Create a primary adhesive capsulitis (frozen shoulder) case for a 52‑year‑old right‑hand‑dominant female office worker with type 2 diabetes mellitus and hypertension, including presentation, imaging findings, and management plan.

Clinical Case: Primary Adhesive Capsulitis in a High-Risk Patient

Patient Presentation

A 52-year-old right-hand-dominant female office worker presents with a 4-month history of progressive right shoulder pain and stiffness that is severely limiting her ability to perform daily activities at work and home.

Chief Complaint

• Insidious onset of deep, aching right shoulder pain that is worse at night, disrupting sleep 1
• Progressive inability to reach overhead or behind her back 1
• Difficulty with basic tasks such as fastening a bra, reaching for items on high shelves, or tucking in her shirt 1

Medical History

• Type 2 diabetes mellitus diagnosed 7 years ago, currently on metformin 1000 mg twice daily with suboptimal glycemic control (HbA1c 8.2%) 2
• Hypertension controlled on lisinopril 20 mg daily 2
• No history of shoulder trauma, surgery, or immobilization 1
• Sedentary occupation with prolonged computer work 3

Physical Examination Findings

Inspection:

• No visible deformity, atrophy, or swelling of the shoulder 1
• Patient holds arm protectively against body 1

Range of Motion (Measured actively and passively):

• Forward elevation: 85° (normal 180°) 1, 4
• External rotation: 15° (normal 90°) - most severely restricted 1, 4
• Internal rotation: Unable to reach posterior superior iliac spine (normally reaches T6-T8) 1
• Abduction: 70° (normal 180°) 1
• Pain throughout range of motion, particularly at end-range 1
• Passive range of motion equally restricted as active range - this is the hallmark finding distinguishing adhesive capsulitis from rotator cuff pathology 1

Strength Testing:

• Difficult to assess secondary to pain and restricted motion, but no focal weakness when tested within available range 1

Special Tests:

• Negative impingement signs 1
• No focal tenderness over rotator cuff insertion sites 1

Imaging Findings

Plain Radiographs (AP and Lateral Views)

• No significant abnormalities - normal glenohumeral joint space, no fracture, dislocation, or calcifications 1
• Radiographs primarily serve to exclude other pathology such as osteoarthritis, calcific tendinitis, or occult fracture 1

Non-Contrast MRI (1.5T Scanner)

Key diagnostic findings:

• Coracohumeral ligament thickening >3 mm - highly specific for adhesive capsulitis 1, 4
• Axillary recess capsular thickening >4 mm - correlates significantly with restriction in elevation (r = -0.42; p = 0.003) and lateral rotation (r = -0.38; p = 0.008) 4
• Hypersignal in the rotator interval on T2-weighted images indicating inflammation 4
• Obliteration of the subcoracoid fat triangle 4
• No rotator cuff tears, labral pathology, or glenohumeral joint effusion 1

Diagnosis

Primary adhesive capsulitis (frozen shoulder) of the right shoulder in a patient with poorly controlled type 2 diabetes mellitus.

Diagnostic Rationale

• Clinical diagnosis based on characteristic history of insidious onset pain with progressive global restriction of both active and passive shoulder range of motion, particularly external rotation 1
• MRI findings of coracohumeral ligament and capsular thickening provide high specificity for the diagnosis 1, 4
• Critical association with diabetes: This patient has a 38.6% likelihood of having adhesive capsulitis given her diabetic status, which is 2-4 times higher than the general population 5
• Her poor glycemic control (HbA1c 8.2%) further increases risk, as diabetes is believed to play a role in musculoskeletal complications through glycosylation of collagen and microvascular changes 6, 5

Management Plan

Immediate Priorities

1. Optimize Glycemic Control

• Intensify diabetes management immediately - achieving glycemic control can prevent or delay diabetic complications including musculoskeletal manifestations 2, 6
• Target HbA1c <7% through medication adjustment and lifestyle modification 2
• This patient requires urgent diabetes optimization as poor control is associated with worse outcomes in adhesive capsulitis treatment 3

2. Screen for Prediabetes/Undiagnosed Diabetes in Context

• While this patient has known diabetes, the finding of adhesive capsulitis should prompt screening of family members, as 71.5% of patients with adhesive capsulitis have either diabetes or prediabetes 5
• Early diagnosis of diabetes reduces risk of microvascular complications 5

Conservative Treatment (First-Line for 6-12 Weeks)

Pharmacologic Management:

• Intra-articular corticosteroid injection combined with physiotherapy provides greater improvement than physiotherapy alone 1

