Can you provide an APTA‑compliant SOAP note for a 55‑year‑old right‑hand dominant female office worker with a 9‑month history of adhesive capsulitis of the right shoulder, type 2 diabetes mellitus, hypothyroidism, and current use of metformin, levothyroxine, and ibuprofen for shoulder pain?

SOAP Note for Adhesive Capsulitis >6 Months (APTA-Compliant)

SUBJECTIVE

Chief Complaint:

• 55-year-old right-hand-dominant female office worker reports 9 months of progressive right shoulder pain and stiffness limiting work and daily activities 1

History of Present Illness:

• Pain began insidiously 9 months ago without trauma 2
• Progressive loss of shoulder motion, particularly difficulty reaching overhead and behind back 3
• Pain worse at night, interfering with sleep on right side 1
• Currently taking ibuprofen for pain with partial relief 1
• No history of shoulder surgery or immobilization 3

Past Medical History:

• Type 2 diabetes mellitus (on metformin) - critical risk factor 3, 2
• Hypothyroidism (on levothyroxine) - critical risk factor 3, 2

Medications:

• Metformin (diabetes management)
• Levothyroxine (thyroid replacement)
• Ibuprofen PRN (shoulder pain) 1

Functional Limitations:

• Unable to reach overhead shelves at work 1
• Difficulty with self-care activities (hair washing, fastening bra) 1
• Reduced typing efficiency due to compensatory postures 1

OBJECTIVE

Observation:

• Guarded posture with right shoulder held in adduction and internal rotation 3
• Visible muscle atrophy in supraspinatus and infraspinatus fossae (chronic stage) 4

Range of Motion (Goniometric Measurements):

• External rotation: 10° (normal 90°) - MOST SEVERELY RESTRICTED 3, 1
• Abduction: 80° (normal 180°) 3
• Forward flexion: 100° (normal 180°) 3
• Internal rotation: Unable to reach posterior superior iliac spine 3
• Key finding: Equal restriction of active AND passive ROM in all planes 3

Strength Testing:

• Deferred due to pain and severe motion restriction 3
• No focal weakness noted in available range 3

Special Tests:

• Passive external rotation with scapular stabilization: severely limited with capsular end-feel 3
• Empty can test: not performed due to motion restriction 3

Palpation:

• Diffuse tenderness over anterior and posterior glenohumeral joint 1
• No focal tenderness over rotator cuff insertions 3

Functional Assessment:

• Unable to perform overhead reaching tasks 1
• Compensatory trunk lean during attempted elevation 1

ASSESSMENT

Primary Diagnosis:

• Adhesive capsulitis (frozen shoulder), right shoulder, Stage 2 (frozen phase) - 9-month duration 2, 4

Clinical Reasoning:

• Diagnosis confirmed by equal restriction of active and passive motion in all planes, with external rotation most severely affected 3
• Duration of 9 months places patient in frozen phase (typically 4-12 months) 4
• High-risk profile: diabetes mellitus and hypothyroidism are established risk factors 3, 2
• Differential diagnoses excluded: Rotator cuff syndrome ruled out because passive motion equally restricted (rotator cuff would show preserved passive motion) 3

Prognosis:

• Recent evidence challenges the traditional "self-limiting" theory - persistent functional limitations occur if left untreated 2
• Condition typically persists 2-3 years total, but patients may suffer pain and limited ROM beyond this timeframe 4
• Diabetic patients often have more prolonged and severe course 2

Impairments:

• Severe capsular restriction, particularly external rotation 3, 1
• Pain limiting participation in rehabilitation 1
• Functional disability affecting work and ADLs 1

PLAN

Immediate Treatment Algorithm (Evidence-Based)

Phase 1: First-Line Treatment (Weeks 1-6)

1. Pharmacologic Pain Control:

• Continue ibuprofen at therapeutic doses (400-800mg TID with food) as first-line analgesic to enable participation in physical therapy 1
• Consider short-term oral prednisone taper if pain prevents therapy participation 2, 5
• If inadequate response within 2 weeks, proceed to intra-articular triamcinolone injection - particularly effective in stage 1 but beneficial in stage 2 1

2. Physical Therapy (3x/week minimum):

• Initiate stretching and mobilization exercises immediately, concentrating on external rotation and abduction movements 1
• External rotation is the single most critical factor - prioritize this movement 1
• Gradually increase active ROM while restoring proper shoulder girdle alignment 1
• CRITICAL CONTRAINDICATION: Avoid overhead pulley exercises - highest risk of worsening shoulder pain 1, 3

3. Adjunctive Modalities:

• Ice, heat, and soft-tissue massage for pain relief 1
• Functional electrical stimulation may be employed for short-term pain management 1

Phase 2: Second-Line Interventions (If inadequate response at 6-12 weeks)

1. Injectable Therapies:

• Intra-articular triamcinolone injection provides significant pain relief 1, 6
• Subacromial corticosteroid injection if subacromial inflammation component identified 1
• Consider suprascapular nerve block for refractory pain 6, 7

2. Advanced Conservative Options:

• Hydrodilatation (distension arthrography) 2, 7
• Manipulation under anesthesia 2, 5, 7

3. Surgical Referral (If minimal improvement after 6-12 weeks of aggressive conservative treatment):

• Arthroscopic capsular release 2, 5, 7
• Open capsular release for recalcitrant severe cases 7

Critical Pitfalls to Avoid

• Never use overhead pulley exercises 1, 3, 6
• Never immobilize shoulder with slings or wraps - promotes frozen shoulder progression 1
• Do not delay formal physical therapy beyond 6-8 weeks - permanent shoulder dysfunction may result 1
• Avoid peritendinous/intratendinous corticosteroid injections - may inhibit healing and predispose to rupture 1

Patient Education

• Educate on proper shoulder positioning and ROM exercises for home program 6, 1
• Explain expected timeline: condition typically persists 2-3 years but treatment accelerates recovery 4
• Discuss diabetes control importance - better glycemic control may improve outcomes 2
• Warn against aggressive self-stretching or overhead activities 1

Follow-Up Plan

• Re-evaluate in 2 weeks to assess pain control and therapy tolerance 1
• If inadequate progress at 6 weeks, proceed to intra-articular injection 1
• If minimal improvement at 12 weeks despite combined therapy, refer to orthopedics for surgical consultation 2, 5
• Monitor for development of shoulder-hand syndrome given diabetes risk 3

Goals (12-week timeframe)

Short-term (4 weeks):

• Reduce pain from 7/10 to 4/10 on VAS 1
• Increase external rotation to 30° 1
• Improve sleep quality 1

Long-term (12 weeks):

• Achieve external rotation 60° 1
• Achieve abduction 120° 1
• Return to full work duties without compensatory postures 1
• Independent with home exercise program 1

Functional Outcomes:

• Able to reach overhead shelves 1
• Able to perform self-care activities independently 1
• Return to normal typing posture 1

Coordination of Care

• Communicate with primary care physician regarding diabetes and thyroid management optimization 3, 2
• Consider endocrinology referral if HbA1c >8% - poor glycemic control worsens prognosis 2
• Orthopedic surgery consultation if no improvement by 12 weeks 2, 5

Physical Therapist Signature: ___________________
Date: ___________________
License #: ___________________