A 57-year-old woman with a 6-month gradual dull nocturnal left shoulder ache radiating to the biceps, limited active and passive internal rotation, external rotation, and flexion, normal strength and no pain with resisted abduction, external rotation, or supination, and a history of hypothyroidism and treated breast cancer—what is the most likely diagnosis: adhesive capsulitis, biceps tendinitis, cervical radiculopathy, glenohumeral osteoarthritis, or rotator cuff tear?

Adhesive Capsulitis

The most consistent diagnosis with this patient's presentation is adhesive capsulitis (frozen shoulder), characterized by the equal restriction of both active and passive range of motion in all planes—particularly external rotation—combined with her risk factors of hypothyroidism and prior breast cancer treatment. 1

Clinical Reasoning for Adhesive Capsulitis

The hallmark feature distinguishing adhesive capsulitis from other shoulder pathology is the equal restriction of both active and passive motion in all planes, with external rotation being the most severely affected, followed by abduction. 1 This patient demonstrates:

• Limited internal rotation, external rotation, and flexion both actively and passively 1
• No pain with resisted isometric testing (abduction, external rotation, supination), which rules out primary tendon pathology 1
• Vague anterior tenderness rather than focal tendon pain 1

Why Other Diagnoses Are Less Likely

Rotator cuff tear is excluded because:

• Rotator cuff syndrome shows preserved passive motion with weakness and pain primarily during active movement 1
• This patient has normal strength with resisted testing and equal active/passive restriction 1
• Rotator cuff pathology demonstrates focal weakness with decreased range of motion during abduction with external or internal rotation, but passive motion remains relatively preserved 1

Biceps tendinitis is excluded because:

• There is no pain with resisted supination of the forearm, which would be expected with biceps pathology 1
• The global restriction of motion in all planes is inconsistent with isolated biceps tendon involvement 2

Cervical radiculopathy is excluded because:

• The patient has normal strength and movement in the elbow, wrist, and hand 1
• There are no neurological deficits or dermatomal pain patterns 3
• The restriction is purely glenohumeral rather than reflecting nerve root compression 3

Glenohumeral osteoarthritis is excluded because:

• While osteoarthritis can produce a similar clinical picture, it must be distinguished from adhesive capsulitis 4
• The 6-month gradual onset and nocturnal pain pattern are more consistent with adhesive capsulitis 2, 5
• Osteoarthritis typically shows radiographic changes and crepitus on examination 3

Critical Risk Factors Present

This patient has two major risk factors for adhesive capsulitis:

• Hypothyroidism: Thyroid disease is a well-established systemic risk factor for developing adhesive capsulitis 1, 2
• Breast cancer treatment history: Breast cancer treatment is identified as a significant risk factor, with oncology-related therapies associated with higher incidence of adhesive capsulitis 1, 6

The condition predominantly affects middle-aged women, which matches this 57-year-old female patient. 2, 5

Diagnostic Approach

MRI without contrast is the usually appropriate imaging study (rating 9) when radiographs are noncontributory, though imaging is not necessary to make the clinical diagnosis. 1 Key MRI findings include:

• Thickening of the coracohumeral ligament (high specificity) 2, 5
• Thickening of the axillary pouch and rotator interval joint capsule 5
• Obliteration of the subcoracoid fat triangle 5

Ultrasound is equally appropriate depending on local expertise (rating 9) for evaluation. 1

Management Considerations

The patient should avoid aggressive overhead pulley exercises, especially given her breast cancer treatment history, as such activities can exacerbate shoulder complications. 1, 6

Formal physical therapy should be instituted by 6-8 weeks if full shoulder function is not achieved, as delays beyond this timeframe may result in permanent shoulder dysfunction. 6

Treatment options include:

• Nonsteroidal anti-inflammatory drugs and short-term oral corticosteroids 2, 3
• Intra-articular corticosteroid injections combined with physiotherapy may provide greater improvement than physiotherapy alone 2
• Hydrodilatation as an adjunctive measure 2
• Surgical options (manipulation under anesthesia or arthroscopic capsule release) for refractory cases after 6-12 weeks of conservative treatment 2, 5

Common Pitfall to Avoid

The single most important pitfall is delaying intervention, as the window for prevention and early treatment is narrow. 6 Recent evidence challenges the traditional belief that adhesive capsulitis fully resolves without treatment—persistent functional limitations can occur if left untreated. 2