  • Perform glenohumeral joint injection with 40 mg triamcinolone acetonide or equivalent 1
  • May repeat injection if initial response is inadequate after 4-6 weeks 1

• Short-term oral corticosteroids (e.g., prednisone 30 mg daily for 3 weeks with taper) as an alternative or adjunct 1

  • Caution: Monitor blood glucose closely in diabetic patients, as corticosteroids will worsen hyperglycemia 2
  • Adjust diabetes medications proactively during corticosteroid course 2

• NSAIDs for pain control (e.g., naproxen 500 mg twice daily with food) 1, 6

  • Monitor blood pressure given her hypertension 2
  • Consider proton pump inhibitor for gastroprotection 2

Physical Therapy:

• Initiate structured physiotherapy program immediately - this is the cornerstone of treatment 1, 6
• Focus on gentle range-of-motion exercises, stretching, and progressive strengthening 1
• Pendulum exercises, wall walks, and pulley exercises 1
• Avoid aggressive manipulation that may cause pain and protective muscle spasm 1
• 2-3 sessions per week for 6-12 weeks 1

Alternative Therapies:

• Acupuncture may be considered as adjunctive treatment 1
• Hydrodilatation (distension arthrography) can be considered if initial conservative measures fail 1

Surgical Intervention (If Conservative Treatment Fails)

Indications for surgical referral after 6-12 weeks of nonsurgical treatment with minimal improvement: 1

1. Manipulation under anesthesia (MUA)

   • Forceful passive manipulation to break adhesions 1
   • Risk of fracture, dislocation, or rotator cuff tear 1

2. Arthroscopic capsular release (preferred over MUA)

   • Direct visualization and controlled release of contracted capsule 1
   • Lower complication rate than MUA 1
   • Allows identification and treatment of concomitant pathology 1

Critical Pitfalls to Avoid

• Do not assume spontaneous resolution - recent evidence shows persistent functional limitations if left untreated, challenging the traditional belief of complete resolution within 1-2 years 1
• Do not use corticosteroids without addressing diabetes control - worsening hyperglycemia will compound the underlying pathophysiology 2, 6
• Do not delay physiotherapy - early mobilization is essential to prevent progression 1
• Do not perform aggressive passive stretching early - this may worsen inflammation and pain 1
• Do not miss bilateral involvement - adhesive capsulitis can affect both shoulders, particularly in diabetic patients 6

Blood Pressure Management in Context

• Continue lisinopril 20 mg daily with target BP <130/80 mmHg 2
• ACE inhibitors are preferred in diabetic patients for renal protection 2
• Monitor for orthostatic hypotension, which can be a manifestation of diabetic autonomic neuropathy 2

Cardiovascular Risk Assessment

• Assess 10-year ASCVD risk given her age, diabetes, and hypertension 2
• Check fasting lipid panel 2
• If LDL-C elevated, initiate moderate- to high-intensity statin therapy based on risk stratification 2
• Consider aspirin 75-100 mg daily if 10-year ASCVD risk >10% 2

Screening for Diabetic Complications

Given her 7-year diabetes duration and poor control, perform comprehensive screening: 2

• Annual comprehensive eye examination by ophthalmologist for diabetic retinopathy 2
• Urine albumin-to-creatinine ratio and eGFR for diabetic kidney disease 2
• Foot examination with 10-g monofilament testing for peripheral neuropathy 2
• Assessment for cardiovascular autonomic neuropathy (resting tachycardia, orthostatic hypotension) 2

Follow-Up Schedule

• 2 weeks: Reassess pain control and diabetes management adjustments 1
• 6 weeks: Evaluate response to corticosteroid injection and physiotherapy; consider repeat injection if inadequate response 1
• 12 weeks: If minimal improvement, refer to orthopedic surgery for consideration of manipulation under anesthesia or arthroscopic capsular release 1
• Every 3 months: Monitor HbA1c until target <7% achieved 2

Patient Education

• Explain that adhesive capsulitis is strongly associated with diabetes and that optimizing blood glucose control is essential for treatment success 6, 5, 3
• Set realistic expectations: improvement may take 6-12 months even with treatment 1
• Emphasize importance of daily home exercise program in addition to formal physiotherapy 1
• Counsel on proper diabetes self-management including diet, exercise, and medication adherence 2

Occupational Considerations

• Provide work restrictions: avoid overhead reaching and heavy lifting with right arm 1
• Consider ergonomic assessment of workstation to minimize shoulder strain 3
• May require temporary job modifications during acute phase 1