What is the diagnosis and treatment for a 57-year-old female with a dull ache in the shoulder that persists at night, radiates to the biceps, and has limited range of motion (ROM) in internal rotation, external rotation, and flexion, but normal strength, without any history of injury?

Adhesive Capsulitis (Frozen Shoulder)

This clinical presentation is classic for adhesive capsulitis (frozen shoulder), and treatment should begin immediately with physical therapy focusing on range of motion exercises, NSAIDs for pain control, and consideration of corticosteroid injection if conservative measures fail within 4-6 weeks. 1, 2

Diagnostic Reasoning

The constellation of findings strongly indicates adhesive capsulitis:

• Night pain that disrupts sleep is pathognomonic for adhesive capsulitis 3
• Inability to perform activities of daily living (unhooking bra strap) indicates severe functional limitation in internal rotation, a hallmark of this condition 4, 3
• Global restriction of passive ROM in internal rotation, external rotation, and flexion with preserved strength distinguishes adhesive capsulitis from rotator cuff tears 3
• No history of trauma and age 57 years fits the typical demographic (40-60 years, more common in women) 4, 3
• Pain radiating to biceps reflects the diffuse capsular inflammation characteristic of this condition 3

The preserved strength is critical—it rules out significant rotator cuff tears, which would show weakness on specific testing 3, 5.

Initial Diagnostic Workup

Obtain standard shoulder radiographs (AP views in internal and external rotation, plus axillary lateral or scapular Y view) to exclude other pathology such as glenohumeral osteoarthritis, calcific tendinitis, or fractures 1, 6

• Plain films are typically normal in adhesive capsulitis but are necessary to rule out alternative diagnoses 1
• Advanced imaging (MRI) is not initially indicated unless diagnosis remains unclear after radiographs or symptoms fail to improve with appropriate conservative management 1, 2

Treatment Algorithm

First-Line Conservative Management (Weeks 0-6)

Physical therapy is the cornerstone of treatment:

• Range of motion exercises focusing specifically on external rotation and abduction 1
• Gentle stretching and mobilization techniques, progressing gradually 2
• Avoid overhead pulleys which can cause uncontrolled abduction and worsen symptoms 1

Pain management:

• Start with acetaminophen as first-line oral analgesic 2
• If inadequate relief, use NSAIDs at the lowest effective dose for shortest duration 2
• Activity modification to reduce stress during healing 2

Second-Line Interventions (If inadequate response at 4-6 weeks)

Corticosteroid injection:

• Glenohumeral intra-articular corticosteroid injection is appropriate when inflammation-related pain persists 2
• This can provide significant pain relief and facilitate physical therapy participation 2

Refractory Cases (After 3-6 months of conservative treatment)

Consider manipulation under anesthesia or surgical intervention:

• Glenohumeral gliding manipulation under interscalene brachial plexus block has shown dramatic improvements (average 68° increase in flexion, 77° in abduction, 49° in external rotation immediately post-manipulation) 4
• This can be performed in an office setting by practitioners knowledgeable in manipulation techniques 4
• Surgical capsular release is reserved for cases failing all conservative measures 2

Critical Clinical Pearls

The limitation of external rotation correlates directly with pain severity, particularly night pain 7. This means that therapeutic interventions targeting external rotational dysfunction should be prioritized to reduce night pain 7.

Common pitfalls to avoid:

• Aggressive or improper passive range of motion can cause more harm than good 8
• Failing to address the global capsular restriction—focusing only on one plane of motion is insufficient 3
• Premature advanced imaging when clinical diagnosis is clear wastes resources 1

Screen for associated conditions:

• Diabetes and thyroid disorders are commonly associated with adhesive capsulitis 3

Expected Timeline

Symptoms typically persist for 3-16 months with conservative treatment 4. Most patients show measurable improvement with consistent physical therapy over 9 weeks average 4, though complete resolution may take 12-18 months.