma or immobilization 2
Physical Therapy as First-Line Treatment
Physical therapy is the recommended first-line intervention and should be attempted for 6-12 months before considering any other interventions. 2, 3
The physical therapy prescription should specifically include: 1
- Range of motion exercises focusing on gentle stretching and mobilization techniques, particularly increasing external rotation and abduction 1
- Rotator cuff and posterior shoulder girdle strengthening exercises 1
- Anterior shoulder girdle flexibility work to address common restrictions 1
- Scapular mobility assessment and treatment to optimize shoulder mechanics 1, 2
What to Avoid
- Do not order MRI at this stage—diagnosis is clinical, and imaging is only considered if conservative management fails after 6-12 months or if alternative diagnoses are suspected 2
- Avoid aggressive passive range of motion and overhead pulley exercises, as these can worsen shoulder pain and potentially cause harm 1, 2
Additional Management Considerations
Pain Control During Physical Therapy
- Offer acetaminophen or NSAIDs (such as ibuprofen or naproxen) for pain relief to facilitate participation in physical therapy 1, 4
- Consider acupuncture as an adjunct if pain limits therapy participation, as it has demonstrated effectiveness for musculoskeletal pain in breast cancer survivors 1
Monitoring Tamoxifen Effects
- Be aware that tamoxifen can have antiresorptive properties but may contribute to musculoskeletal symptoms in some patients 1
- The osteopenia noted on X-ray requires attention: ensure adequate calcium (1200 mg/day total intake) and vitamin D3 (600-1000 IU/day) supplementation 1
- Consider DEXA scan to quantify bone density given her breast cancer history, tamoxifen use, and radiographic osteopenia 1, 5
Follow-Up Plan
- Reassess in 6-12 weeks for response to physical therapy 2
- Red flags requiring earlier re-evaluation or alternative workup include: 2
- Progressive neurologic symptoms
- Unremitting night pain
- Constitutional symptoms (fever, weight loss)
- Lack of any improvement after 3 months of consistent physical therapy
If Physical Therapy Fails
- After 6-12 months of failed conservative management, consider further evaluation with MRI to assess for alternative diagnoses such as rotator cuff tear or other structural pathology 2
- Subacromial corticosteroid injection may be considered if pain is thought to be related to subacromial inflammation, though this is typically a secondary consideration after physical therapy 1